End-to-patch anastomosis for microvascular transfer of free flaps with small pedicle.

BACKGROUND: Although perforator-to-perforator anastomosis in supermicrosurgery may be used in transferring free flaps with small vessels, it is still difficult in certain situations that include potentially infected wounds. Moreover, it is limited to smaller flaps. Anastomosis of large vessels is still safer for transfer of a large flap for most surgeons. The harvesting of a patch of the parent artery together with the perforator supplying the flap allows the surgeon to perform an anastomosis between the vessel ends of larger caliber, and possibly with greater anastomotic success. METHOD: When the vascular pedicle of a free flap is < 0.8 mm, an option is to take a cuff of the major artery for an end-to-patch anastomosis. From 1983 to 2013, this method was applied to the anteromedial thigh (AMT) flap (seven cases), the groin flap (81 cases), and the free Becker's flap (five cases). When a patch was taken from the femoral artery, direct anastomosis for the major artery was performed using 5/0 Prolene sutures, followed by coverage with local soft tissue. When a patch was taken from the ulnar artery, a patch of vein graft was used for repair of the ulnar artery. In one case, a segment of the femoral artery was harvested with an AMT flap and a segment of a sartorius muscle flap; the compound tissue was transferred to the neck with the femoral artery to replace the left carotid artery. In the donor site, the defect of the femoral artery was reconstructed with an artificial graft. RESULTS: The flaps had no failure or partial necrosis, but one patient developed bleeding from the femoral artery 2 days postoperatively. It was treated by adding one more suture for the femoral artery and coverage with the sartorius muscle. In the ulnar artery, the patients did not complain of cold intolerance and the postoperative angiogram showed good patency of the ulnar artery after an average follow-up of 1 year. CONCLUSION: For the majority of plastic surgeons, this method provides a reliable and comfortable anastomosis when transferring a flap with small vessels. The only concern is to repair the donor artery carefully and ensure coverage of the repair site with local tissue.

Early results of robotic assisted nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: Minimally invasive nasopharyngectomy with the da Vinci surgical robot has been shown to be a feasible operation for salvage of recurrent nasopharyngeal carcinoma. The current case series presents the early results of robotic nasopharyngectomy. METHODS: We conducted a prospective series of patients who underwent robotic nasopharyngectomy for recurrent nasopharyngeal carcinoma in a single institution. RESULTS: Twelve patients underwent robotic nasopharyngectomy. The median operating time was 225 minutes. Median follow-up time was 23.8 months. Nine patients had clear resection margins, 2 patients had close margins, and 1 patient had positive margin. Two patients developed local recurrence and 1 patient had distant metastasis. Two patients in the cohort died of unrelated causes. The 2-year local control rate was 86%. The 2-year overall survival and disease-free survival was 83% and 61%, respectively. CONCLUSION: Early results of robotic nasopharyngectomy showed a high local control rate. The operating time was comparable to open surgery and morbidities were low.

Stenting of the eustachian tube to prevent otitis media with effusion after maxillary swing approach nasopharyngectomy.

OBJECTIVES/HYPOTHESIS: Our previous report recommended that the management of ipsilateral otitis media with effusion (OME) after maxillary swing nasopharyngectomy was observation. The idea of introducing a stent into the eustachian tube (ET) at the nasopharyngeal side after nasopharyngectomy may prevent postoperative OME. The purpose of this study was to examine the feasibility of intraoperative ET stenting and the efficacy of preventing ipsilateral OME formation. STUDY DESIGN: Prospective cohort study. METHODS: From 2009 to 2011, 28 patients with nasopharyngectomy via the maxillary swing approach were recruited. Patients with curative resection were recruited (n = 21). ET stenting was performed intraoperatively using a 16-gauge Angiocath (BD Medical Systems, Franklin Lakes, NJ) with dimensions of 1.7 mm × 30 mm. The stent stays inplace indefinitely. The otologic status was evaluated using otoscopy, pure-tone audiogram, and tympanogram at 3 months, 6 months, and 1 year after the surgery. The outcomes were analyzed and compared with historical control. RESULTS: There were 9 (43%) patients with no OME at 6 months after surgery, and 15 (71%) patients had no OME at 1 year postoperatively. The results were statistically significant (P < .0001) when compared with our historical control of no ET stenting. There was no incidence of adverse effects of the stenting, such as acute otitis media, dislodgement of the stent, otalgia, and nasal pain. CONCLUSIONS: ET stenting was feasible after nasopharyngectomy. ET stenting prevented a significant number of patients from suffering from ipsilateral OME and alleviated the symptoms of unilateral aural fullness and unilateral conductive hearing impairment up to at least 1 year after the surgery. ET stenting is recommended in all patients after maxillary swing nasopharyngectomy.

