Efficacy of S53P4 Bioactive Glass for the Secondary Obliteration of Chronically Discharging Radical Cavities.

Objective: Present the results of the secondary obliteration of chronically discharging radical cavities using S53P4 bioactive glass (BAG). Study Design: Retrospective cohort study. Setting: Single-center study. Methods: A single-center retrospective cohort study was conducted of all patients that underwent secondary obliteration of persistently draining radical cavities using S53P4 BAG between 2011 and 2022. Patients with middle ear cholesteatoma were excluded. The main outcome was postoperative otorrhea, as indicated by Merchant grading. Results: In total, 97 patients were included. The median postoperative follow-up time was 3.9 years (range 0.5-10.4). Average time between the original canal wall down surgery and the secondary obliteration was 25.3 years (SD 11.7, range 2-66). At the most recent follow-up visit, a Merchant grade of 0 to 1 was observed in 95% of the cases. There were no cases of sensorineural hearing loss or facial palsy, one case developed a retro auricular skin defect and 1 patient developed CSF leakage. Minor complications were seen in 10 patients (10%). Ossicular chain reconstruction with a titanium prosthesis was performed in 42 cases, resulting in a median improvement of 11.2 dB in air conduction thresholds. In 9/42 cases (21%), closure of the postoperative air-bone gap to ≤20 dB was achieved. Twenty-five percent of cases could be discharged from out-patient visits. Conclusion: Revision of persistently draining radical cavities with BAG obliteration is feasible and results in a dry and safe ear in 95% of the patients, thereby enabling wearing of a conventional hearing aid. Out-patient visits could be ceased in 25% of the cases.

Cholesteatoma surgery in the pediatric population: remaining challenges in the era of mastoid obliteration.

PURPOSE: To present the first pediatric study on the safety and efficacy of mastoid obliteration using S53P4 bioactive glass (BAG) for cholesteatoma surgery. METHODS: A single-center retrospective cohort study was conducted. Inclusion criteria were pediatric cases (≤ 18 years) and at least at least one year of follow-up including non-echo planar diffusion-weighted MRI to assess cholesteatoma recidivism. Both canal wall up (CWU) and canal wall down (CWD) procedures were evaluated. RESULTS: A total of 61 cases (56 patients) were included. Most cases had an otologic history before the development of the cholesteatoma. CWU procedure was performed in 18 cases (30%) and CWD procedure in 43 cases (70%). The cholesteatoma recidivism rate was 33% after a mean follow-up period of 58 months. Kaplan-Meier curve estimated a 5-year recidivism rate of 40%. Few complications were seen that were all minor and resolved spontaneously or after local or systemic treatment. Control of the infection (merchant grade 0-1) was achieved in 98% of the cases. Closure of the air-bone gap within 20 dB was achieved in 22% of the cases with complete audiometric evaluation. CONCLUSION: In this MRI-controlled study, we show the safety and efficacy of S53P4 BAG for mastoid obliteration in a pediatric cholesteatoma cohort. Postoperative complications were both rare and minor, and a dry ear was achieved in almost all patients. Nevertheless, persistent hearing loss and the apparent high recidivism rate reflect the challenging nature of pediatric cholesteatoma.

Mastoid Obliteration Using S53P4 Bioactive Glass in Cholesteatoma Surgery: A 10-Year Single-Center Experience in 173 Adult Patients with Long-Term Magnetic Resonance Imaging Controlled Follow-up.

