Vertical partial laryngectomy with temporoparietal free flap reconstruction for recurrent laryngeal squamous cell carcinoma: technique and long-term outcomes.

OBJECTIVES: To present a technique for reconstruction of the vertical partial laryngectomy defect using a vascularized carrier consisting of a temporoparietal free flap, cartilage graft, and buccal mucosal graft; to evaluate the oncologic outcomes with respect to locoregional control and overall survival; and to provide an assessment of patient quality of life and functional outcomes. DESIGN: Retrospective medical record review and prospective cross-sectional analysis of functional outcomes. SETTING: Princess Margaret Hospital-University Health Network and the Odette Cancer Centre-Sunnybrook Health Sciences Centre. METHODS: We collected data on patient demographic characteristics, tumor staging, initial treatment, recurrence, management, and follow-up. Prospectively, a cross-sectional study was performed using the European Organization for Research and Treatment of Cancer Quality of Life of Cancer Patients Questionnaire C30 and HN35 module and voice and swallowing results using the Voice Handicap Index and Swallowing Quality of Life index. MAIN OUTCOME MEASURES: Local recurrence-free survival, cause-specific survival, and overall survival. RESULTS: Forty men met inclusion criteria (median age, 65.0 years). Local recurrence-free survival was 84% at 3 years and 75% at 5 years. Cause-specific survival was 88% at 3 years and 78% at 5 years. Thirty-eight patients were successfully decannulated; all patients tolerated oral intake after the surgical procedure. The C30 and HN35 symptomatic results were comparable with patients with standardized stages I and II head and neck tumors. The Voice Handicap Index results were comparable with patients with functional dysphonia. Patients' swallowing was in the normal range. CONCLUSIONS: Patients receiving vertical partial laryngectomy with temporoparietal free flap reconstruction for recurrent glottic carcinoma following radiation treatment failure have high rates of locoregional control. The use of the temporoparietal free flap in this patient population produces high-quality voice results and normal swallowing and has no major effect on quality of life.

Prognostic impact of intraoperative microscopic cut-through on frozen section in oral cavity squamous cell carcinoma.

OBJECTIVE: Although the literature suggests that a positive tumour margin on permanent section portends a poor oncologic outcome, the prognostic implication of microscopic tumour cut-through (ie, positive tumour margin on intraoperative frozen section) that is surgically revised to a negative final margin on permanent section is currently unclear. Therefore, this study aimed to analyze the influence of microscopic tumour cut-through on disease recurrence and survival and to establish clinicopathologic variables associated with tumour cut-through. DESIGN: A retrospective chart review. SETTING: The Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto. METHODS: Comprehensive clinicopathologic data were collected, including demography, clinical tumour staging (TNM), treatment, histopathologic details, recurrence, management, and follow-up. MAIN OUTCOME MEASURES: Local cancer control and disease-specific survival were the main outcome measures of interest. The Kaplan-Meier method was used to assess outcome measures by patient group, and the log-rank test was used to compare survival curves. Univariate and multivariate Cox proportional hazard regression analyses were used to test the association of various clinical factors and to identify independent prognostic factors of local control and disease-specific survival. RESULTS: Sixty-five patients met inclusion criteria for our study (37 males; median age 64.4 years). Both local control and disease-specific survival were statistically significantly reduced in patients with positive intraoperative frozen section despite revision to obtain negative margins (p < .05). Multivariate analysis showed that microscopic tumour cut-through independently predicted poorer local control and disease-specific survival (p < .05). CONCLUSIONS: This study in patients receiving primary surgery for oral squamous cell carcinoma shows that microscopic tumour cut-through on intraoperative frozen section independently portends a poorer oncologic prognosis, regardless of ultimate tumour margin pathology.

Inverted papilloma of the sphenoid sinus: clinical presentation, management, and systematic review of the literature.

OBJECTIVES: Inverted papilloma (IP) of the sphenoid sinus is a rare neoplasm with a nonspecific and insidious presentation that is further complicated by difficult access for assessment and follow-up. In conjunction with a systematic review of the English literature, we review our experience with IP of the sphenoid sinus to better delineate the clinical presentation, prevalence, management, and recurrence of this challenging lesion. METHODS: A systematic search strategy was developed to assess and summarize the best available evidence on sphenoid IP. A retrospective chart review of the 5-year database of one tertiary care Otolaryngology-Head and Neck Surgery practice was performed; all patients with histologically confirmed IP of the nasal cavity or paranasal sinuses were included. RESULTS: Seventy-one patients (49 males, 22 females; mean age, 57.2 years) treated between June 2003 and January 2009 were included. Nine patients were diagnosed with IP originating in the sphenoid sinus. Two of these patients were asymptomatic, and in the remaining seven patients the most common presentation was headache (42.9%), followed by visual disturbances, hearing loss, and nasal obstruction (28.6% each). Review of the literature confirms our finding that the most common presenting symptom is headache (45.0%), followed by nasal obstruction (30.0%) and epistaxis (22.5%). CONCLUSIONS: This is the largest reported series of sphenoid sinus IP in the English literature. We have demonstrated a predominance of neurological and visual symptoms in symptomatic patients with sphenoid IP, and suggest that these may be early manifestations of sphenoid IP, before the more common sinonasal symptoms develop secondary to extension into the nasal cavity and paranasal sinuses.