The role of myringotomy and ventilation tube insertion in maxillary swing approach nasopharyngectomy: review of our 10-year experience.

OBJECTIVES/HYPOTHESIS: The use of myringotomy with ventilation tube insertion after maxillary swing nasopharyngectomy was originally described to prevent the occurrence of otitis media with effusion. The outcome of this otologic procedure has never been reviewed and discussed. The purpose of this study is to examine the role of myringotomy with ventilation tube insertion in this group of patients. STUDY DESIGN: Retrospective review. METHODS: One hundred forty-two patients with maxillary swing nasopharyngectomy were recruited from 1999 to 2008. The otologic status was evaluated using otoscopy, pure tone audiogram, and tympanogram at 3 months, 6 months, and then yearly after the operation. The results were reviewed periodically during that 10-year period. During this period, there were three groups; the first group had myringotomy with ventilation tube inserted, the second group had myringotomy alone, and the third group had no myringotomy performed. RESULTS: There were significantly (P < .0001) more patients in the myringotomy with ventilation tube insertion group who suffered from adverse otologic complications such as discharging grommet, discharging chronic suppurative otitis media, and perforated eardrum when compared with patients with myringotomy alone and patients without myringotomy at 3 months, 6 months, and 12 months. There were no differences in the incidence of acute otitis media among all three groups of patients. CONCLUSIONS: Patients who underwent maxillary swing nasopharyngectomy and myringotomy with ventilation tube insertions suffered from more otologic complications. The routine use of myringotomy with or without ventilation tube insertion for this group of patients is not recommended.

Secondary head and neck cancer in patients with history of hematological malignancy.

BACKGROUND: Head and neck cancer is a common second cancer in patients with a history of hematological malignancies. The purpose of this study was present the clinical characteristics and treatment outcomes of this group of patients. METHODS: A retrospective analysis was conducted of all patients who had a history of hematological malignancy and developed head and neck cancer in a 10-year period. RESULTS: The cohort had 10 patients; median age was 45.8 years. Most patients were nonsmokers and nondrinkers. Seven patients had chronic graft-versus-host disease. The median interval between the completion of treatment of hematological malignancy and the development of head and neck cancers was 8.79 years (range, 2.33-26.83 years). Six patients were alive and disease-free, 3 developed local recurrence, and 3 had metachronous head and neck cancers. CONCLUSION: The risk factors and etiology of head and neck cancers in patients with hematological malignancy may be different from the ordinary population.

Long-term hearing results and otological complications of nasopharyngeal carcinoma patients: comparison between treatment with conventional two-dimensional radiotherapy and intensity-modulated radiotherapy.

OBJECTIVE: To assess the long-term audiological outcome and otological complications of nasopharyngeal carcinoma patients who have received intensity-modulated radiotherapy (IMRT) versus conventional two-dimensional radiotherapy (2 DRT). STUDY DESIGN: Prospective study on the audiological outcome and otological complications 5-9 years after radiotherapy. METHODOLOGY: Patients had pure-tone audiogram before radiotherapy and 5 years after radiotherapy. Otological examination was performed 5-9 years after radiotherapy by an otolaryngologist. RESULTS: There is a significant deterioration of the hearing threshold 5 years after radiotherapy but there is no statistically significant difference in the deterioration of hearing between IMRT and 2 DRT. Six patients in the 2 DRT group and 1 patient in the IMRT group had osteoradionecrosis of the external auditory canal (p = 0.042). CONCLUSION: There are fewer incidences of osteoradionecrosis of the external auditory canal in patients treated with IMRT. There is no difference in bone conduction threshold in patients treated with IMRT or 2 DRT.

Prediction of surgical outcome using plasma Epstein-Barr virus dna and (18)F-FDG PET-CT scan in recurrent nasopharyngeal carcinoma.