OBJECTIVE: To present the long-term outcomes of mastoid obliteration in cholesteatoma surgery using S53P4 bioactive glass (BAG) in an adult population. STUDY DESIGN: Retrospective cohort study. SETTING: Single-center study. PATIENTS: All 173 adult patients who underwent primary or revision surgery for cholesteatoma with mastoid obliteration using S53P4 BAG with at least 1 year of follow-up including nonecho planar diffusion-weighted magnetic resonance imaging (MRI) (non-EP DWI MRI) and/or second-look surgery to evaluate recidivism. Both canal wall up (CWU) and canal wall down (CWD) procedures were included. INTERVENTIONS: Patients underwent CWU or CWD mastoidectomy using S53P4 BAG. MAIN OUTCOME AND MEASURES: Cholesteatoma recidivism, postoperative complications, Merchant grade, hearing outcome. RESULTS: Cholesteatoma recidivism was assessed by MRI in 97% of all cases and second-look surgery look surgery in 3% of cases. After a mean follow-up period of 53 months, cholesteatoma recidivism was seen in 10% of the cases (n = 18). Using the Kaplan-Meier curve to extrapolate, a 5-year recidivism rate of 12% was estimated. Only minor complications occurred, all resolving spontaneously or after minor treatment. Merchant grade of 0 to 1 was achieved 95% of the patients, no persistently wet ears were observed. Closure of the air-bone gap within 20 dB was possible in 32%. CONCLUSION: In this long-term (up to 10 yr) follow-up study, we demonstrated the safety of S53P4 BAG. Minimal and only minor postoperative complications were observed. The effectiveness of BAG was indicated by the low rate of recidivism, even when using non-EP DWI MRI, a sensitive and specific noninvasive technique to detect cholesteatoma recidivism.

Treatment of Frontal Secondary Headache Attributed to Supratrochlear and Supraorbital Nerve Entrapment With Oral Medication or Botulinum Toxin Type A vs Endoscopic Decompression Surgery.

IMPORTANCE: Endoscopic surgical decompression of the supratrochlear nerve (STN) and supraorbital nerve (SON) is a new treatment for patients with frontal chronic headache who are refractory to standard treatment options. OBJECTIVE: To evaluate and compare treatment outcomes of oral medication, botulinum toxin type A (BoNT/A) injections, and endoscopic decompression surgery in frontal secondary headache attributed to STN and supraorbital SON entrapment. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 22 patients from a single institution (Diakonessen Hospital Utrecht) with frontal headache of moderate-to-severe intensity (visual analog scale [VAS] score, 7-10), frontally located, experienced more than 15 days per month, and described as pressure or tension that intensifies with pressure on the area of STN and SON. A screening algorithm was used that included examination, questionnaire, computed tomography of the sinus, injections of local anesthetic, and BoNT/A in the corrugator muscle. INTERVENTIONS: Different oral medication therapy for headache encountered in the study cohort, as well as BoNT/A injections (15 IU) into the corrugator muscle. Surgical procedures were performed by a single surgeon using an endoscopic surgical approach to release the supraorbital ridge periosteum and to bluntly dissect the glabellar muscle group. MAIN OUTCOMES AND MEASURES: Headache VAS intensity after oral medication and BoNT/A injections. Additionally, early postoperative follow-up consisted of a daily headache questionnaire that was evaluated after 1 year. RESULTS: In total, 22 patients (mean [SD] age, 42.0 [15.3] years; 7 men and 15 women) were included in this cohort study. Oral medication therapy reduced the headache intensity significantly (mean [standard error of the mean {SEM}] VAS score, 6.45 [0.20] [95% CI, 0.34-3.02; P < .001] compared with mean [SEM] pretreatment VAS score, 8.13 [0.22]). Botulinum toxin type A decreased the mean (SEM) headache intensity VAS scores significantly as well (pretreatment, 8.1 [0.22] vs posttreatment, 2.9 [0.42]; 95% CI, 3.89-6.56; P < .001). The mean (SEM) pretreatment headache intensity VAS score (8.10 [0.22]) decreased significantly after surgery at 3 months (1.30 [0.55]; 95% CI, 5.48-8.16; P < .001) and 12 months (1.09 [0.50]; 95% CI, 5.71-8.38; P < .001). There was a significant decrease of headache intensity VAS score in the surgical group over the BoNT/A group (mean [SEM] VAS score, 2.90 [0.42]) after 3 months (mean [SEM] VAS score, 1.30 [0.55]; 95% CI, 0.25-2.93; P < .001) and 12 months (mean [SEM] VAS score, 1.09 [0.50]; 95% CI, 0.48-3.16; P < .001) after surgery. CONCLUSIONS AND RELEVANCE: Endoscopic decompression surgery had a long-lasting successful outcome in this type of frontal secondary headache. Even though BoNT/A had a positive effect, the effect of surgery was significantly higher. LEVEL OF EVIDENCE: 3.

