The Submental Island Flap Is a Viable Reconstructive Option for a Variety of Head and Neck Ablative Defects.

BACKGROUND: The submental island flap (SIF) is a pedicled flap based upon the submental artery and vein. Its utility in reconstruction following ablative head and neck procedures has been applied to various subsites including skin, lip, buccal mucosa, retromolar trigone, parotidectomy defects, and tongue. We review our experience using the SIF for reconstruction following tumor ablation. METHODS: This prospective case series with medical record review includes consecutive patients undergoing SIF reconstruction following ablative surgery for malignancy at a single tertiary care facility between November 2014 and November 2016. We examined preoperative variables, surgical procedures, and postoperative outcomes. RESULTS: Thirty-seven patients met inclusion criteria. Twenty-nine were male; the average age was 64.3 (±12.4) years. Seventeen cancers involved the oral cavity, 11 involved the skin, 8 were in the oropharynx, and 1 was in the paranasal sinus. The average size of the SIF was 38.8 cm2 (±17.6 cm2). Four partial flap losses occurred; none required revision surgery. The average length of stay for these patients was 7.2 (±6.1) days. CONCLUSION: The SIF is a robust flap that can be reliably used for a variety of head and neck defects following tumor ablation with an acceptable rate of donor- and flap-related complications.

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review.

OBJECTIVE: Postoperative use of anticoagulation after free tissue transfer in head and neck ablative procedures is common practice, but a clear protocol has not been well established. The outcome measures including total flap failure, thrombosis, and hematoma formation for different anticoagulation regimens in free tissue transfer in the head and neck were reviewed. DATA SOURCES: PubMed, Ovid, and Cochrane databases were examined for patients who underwent free tissue transfer following head and neck ablative procedures. REVIEW METHODS: Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting anticoagulation regimens following free tissue transfer in head and neck ablative procedures. Outcomes included total flap failure, thrombosis, and hematoma formation. Two independent reviewers assessed the quality of the articles by using the Methodological Index for Non-Randomized Studies. RESULTS: A total of 368 articles were identified. An additional 36 articles were identified through screening of reference lists. Twenty-one of these studies met final inclusion criteria for qualitative analysis. Outcome data on total flap failure, thrombosis, and hematoma formation were extracted and analyzed for comparison against all anticoagulation regimens. Total flap failure, thrombosis, and hematoma formation rates were 4.4%, 4.5%, and 2.2%, respectively. Individual study rates ranged from 0.0% to 10.7%, 0.0% to 10.4%, and 0.6% to 7.2%, respectively. CONCLUSIONS: There is not adequate evidence to develop a standardized anticoagulation protocol for head and neck free flap procedures. Comparable flap complications were reported between all the employed anticoagulation methods studied, though significant variability in study design among articles existed. Prospective, randomized studies are warranted to determine the optimal postoperative anticoagulation regimen following free tissue transfer of the head and neck. Laryngoscope, 128:412-421, 2018.

Minimum lymph node yield in elective level I-III neck dissection.

OBJECTIVES/HYPOTHESIS: Unlike lymphadenectomy at other sites, there is no discrete lymph node count defining an adequate neck dissection. The purpose of this study was to determine the minimum lymph node yield (LNY) of an elective level I-III neck dissection required to reliably capture any positive nodes present in these nodal basins. STUDY DESIGN: Retrospective single-institution analysis. METHODS: All patients with the diagnosis of head and neck squamous cell carcinoma who underwent elective level I-III neck dissection between 2004 and 2015 at our institution were analyzed. Preoperatively, patients had no clinical or radiographic evidence of lymphadenopathy. Patients with unknown number of lymph nodes on pathology report were excluded. Age, gender, race, history of radiation, tumor subsite, stage, surgeon, LNY, and number of positive nodes were recorded; bilateral neck dissections were reported separately. RESULTS: One hundred eighteen level I-III neck dissections met criteria and were included in the study. Mean LNY was 21.15, and metastatic disease was present in 24.5% of cases, with 8.4% of cases being N2. The highest portion of positive lymph nodes was present in the group with 18 to 24 lymph nodes (36%), which was significantly higher than the group with <18 (14.89%) (P = .044). CONCLUSIONS: Although there is no accepted minimum for LNY in level I-III neck dissection, at least 18 nodes may be considered an adequate LNY. Such a yield reliably allows for capture of occult disease within these nodal basins. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2070-2073, 2017.