BACKGROUND: This study was carried out to determine the role of plasma Epstein-Barr virus (pEBV)-DNA and positron-emission tomography (PET)-CT scan in predicting the outcome of nasopharyngectomy and cervical lymphadenectomy for recurrent nasopharyngeal carcinoma (NPC). METHODS: Between 2007 and 2009, we recruited patients who had local or regional recurrent NPC after radiotherapy. The relationship between preoperative pEBV-DNA level, maximal standard uptake value (SUVmax), and surgical outcome was analyzed. RESULTS: Forty-two patients had local tumor recurrence. Their median pEBV-DNA level and SUVmax were 348 copies and 4.7, respectively. Both values were significantly lower than those with palliative nasopharyngectomy. Twenty-two patients had regional failure. Their mean pEBV-DNA level and tumor SUVmax were 626 copies and 7.6, respectively. The metastatic lymph nodes with extracapsular spread had a significantly higher mean SUVmax. CONCLUSIONS: Preoperative pEBV-DNA and PET-CT predict the surgical outcome of nasopharyngectomy for recurrent NPC. Similarly, PET-CT scan predicts the presence of extracapsular spread of metastatic lymph nodes. These patients may warrant further postoperative adjuvant therapy.

Efficacy of neck dissection for locoregional failures versus isolated nodal failures in nasopharyngeal carcinoma.

BACKGROUND: Neck dissection has been shown to be effective in controlling nodal failures in nasopharyngeal carcinoma. Its efficacy in controlling the disease in patients with synchronous locoregional failure is, however, not documented. METHOD: A retrospective review of all patients who underwent neck dissection for nodal failures with or without treated local failure within 6 months was conducted for this study. The survivals of these 2 groups of patients were analyzed. RESULTS: The 5-year overall survival of the whole cohort was 58%. There was no difference in 5-year disease specific survival (68% vs 40%; p = .121) and 5-year progression free survival (44% vs 36%; p = .334) when comparing patients with isolated nodal failures and synchronous locoregional failures. Multivariate analysis showed that only the initial N classification affects survival. CONCLUSION: Neck dissection is efficacious in patients with nasopharyngeal carcinoma with nodal failure, with or without synchronous local failures.

Natural course and tumor doubling time of nasopharyngeal carcinoma. A study of 15 patients.

Nasopharyngeal carcinoma (NPC) is a non-lymphomatous carcinoma that develops in the epithelial lining of the nasopharynx. The knowledge of natural course of tumor progression has been based on anatomical model without clinical correlation. This study is the first to describe and analyze the natural progression of NPC based on clinical information and calculate the tumor growth rate of NPC. Fifteen NPC patients who refused treatment after initial work-up and then subsequent re-presentation at a later time were recruited during the period from January 2003 to August 2009. Clinical data were analyzed and CT scans were used to calculate the tumor volumes. The time interval between the first planning CT image and the subsequent planning CT image was used to calculate the rate of tumor growth in this group of patients. The tumor volume doubling time can be calculated by using the formula DT=tln2/(lnV2-lnV1), where t is the time interval between measurements and V(2) and V(1) are the tumor volumes at the end and beginning of the time interval, respectively. Cranial nerves palsies such as diplopia and systemic upset were the most common reason for re-presentation and the consent for treatment. The median growth rate was 1.63mm(3) per day and the median tumor doubling time was 279days. This study is the first report in the literature looking at the natural progression of nasopharyngeal carcinoma (NPC) based on clinical information. The current study showed that NPC has a propensity to grow superiorly to involve the skull base rather than laterally or anteriorly. Although the tumor growth rate was very variable, the median natural NPC growth rate was 1.63mm(3)/day.

Is virtual endoscopy of the middle ear useful?

Virtual endoscopy is a relatively new imaging technology in otology, and therefore data on its efficacy in clinical situations are limited. We conducted a prospective study to evaluate the clinical relevance of radiologic diagnoses based on virtual endoscopy of the middle ear. Our patient population was made up of 30 adults who were scheduled to undergo surgery to correct conductive hearing loss of unknown etiology. Virtual endoscopy was performed on three-dimensional images that were constructed from images obtained with conventional two-dimensional computed tomography (CT). Findings on virtual endoscopy were then compared with the subsequent surgical findings. Virtual endoscopy suggested a middle ear pathology in 19 patients and a normal middle ear in 11 patients. Postoperatively, we found that the virtual diagnoses correlated moderately well with the surgical findings in the group of patients with predicted pathology; 13 of these 19 patients were found to have middle ear problems such as ossicular chain anomalies, otosclerosis, and cholesteatoma (positive predictive value: 68%). However, among the 11 patients whose middle ear structures were radiologically predicted to be normal, only 2 had negative middle ear findings on surgical exploration; of the remaining 9 patients, 8 had otosclerosis and 1 had malleus fixation (negative predictive value: 18%). Thus, the sensitivity and specificity of virtual endoscopy were 59 and 25%, respectively. Virtual endoscopy provides images from a surgeon's perspective, and so it has the potential to be useful in the preoperative evaluation of the middle ear cavity. With ongoing advancements in computer systems and imaging techniques, the cost, reliability, and efficacy of virtual endoscopy may improve. However, further clinical validation and cost-benefit analysis are required before we can determine if it has any additional advantages over conventional two-dimensional CT.