Double free-flap reconstruction: indications, challenges, and prospective functional outcomes.

OBJECTIVE: To investigate the increasing use of double free flaps in the reconstruction of large head and neck defects. DESIGN: A 5-year retrospective medical record review in a large tertiary care head and neck oncology program. Prospectively collected functional data were also analyzed. SETTING: Academic research. PATIENTS: A consecutive series of 35 patients (24 men and 11 women; mean age, 57.7 years). MAIN OUTCOME MEASURES: The use of double free flaps in the reconstruction of large head and neck defects and prospective functional outcomes. RESULTS: The most common indication for surgery (n = 25 [71.4%]) was squamous cell carcinoma. The most common double free-flap combination (n = 22 [62.9%]) included an osteocutaneous fibular free flap with a fasciocutaneous radial forearm free flap. Objective evaluation by naive listeners demonstrated a mean single-word intelligibility score of 66.2% and a mean sentence intelligibility score of 84.8% in this group of patients. Modified barium swallow study results revealed no evidence of laryngeal penetration for swallowing liquid consistencies in 21 patients (60.0%), pudding consistencies in 30 patients (85.7%), and cookie consistencies in 32 patients (91.4%). CONCLUSIONS: With proper patient selection and planning and the use of 2 surgical teams, the length of surgery and complication rates are not significantly increased in double free-flap reconstruction. Furthermore, by using 2 free flaps, the best osseous and soft-tissue elements may be independently selected, yielding appropriate tissue characteristics for ideal defect reconstruction.

The implantable Cook-Swartz Doppler probe for postoperative monitoring in head and neck free flap reconstruction.

OBJECTIVE: To determine if the implantable Cook-Swartz Doppler Flow Monitoring System (Cook Vascular Inc, Vandergrift, Pennsylvania) improves surgical salvage rates for compromised free flaps. DESIGN: Retrospective medical record review spanning 2002 to 2006 for a large head and neck oncology program. SETTING: A tertiary care hospital. PATIENTS: A consecutive series of 351 patients (244 men and 107 women; mean age, 58.63 years) who underwent free flap reconstruction of head and neck defects that were monitored using the implantable Doppler probe were included. RESULTS: The most common indication for surgery was squamous cell carcinoma (81.0%), followed by functional reconstruction (4.3%). The most common free flap used was radial forearm (68.0%), followed by the fibular free flap (19.0%). With operative exploration used as the gold standard, the Cook-Swartz Doppler Flow Monitoring System had a sensitivity of 65.8% and specificity of 98.2% for the detection of flap compromise. For the detection of vascular compromise of the monitored vessel (excluding flap compromise cases whereby flow in the monitored vessel was not compromised on operative exploration, ie, venous obstruction, hematoma formation, and necrotizing fasciitis), the sensitivity increased to 100%. CONCLUSIONS: This is the largest reported series, to our knowledge, of implantable Cook-Swartz Doppler use, and our experience would suggest that this is a reliable technique for postoperative monitoring in head and neck reconstruction. Our use of the implantable Doppler probe allowed us to recognize vascular compromise early, resulting in an overall flap success rate of 98.1%, with a 92.0% salvage rate of flaps that experienced vascular compromise of the monitored vessel.

Airway pathologic abnormalities in symptomatic children with congenital cardiac and vascular disease.

OBJECTIVE: To identify the epidemiological profile of airway abnormalities in symptomatic children with cardiac or vascular anomalies. DESIGN: Retrospective medical chart review. SETTING: Tertiary referral pediatric hospital. PATIENTS: Children with airway-related symptoms and coexistent cardiac or vascular abnormality were included. The source for patient identification was a prospectively kept database. MAIN OUTCOME MEASURES: Endoscopic airway diagnoses, presenting airway symptoms, cardiac diagnoses, other comorbid conditions and pertinent diagnoses, patient demographics, source of referral, treatments, and follow-up. RESULTS: The study population comprised 77 patients (45 male and 32 female; mean age, 18.2 months) treated between June 2002 and July 2006. Only 4 patients had no findings. The most common airway abnormality was laryngeal paralysis (n=32), followed by subglottic stenosis (n=18). Congenital and acquired lesions were equally encountered (n=70 and n=64, respectively). The most frequent presentation was intolerance to feed (n=51) (stridor and/or failure of extubation). Of the 77 patients, 32 (42%) required airway surgical intervention (open vs closed); 36 (47%) still require otolaryngologic follow-up; and 32 (42%) had a named syndrome or general multisystem condition. CONCLUSIONS: At least 3% of all children with cardiac disease will harbor airway problems. Laryngeal paralysis was the most common problem encountered. Given the successes achievable in treating children with complex cardiac abnormalities, attention should be paid to concomitant and consequential airway problems. Counseling processes should acknowledge the role of early otolaryngologic involvement.