NSQIP as a Predictor of Length of Stay in Patients Undergoing Free Flap Reconstruction.

OBJECTIVE: The National Surgical Quality Improvement Program (NSQIP) calculator was created to improve outcomes and guide cost-effective care in surgery. Patients with head and neck cancer (HNC) undergo ablative and free flap reconstructive surgery with prolonged postoperative courses. METHODS: A case series with chart review was performed on 50 consecutive patients with HNC undergoing ablative and reconstructive free flap surgery from October 2014 to March 2016 at a tertiary care center. Comorbidities and intraoperative and postoperative variables were collected. Predicted length of stay was tabulated with the NSQIP calculator. RESULTS: Thirty-five patients (70%) were male. The mean (SD) age was 67.2 (13.4) years. The mean (SD) length of stay (LOS) was 13.5 (10.3) days. The mean (SD) NSQIP-predicted LOS was 10.3 (2.2) days (P = .027). DISCUSSION: The NSQIP calculator may be an inadequate predictor for LOS in patients with HNC undergoing free flap surgery. Additional study is necessary to determine the accuracy of this tool in this patient population. IMPLICATIONS FOR PRACTICE: Head and neck surgeons performing free flap reconstructive surgery following tumor ablation may find that the NSQIP risk calculator underestimates the LOS in this population.

Impact of pharyngeal closure technique on fistula after salvage laryngectomy.

IMPORTANCE: No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy. We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge. OBJECTIVE: To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx. DESIGN: Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers. SETTING: Academic, tertiary referral centers. PATIENTS: The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up. MAIN OUTCOMES AND MEASURES: Fistula incidence, severity, and predictors of fistula. RESULTS: Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P < .001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P < .001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25% (P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15% (P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks). CONCLUSIONS AND RELEVANCE: Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.

Oropharyngeal reconstruction using the supraclavicular artery island flap: a new flap alternative.

UNLABELLED: Oropharyngeal reconstruction following head and neck oncologic resection has utilized local, regional, and free tissue transfer flap options. The modality utilized is often guided by the type of defect created as well as the surgeon's preference. In this article, the authors introduce the application of the supraclavicular artery island flap as a reconstructive modality following oropharyngeal oncologic ablation. Five patients underwent head and neck oncologic resection for oropharyngeal squamous cell carcinoma followed by single-stage reconstruction with an ipsilateral supraclavicular artery island flap. There were no flap failures and only one postoperative complication consisting of a postoperative oral-cutaneous fistula that resolved without surgical intervention. There were no donor-site complications. The supraclavicular artery island flap is a viable alternative for oropharyngeal reconstruction following head and neck oncologic resection. It is a regional flap that can be harvested without microsurgical expertise and yields reliable postoperative results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Combined mycophenolate mofetil and prednisone therapy in tamoxifen- and prednisone-resistant Reidel's thyroiditis.

BACKGROUND: Mycophenolate mofetil is a recently identified therapy for disorders associated with systemic fibrosis, but has never been reported in the treatment of Reidel's thyroiditis. We report the first case of Reidel's thyroiditis that became resectable after treatment with mycophenolate and prednisone. SUMMARY: A 27-year-old woman presented to an outside hospital with thyromegaly associated with compressive symptoms. The patient underwent a neck exploration with thyroid biopsy that revealed evidence of fibrosing variant Hashimoto's thyroiditis. The patient was then treated with tamoxifen and prednisone at an outside hospital without resolution. After initial evaluation she underwent an open thyroid wedge biopsy that revealed Reidel's thyroiditis. She was subsequently treated with both 1 g mycophenolate twice daily and 100 mg prednisone daily. The patient experienced immediate subjective improvement of compressive symptoms and objective decrease in mass size at 30 days, as seen by serial computed tomography examination. By 90 days of therapy the mass had decreased to a size small enough to allow subtotal thyroidectomy, which was completed over two staged procedures. CONCLUSIONS: Reidel's thyroiditis remains a primarily surgical disease. Patients who are not surgical candidates have been treated with tamoxifen and prednisone with equivocal results. Our report is the first to suggest the combination of mycophenolate and prednisone as a viable treatment option for patients with Reidel's thyroiditis.