Second primary squamous cell carcinoma arising in the skin of a pectoralis major myocutaneous flap 12 years after floor of mouth reconstruction.

Second primary squamous cell carcinoma (SCC) in the skin of a flap used for reconstruction of floor of mouth is rare. A case of SCC arising in the pectoralis major myocutaneous flap that was used to reconstruct the floor of mouth 12 years after subtotal glossectomy and resection of the floor of mouth is reported. The tumour is a second primary SCC arises in the skin of a myocutaneous flap without any obvious risk factors. Review of the literature reveals four previous similar reports and the findings are summarized. In summary, squamous epithelium of the skin flap after prolonged exposure to non-physiological stimuli may lead to metaplasia and possible carcinoma formation. Long-term follow up and awareness of this complication are needed for head and neck cancer patients after resection and reconstruction.

Ultrasonographic screening for occult thyroid cancer.

BACKGROUND: It has been shown that occult thyroid carcinoma can be identified in about 10% of thyroid glands in autopsy. The purpose of this study was to evaluate the prevalence of asymptomatic thyroid carcinoma in the Hong Kong Chinese population by ultrasonographic screening. METHODS: Volunteer subjects without symptoms of thyroid disease were recruited for ultrasonographic screening for thyroid cancer. A total of 1140 subjects were recruited in this study. RESULTS: Thyroid nodules were found in 45% subjects (511 of 1140); the mean age was 48 years. Ultrasonographic-guided aspiration cytology was performed in 258 subjects. Twenty-six subjects (2.3%) had cytologic findings suspicious of malignancy. Fourteen subjects (1.2%) had pathologic diagnosis of thyroid cancer, including 13 papillary carcinomas and 1 follicular carcinoma. CONCLUSION: A high incidence of occult thyroid cancer could be identified on ultrasonographic screening. Subjects could benefit with early diagnosis with either early intervention or close monitoring.

Prospective randomized study of selective neck dissection versus observation for N0 neck of early tongue carcinoma.

BACKGROUND: There are controversies on the benefits of elective neck dissection (END) for oral tongue carcinoma. METHOD: This is a prospective randomized study of elective selective I, II, III neck dissection versus observation for N0 neck of stage I to II oral tongue carcinoma. There were 35 patients on the observation arm and 36 patients on the END arm. The main outcome assessment parameters are node-related mortality and disease-specific survival rate. RESULTS: There were 11 patients in the observed arm and 2 patients in the END arm who developed nodal recurrence alone without associated local or distant recurrence. All 13 patients were salvaged, and no patient died of nodal recurrence. The 5-year disease-specific survival rate was 87% for the observation arm and was 89% for the END arm; the 2% difference was not significant. CONCLUSION: Observation may be an acceptable alternative to END if strict adherence to a cancer surveillance protocol is followed.

Identification of pyruvate kinase type M2 as potential oncoprotein in squamous cell carcinoma of tongue through microRNA profiling.

MicroRNAs (miRNAs) are noncoding RNAs with specific regulatory role in gene expression. Recent reports suggested their involvement in human malignancies. Currently, there is no information concerning miRNA expression and functions in squamous cell carcinoma (SCC) of tongue. In this study, we evaluated the expression patterns of 156 mature miRNAs in tongue SCC using Taqman-based microRNA assays. Of these 156 miRNAs, miR-133a and miR-133b were significantly reduced in tongue SCC cells in comparison with the paired normal epithelial cells. Tongue SCC cell lines transfected with miR-133a and miR-133b precursors displayed reduction in proliferation rate. In addition, the number of apoptotic cells was increased in response to the introduction of precursors. Computational target gene prediction suggested that both miR-133a and miR-133b are targeting transcript of pyruvate kinase type M2 (PKM2), a potential oncogene in solid cancers. In tongue SCC cell lines, PKM2 expression was reduced in response to miR-133a and miR-133b precursors transfection. Immunohistochemical staining results of tongue SCC tissues suggested that PKM2 was overexpressed in tongue SCC and was associated with the downregulation of miR-133a and miR-133b. Our results suggested that aberrant reduction of miR-133a and miR-133b was associated with the dysregulation of PKM2 in SCC of tongue.