Decompression endoscopic surgery for frontal secondary headache attributed to supraorbital and supratrochlear nerve entrapment: a comprehensive review.

In the last decade, a new surgical treatment modality was developed for frontal secondary headache, based on the assumption that the trigger of this pain entity is the entrapment of peripheral sensory nerves. The surgery entails a procedure, where an endoscopic approach is used to decompress the supraorbital and supratrochlear nerve branches, which are entrapped by the periosteum in the region of the corrugator supercilii muscle. Candidates for the surgery define their headache as moderate to severe persistent daily pressure or tension, localized in the frontal area, sometimes accompanied by symptoms of nausea and photophobia mimicking a primary headache-migraine. We created a step-by-step screening algorithm which is used to differentiate patients that have the highest chance for a successful surgical decompression. Up to now, published data regarding this type of surgery demonstrate long-lasting successful outcomes while adverse effects are minor. This article reviews and discusses from a surgeon's perspective decompression surgery for secondary headache attributed to supraorbital and supratrochlear nerve entrapment.

Mastoid obliteration with S53P4 bioactive glass in cholesteatoma surgery.

CONCLUSION: Evaluation of the follow-up of 67 patients shows that S53P4 bioactive glass (BAG) granules are safe and effective as obliteration material in cholesteatoma surgery. OBJECTIVES: To investigate the safety and efficacy of mastoid obliteration using S53P4 BAG in cholesteatoma surgery. Clinical outcomes were infection control (Merchant's grading), cholesteatoma recidivism, and audiometric performance. METHODS: Retrospective follow-up study at the Diakonessenhuis, Utrecht, the Netherlands. Eighteen young (age <17 years) and 49 adult (age ≥17 years) patients treated for cholesteatoma underwent tympanomastoidectomy with mastoid obliteration using S53P4 BAG in the period 2012-2015. Outcome was monitored with clinical otoscopy, otorrhea incidence measurement (Merchant's grading), DW-MRI, and audiographic performance analyses (pure tone average and air bone gap). RESULTS: During the follow-up period (mean = 22 months; range = 12-54 months) cholesteatoma recidivism was observed in 6% of the patients (four ears), mostly in young patients (three ears). An acceptably dry ear (Merchant grade 0-1) was achieved in 96% of all cases. The remaining 4% of cases scored a Merchant grade 2. Overall, both air conduction thresholds and air bone gap were slightly lowered when comparing post-operative values to pre-operative values and significantly in the case of ossicular reconstruction. In none of the patients (0%) did post-operative wound infections occur.

Aggressive basal cell carcinoma of the head and neck: challenges in surgical management.

With exponentially increasing numbers of basal cell carcinoma (BCC) of the head and neck region, also the locally advanced BCCs are increasing in number. These tumours are associated with aggressive biological behaviour with invasion of soft tissues, organs or bone and present with wide variation in management strategies. The objectives of the study was to describe the biological behaviour of aggressive BCCs and their clinical presentation in the head and neck region with a series of cases treated in our tertiary hospital, discuss management plans of such complex cases in terms of surgical planning and reconstruction. A series of five cases of aggressive BCC in the head and neck region with involvement of organs such as nose, orbit, temporal bone, facial nerve, paranasal sinuses and mandible was studied. Locally advanced, aggressive BCC should be evaluated and treated as head and neck tumours. Multidisciplinary team (MDT) discussion is advisable wherein the strategies on surgical excision, reconstruction options, facial nerve rehabilitation, indications for prosthesis and further adjuvant treatment such as radiotherapy and chemotherapy are carefully planned.