CyberKnife stereotactic radiosurgery for recurrent squamous cell carcinoma of the head and neck following salvage surgery with close or positive margins.

Squamous cell carcinoma of the head and neck (SCCHN) has traditionally been treated with a combination of surgery, chemotherapy, and external beam radiotherapy. While cure is generally the goal of these therapeutic modalities, recurrence is an unfortunately common outcome. Salvage surgery often results in close or positive surgical margins and the patient is at high risk for recurrence. Cyberknife stereotactic radiosurgery is a novel treatment that may benefit this subset of patients. This targeted treatment has shown promise in improving local control rates of tumors at multiple sites; however, the data for recurrent SCCHN is limited. In this case series, we present our experience with Cyberknife therapy in SCCHN patients who have undergone salvage surgery with close or positive margins.

Mixed medullary-papillary carcinoma of the thyroid: a case report.

With fewer than 40 cases described in the otolaryngology literature, mixed medullary papillary thyroid carcinoma represents a rare but phenotypically distinct tumor. While isolated medullary carcinoma may be admixed with normal follicular structures, true mixed carcinoma displays morphological and immunological characteristics of medullary and papillary carcinoma within a single lesion. We report the case of a 73-year old woman initially evaluated for a multinodular thyroid goiter. The patient denied a family history of medullary thyroid carcinoma or other endocrine neoplasms. Fine needle aspiration of a nodule of the thyroid isthmus suggested a follicular neoplasm with abundant Hurthle cells and colloid present. Considering these findings, the patient underwent a left thyroid lobectomy with isthmusectomy. Histopathological analysis of the surgical specimen revealed a medullary thyroid carcinoma measuring 0.4 cm in size. Within this lesion, a distinct focus of papillary thyroid carcinoma, follicular variant, measuring 0.1 cm was also identified. Mixed medullary-papillary thyroid carcinoma is a rare clinical entity but merits consideration in the differential diagnosis of thyroid nodules particularly in patients with a family history of thyroid malignancy. The foundation of treatment of this lesion is total thyroidectomy with central compartment node dissection in the clinically N0 neck and dissection of levels II-VII in the node-positive neck.

Synaptic and morphologic properties in vitro of premotor rat nucleus tractus solitarius neurons labeled transneuronally from the stomach.

Neurons in the rat nucleus tractus solitarius (NTS) possess morphologic characteristics that have been correlated with the type of synaptic information they receive. These features have been described for viscerosensory neurons but not for premotor NTS neurons. The morphologic and synaptic features of neurons in the rat caudal NTS were assessed using whole-cell patch-clamp recordings and biocytin labeling in brainstem slices. Gastric-related premotor NTS neurons were identified for recording after inoculation of the stomach wall with a transneuronal retrograde viral label that reports enhanced green fluorescent protein. Three morphologic groups of NTS neurons were identified based on quantitative aspects of soma area and proximal dendritic arborization, measures that were consistent across slice recordings. The most common type of cell (group I) had relatively small somata and one to three sparsely branching dendrites, whereas the other groups had larger somata and more than three dendrites, which branched predominantly close to (group II) or distant from (group III) the soma. Voltage-clamp recordings revealed spontaneous excitatory and inhibitory postsynaptic currents in all neurons, regardless of morphology. Gastric-related premotor NTS neurons composed two of the three morphologic types (i.e., groups I and II). Compared with unlabeled neurons, these cells were less likely to receive constant-latency synaptic input from the tractus solitarius. These results refute the hypothesis that general patterns of synaptic input to NTS neurons depend on morphology. Gastric premotor neurons comprise a subset of NTS morphologic types, the organization of the viscerosensory input to which has yet to be defined.