Role of Infrared Thermography in Planning and Monitoring of Head and Neck Microvascular Flap Reconstruction.

Background: Reconstruction using microvascular free flaps has become the standard of care in head and neck cancer surgery, and their success lies in appropriate planning, adequate revascularization, and early detection of flap compromise so that prompt salvage is possible. This study evaluates the role of infrared thermography in the planning, execution, and postoperative monitoring of microvascular flaps in head and neck reconstructions. Methods: This is a single institutional, prospective observational study conducted at a tertiary care hospital in South India for 13 months. Twenty patients were included, and their thermographic images were captured in the preoperative, intraoperative, and postoperative settings using the infrared camera FLIR T400. These images were analyzed along with the Doppler, and clinical monitoring findings in all the settings and the temperature difference were calculated postoperatively. Results: Hotspot perforator marking was made using infrared camera, and perforator marking was made using hand-held Doppler preoperatively, which correlated in 93% of cases. Intraoperatively, flap rewarming was successfully demonstrated in 19 of 20 cases. Postoperatively, flap compromise was observed on infrared thermography during the first 24 hours but not on clinical monitoring in three cases. The temperature difference values recorded were 5.4°C, 2.4°C, and 4.9°C. The mean of temperature difference of the healthy flaps was 1.0°C (range 0.1°C-1.8°C). Conclusion: Infrared thermography provides simple and reliable imaging, which can be used in perforator marking and flap designing preoperatively and checking the flap perfusion and vascular anastomosis patency intra- and postoperatively.

The folded, bipaddled pectoralis major myocutaneous flap for complex oral cavity defects: Undiminished relevance in the era of free flaps.

Oral cancer often presents at an advanced stage, requiring extensive resection and complex reconstruction, such as free tissue transfers, which may not be available in a remote or resource-constrained facility. The common alternative in these cases is the use of the workhorse flap, the pectoralis major myocutaneous (PMMC) flap for lining and a second regional flap for cover. The results are variable, increase operative time and cost, and may cause additional donor site morbidity. We present a series of patients who underwent reconstruction for complex oral cavity and neck defects with a single PMMC flap with a unique design, folded or bipaddled to serve as both lining and cover. Pre- and post-operative data pertaining to patients with oral cancer who were selected to undergo bipaddled PMMC flap reconstruction in our unit between January 2017 and July 2019 were collected and analysed. Of the 41 patients, 28 were males and 13 were females. The surgical resection involved full-thickness excision of primary tumour and involved skin (face or neck) for oral cancers. The size of skin paddle harvested ranged from 8 to 15 cm horizontally to 6 to 22 cm vertically. Usually, the distal part of the skin paddle formed the mucosal lining and the proximal formed the skin cover. Complication rates in the immediate postoperative period and on initial follow-up visits were comparable to a conventional PMMC flap. Reconstruction of complex head and neck defects requiring mucosal lining and skin cover can be achieved with a single stage, bipaddled PMMC flap, a reliable and easily learnt alternative to technically demanding free tissue transfers. The complication rate observed in our series is remarkably low, even in females. With a proper design of the flap and appropriate orientation of the skin paddle, excellent results can be achieved with a bipaddled PMMC flap.

Role of Ultrasound Acoustic Radiation Force Impulse in Differentiating Benign from Malignant Superficial Lymph Nodes.

OBJECTIVE: The purpose of this study was to evaluate the diagnostic performance of acoustic radiation force impulse (ARFI) imaging in differentiating benign from malignant peripheral lymphadenopathy. MATERIALS AND METHODS: This was a prospective study approved by the Institutional Review Board with financial grant for the same. Ultrasound and ARFI imaging of peripheral lymph nodes were performed and correlated with pathological results, which were used as the reference standard. The virtual touch tissue imaging and virtual touch tissue quantification parameters of ARFI were analyzed in 86 lymph nodes, of which 78 were included in the study. Using receiver operating characteristic curve analysis, the diagnostic usefulness of ARFI values were evaluated with respect to their sensitivity, specificity, and area under the curve. RESULTS: The mean area ratio of benign lymph nodes was 0.88 (±0.2) and that of malignant lymph nodes was 1.17 (±0.14). The mean shear wave velocities (SWV) of benign and malignant lymph nodes were 2.02 m/s (±0.94) and 3.7 m/s (±2.27), respectively. The sensitivity and specificity of virtual touch imaging area ratio in differentiating benign from malignant lymph nodes was 97% and 77%, of SWV was 71% and 70%, and of SWV ratio was 68% and 79%, respectively. CONCLUSION: As ARFI was found to have a superior diagnostic performance over conventional ultrasound and color Doppler in the characterization of lymph nodes, we recommend its routine use in differentiating benign from malignant nodes.

Genomic insights of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) with reduced teicoplanin susceptibility: A case of fatal necrotizing fasciitis.