Quality of life after surgical treatment for oral and oropharyngeal cancer: a prospective longitudinal assessment of patients reconstructed by a microvascular flap.

The aim of this study was to document changes from baseline to 6 and 12 months after treatment in health-related quality of life (HRQOL) in relation to sociodemographic and clinical parameters among advanced oral/oropharyngeal cancer patients treated with reconstructive surgery and adjuvant radiotherapy. The HRQOL of 80 consecutive patients was assessed by the EORTC QLQ-C30 and QLQ-H&N35 questionnaires, pretreatment and 6 and 12 months posttreatment. Several patterns of HRQOL changes were distinguished: most general HRQOL issues do not change after treatment or improve compared to baseline scores (emotional functioning, pain, insomnia, constipation) and most head and neck specific issues deteriorate after treatment but return to pretreatment levels at 12 months, except for senses, opening mouth, sticky saliva, and coughing which remain deteriorated in the long term. Although improvement to baseline levels was noted, it should be kept in mind that baseline levels of patients are often deviant from "normal" scores from the general population. Tumour site and stage, comorbidity, and extensive resections were significantly associated with HRQOL outcomes, as were marital status and age. These results, obtained in a homogenous group of patients, may serve as HRQOL benchmarks for future studies investigating surgical and other treatment modalities.

Quality of life and functional status in patients with cancer of the oral cavity and oropharynx: pretreatment values of a prospective study.

We assessed the pretreatment health-related quality of life (HRQOL) and functional status of patients with advanced oral and oropharyngeal cancer. Eighty patients were investigated. HRQOL was assessed by EORTC QLQ-C30/QLQ-H&N35 questionnaires. Functional status assessment comprised speech and oral function tests. The results revealed a wide range of HRQOL and functional deficits before treatment. HRQOL appeared to be related to some extent to tumor site (patients with oral tumors reported more pain compared to patients with oropharyngeal tumors) and tumor classification (patients with T3-T4 tumors reported more trouble opening the mouth and felt more ill compared to patients with T2 tumors). Comorbidity appeared to have a major impact. Patients with comorbidity had significantly worse scores on several scales/items on both the EORTC questionnaires. Functional deficits were related to tumor site, classification and comorbidity. Patients with oral cavity tumors (versus oropharyngeal tumors), patients with T3-T4 tumors (versus T2 tumors), and patients with comorbidity (versus without comorbidity) scored significantly worse on several speech and oral function tests. Impaired speech and oral function appeared to be clearly related to global quality of life (QLQ-C30) and self-reported speech (QLQ-H&N35). Many patients with advanced oral and oropharyngeal cancer have compromised HRQOL and functional status before the start of treatment. In addition to tumor site and tumor classification, comorbidity appears to have a major impact on HRQOL and functional status. Knowledge of pretreatment HRQOL and functional status levels is useful for better understanding the impact of treatment on these outcomes over time.

Swallowing after major surgery of the oral cavity or oropharynx: a prospective and longitudinal assessment of patients treated by microvascular soft tissue reconstruction.

BACKGROUND: The aim of this study was to analyze swallowing outcome in advanced oral/oropharyngeal cancer patients treated with microvascular reconstructive surgery and adjuvant radiotherapy. METHODS: Eighty patients were included. Patient, tumor, and treatment factors were assessed. Postoperative videofluoroscopic swallowing studies (VFSS) and scintigraphy tests were performed at 6 (n = 54 vs 44) and 12 (n = 32 vs 37) months. Swallowing parameters such as the oropharyngeal swallow efficiency and the Penetration/Aspiration Scale were analyzed. RESULTS: Impaired swallowing status was found at 6 months, which remained stationary at 12 months. Comorbid condition, larger tumors (T3-T4 vs T2), and resections of the base of tongue and soft palate combined (vs defects of other dynamic structures) were associated with most profound swallowing problems (p < .05). CONCLUSIONS: Swallowing difficulties are relatively frequent and can to a large extent be predicted. With the knowledge of this study, better counseling and vigilance as to swallowing difficulties may be possible.