Ear surgery in infants under one year of age: its risks and implications for cochlear implant surgery.

OBJECTIVE: Neonatal hearing screening programs allow early identification of infants with congenital severe hearing impairment. Increasing evidence suggests that early cochlear implantation (CI) facilitates auditory rehabilitation and bilateral implantation exceeds the benefit of unilateral CI fitting. Elective surgery before the age of 12 months has, therefore, become increasingly popular. A team approach between the surgeon and the anesthesia team is required to guarantee the safety for the patient. The implanting surgeon should also be aware of the special constraints relevant at this age group. STUDY DESIGN: Our personal experience at a tertiary children's hospital and a review of the German and English literature published on this subject between 1980 and 2007. SETTING: Tertiary referral otology and skull base center with affiliated children's hospital. PATIENTS: Patients younger than 1 year of age undergoing CI surgeries were analyzed concerning surgical techniques, and anesthesiological aspects of elective surgeries in small infants were evaluated. INTERVENTIONS AND OUTCOME MEASURES: The main focus was on CI surgeries in very young infants. Risk factors involving the surgical planning, intervention, and perioperative anesthesia care were evaluated. RESULTS: The age of the patient and the pediatric experience of the anesthesiologist, but not the duration of the surgery, are relevant risk factors. This review article is intended to highlight the surgical and anesthesiological considerations when performing CI surgery in very young infants and anticipates familiarizing the implanting surgeon with important aspects of hemostasis, pharmacokinetics, and cardiopulmonary reserves in small pediatric patients. CONCLUSION: Elective ear surgery in infants below 1 year of age should be performed in institutions where a continuous experience with this type of patient exists and all the facilities of pediatric perioperative anesthesia care are readily available.

Thyroid dysfunction in laryngectomees-10 years after treatment.

BACKGROUND: Hypothyroidism is 1 of the complications that follow treatment of various head and neck cancers. In the literature, reviews using different primary sites and differences in treatment modalities make comparison of post-treatment hypothyroidism not possible. The objective of this study was to evaluate the incidence of hypothyroidism in a homogenous group of patients who were treated with total laryngectomy and irradiation for laryngeal carcinoma and to assess the importance of different variables in the occurrence of hypothyroidism. METHODS: A retrospective review of 147 total laryngectomy patients between 1993 and 2003 was carried out. Serum thyroxine level and free T4 levels were assessed in all patients. Hypothyroidism was classified as subclinical (increased thyroid-stimulating hormone and normal free T4 levels) and clinical (increased thyroid-stimulating hormone and decreased free T4 levels). RESULTS: The results showed that the overall incidence of hypothyroidism was 49% (44% subclinical and 5% clinical). Hemithyroidectomy and advanced tumor staging were risk factors for the development of hypothyroidism in these patients (p < .05) with a relative risk of 2.1 (CI 95%, 1.4-3.1) and 1.3 (CI 95%, 1.1-1.6), respectively. During follow-up, 19.9% of patients developed hypothyroidism at 3 years, 38.6% at 6 years; at 10 year follow-up, 93.3% of them had hypothyroidism. CONCLUSIONS: In conclusion, hypothyroidism is a frequent complication in patients treated with radiotherapy and total laryngectomy for laryngeal cancer, especially when treatment includes hemithyroidectomy. These patients should have their thyroid function evaluated periodically even 10 years after treatment.

Preoperative measurement of tumor thickness of oral tongue carcinoma with intraoral ultrasonography.

BACKGROUND: Tumor thickness of oral tongue carcinoma is an important independent prognostic factor for local recurrence, subclinical nodal metastasis, and survival. An accurate preoperative assessment of tumor thickness is therefore essential in optimizing treatment algorithm. The present study aims at evaluating the accuracy of intraoral ultrasonography in preoperative measurement of tumor thickness. METHODS: Forty-five patients with oral tongue carcinoma had intraoral ultrasonography to document tumor thickness using a 7.5 MHz right angle probe. The ultrasonic tumor thickness was correlated with the fresh unpreserved surgical specimen pathologic tumor thickness. RESULTS: Ultrasonic tumor thickness had significant correlation with pathologic tumor thickness. The accuracies of ultrasonic measurement of tumor thickness in staging of tumor thickness at cutoff values between 3 and 15 mm were above 91%. CONCLUSION: Intraoral ultrasonography had satisfactory accuracy in the measurement of tumor thickness and is a useful adjunct in assisting pretreatment staging and prognosis evaluation of oral tongue carcinoma.