OBJECTIVES: Glycopeptides are increasingly being used to treat multiresistant methicillin-resistant Staphylococcus aureus (MRSA) infections. Here we report an MRSA isolate with low-level teicoplanin resistance (isolate VB26276) recovered from a patient treated with teicoplanin for fatal necrotizing fasciitis. METHODS: Minimum inhibitory concentrations (MICs) of MRSA isolates to vancomycin and teicoplanin were determined by Etest. Reduced glycopeptide susceptibility was screened by Etest GRD (glycopeptide resistance detection) and population analysis profile (PAP) method. Next-generation sequencing (NGS) was also performed to determine the molecular mechanism of antimicrobial resistance and virulence. RESULTS: The teicoplanin MIC of MRSA isolate VB26276 was 4µg/mL. NGS showed the presence of mutations in the tcaA and tcaB genes of the tcaRAB operon that determines the level of teicoplanin resistance. In addition, a mutation in the vraR gene was found to be associated with teicoplanin resistance, but not with vancomycin heteroresistance. CONCLUSION: Teicoplanin resistance may occur due to point mutations in the teicoplanin resistance operon tcaRAB. Further studies are warranted to determine the contribution of point mutations in tcaRAB to reduced teicoplanin susceptibility.

Predictability of Recurrence using Immunohistochemistry to delineate Surgical Margins in mucosal Head and Neck Squamous Cell Carcinoma (PRISM-HNSCC): study protocol for a prospective, observational and bilateral study in Australia and India.

OBJECTIVES: Treatment failure and poor 5-year survival in mucosal head and neck squamous cell carcinoma (HNSCC) has remained unchanged for decades mainly due to advanced stage of presentation and high rates of recurrence. Incomplete surgical removal of the tumour, attributed to lack of reliable methods to delineate the surgical margins, is a major cause of disease recurrence. The predictability of recurrence using immunohistochemistry (IHC) to delineate surgical margins (PRISM) in mucosal HNSCC study aims to redefine margin status by identifying the true extent of the tumour at the molecular level by performing IHC with molecular markers, eukaryotic initiation factor, eIF4Eand tumour suppressor gene, p53, on the surgical margins and test the use of Lugol's iodine and fluorescence visualisation prior to the wide local excision. This article describes the study protocol at its pre - results stage. METHODS AND ANALYSIS: PRISM-HNSCC is a bilateral observational research being conducted in Darwin, Australia and Vellore, India. Individuals diagnosed with HNSCC will undergo the routine wide local excision of the tumour followed by histopathological assessment. Tumours with clear surgical margins that satisfy the exclusion criteria will be selected for further staining of the margins with eIF4E and p53 antibodies. Results of IHC staining will be correlated with recurrences in an attempt to predict the risk of disease recurrence. Patients in Darwin will undergo intraoperative staining of the lesion with Lugol's iodine and fluorescence visualisation to delineate the excision margins while patients in Vellore will not undertake these tests. The outcomes will be analysed. ETHICS AND DISSEMINATION: The PRISM-HNSCC study was approved by the institutional ethics committees in Darwin (Human Research Ethics Committee 13-2036) and Vellore (Institutional Review Board Min. no. 8967). Outcomes will be disseminated through publications in academic journals and presentations at educational meetings and conferences. It will be presented as dissertation at the Charles Darwin University. We will communicate the study results to both participating sites. Participating sites will communicate results with patients who have indicated an interest in knowing the results. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12616000715471).

Oral Verrucous Carcinoma: Ten Year Experience from a Tertiary Care Hospital in India.

BACKGROUND: Verrucous carcinoma of the oral cavity (OVC) is an uncommon variant of oral squamous cell carcinoma (OSCC). The clinical presentation and surgical outcomes of OVC are unique; however, the management protocols for OVC are largely extrapolated from OSCC. OBJECTIVES: The aim is to study the clinical, histopathological demographics, and outcome of OVC at a tertiary care referral hospital in South India. To study the need for lymph node dissection and the role of adjuvant therapy for close resection margins. MATERIALS AND METHODS: A retrospective review of all patients diagnosed to have OVC between January 2005 and April 2015 was undertaken. Data were collected from hospital records and telephonic interview when possible. RESULTS: Thirty patients were diagnosed to have OVC. The most common site of the presentation was the buccal mucosa. Twenty-three patients had wide local excision of the primary tumor and seven patients had neck dissection as well. None of the patients who underwent neck dissection had node-positive disease pathologically. The margins were considered close in nine patients, only one of these patients received adjuvant radiation therapy; despite among the patients with close resection margins, there was no recurrence or disease-related mortality. Among the thirty patients, there was only one patient who had recurred locally and there was no disease associated mortality. CONCLUSIONS: OVC is a unique variant of OSCC which has a good prognosis. Routine lymphadenectomy can be avoided.

Large retroperitoneal schwannoma mimicking a cystic ovarian mass in a patient with Hansen's disease.

We present a rare case of retroperitoneal cystic schwannoma of the pelvis in a patient with Hansen's disease that mimicked an ovarian cyst. Due to economic constraints and because the lesion was assumed to be of ovarian origin, the patient did not undergo any cross-sectional imaging other than sonography. Sonographically guided fine needle aspiration of the cystic lesion was inconclusive. A cystic schwannoma was diagnosed at laparotomy.