Speech outcome after surgical treatment for oral and oropharyngeal cancer: a longitudinal assessment of patients reconstructed by a microvascular flap.

BACKGROUND: The aim of the study was to analyze speech outcome for patients with advanced oral/oropharyngeal cancer treated with reconstructive surgery and adjuvant radiotherapy. METHODS: Speech tests (communicative suitability, intelligibility, articulation, nasality, and consonant errors) were performed in a control group and in patients before treatment (n = 76), and 6 months (n = 51) and 12 months (n = 42) after treatment. RESULTS: Speech tests were significantly worse for patients before and after treatment compared with the controls. Speech did not improve between 6 and 12 months. After treatment, patients with T3-4 tumors showed a significantly worse score for communicative suitability, intelligibility, and articulation than patients with T2 tumors. No significant differences were found for subsites after treatment, although patients with mobile tongue tumors showed the best results. CONCLUSION: Speech difficulties are significant, and with the knowledge of this study better counseling and vigilance as to speech difficulties may be possible in patients undergoing treatment for oral/oropharyngeal cancer.

Severe comorbidity negatively influences prognosis in patients with oral and oropharyngeal cancer after surgical treatment with microvascular reconstruction.

The aim of the study was to investigate the possible impact of comorbidity on survival of patients undergoing composite resection and microvascular reconstruction for oral/oropharyngeal cancer. Patient, tumour and treatment data were recorded. Comorbidity was graded by the Adult Comorbidity Evaluation (ACE-27) test. Survival and statistics were calculated. Comorbidity score ACE-27 grade 2 was present in 47% of patients, for ACE-27 grade 3 this was 13%. The median follow-up was 50 (3-87) months. Thirty-eight patients died, 32 developed a recurrence. Comorbidity score ACE-27 grade 3 turned out to be a clear predictor for overall survival (p<0.05). For ACE-27 grade 3 (n=13) 5-years survival was 29%, for ACE-27 grade 2 (n=87) this was 64%. No multivariate influences on the effects of comorbidity were found. Improved knowledge of the effect of comorbidity on survival may lead to better patient selection and counselling for major surgery and microvascular reconstruction.

Post-traumatic cutaneous meningioma.

Cutaneous meningiomas are extremely rare tumours and their diagnosis is difficult. We describe the case of a patient who developed a paranasal swelling after head trauma and associated fractures in the same region years before. Histopathological examination of an incisional biopsy revealed the diagnosis of cutaneous meningioma. After one and a half years' follow up, surgical excision was performed because of progressive growth of the tumour and associated aesthetic problems. Extracranial meningiomas can develop probably secondary to trapping of meningeal tissue after trauma. If there is no intracranial connection surgical removal can be considered.

Comorbid condition as a prognostic factor for complications in major surgery of the oral cavity and oropharynx with microvascular soft tissue reconstruction.

BACKGROUND: Identification of factors, especially comorbidity, that affect the incidence and severity of complications in head and neck cancer patients. METHODS: One hundred patients with an oral/oropharynx carcinoma undergoing composite resection and microvascular soft tissue transfer were analyzed. Patient data and tumor and treatment factors were recorded. Comorbidity was graded by an Adult Comorbidity Evaluation 27 (ACE-27) test. Postoperative complications were scored according to their severity. RESULTS: Comorbidity score ACE-27 grade 2 or higher was present in 47% of patients, whereas 33% had a clinically important complication develop. A comorbidity score of ACE-27 grade > or =2 was a strong predictor for complications (p <.001). There were no other predictors for postoperative complications. CONCLUSIONS: Comorbidity is of great importance for prediction of postoperative complications in head and neck cancer patients, especially an ACE-27 grade > or =2. It may be concluded from these results that prevention of complications should focus on comorbidities.