Secondary free tissue transfer in head and neck reconstruction.

BACKGROUND: The incidence of head and neck cancer (H&N) continues to increase together with the need for reconstructive surgery. Head and Neck microsurgeons are likely to encounter challenging secondary free flap surgery on the background of failed primary flaps, radiotherapy treatment or recurrence. The aim of this study was to review our experience of treating such cases in a tertiary referral centre in the United Kingdom. METHODS: We performed a retrospective analysis of all patients undergoing sequential free flap surgery for head and neck defects in our unit during 2010-2017. Parameters recorded included indication for surgery, type and sequence of reconstruction, recipient vessel use and post-operative complications. RESULTS: We identified 17 patients who underwent 39 free tissue transfers for the reconstruction of head and neck defects (five transfers were performed at other units). The radial forearm and anterolateral thigh flaps were most commonly used. Almost a quarter of patients underwent three or more free flap reconstructive procedures. In over a third, the same vein and artery were used for subsequent anastomoses, and we used five vein grafts over 68 anastomoses. There were no flap failures recorded. CONCLUSIONS: Secondary free flaps in the head and neck are required for a variety of aetiologies and can have success rates similar to those for primary free tissue transfers with minimal morbidity and mortality. Free tissue transfer is the best reconstructive option in H&N patients and should still be considered the first choice option in salvage cases until the patient's donor sites have been depleted.

Ramsay Hunt syndrome with cranial polyneuropathy with features of supraglottitis.

A 67-year-old woman presented with a 1-week history of left otalgia and a 1-day history of odynophagia, pain extending into the face and neck, and a productive cough. Flexible nasendoscopy showed features of supraglottitis, with swollen arytenoids and pooling of saliva in the piriform fossae. Laboratory investigations revealed a mildly raised C reactive protein. A CT scan of the neck supported the diagnosis of supraglottitis and pharyngitis, with thickening of the mucosa of the left piriform fossae and left oropharynx. Standard supraglottitis treatment was instigated, but on day 4 of the admission, a vesicular rash and features of cranial nerve involvement (V, VII, VIII, X) developed. A revised diagnosis of Ramsay Hunt syndrome with cranial polyneuropathy was made and later confirmed by varicella zoster virus PCR. After 4 weeks, facial nerve function normalised, but features of other cranial nerve palsies were persistent.

Do salivary bypass tubes lower the incidence of pharyngocutaneous fistula following total laryngectomy? A retrospective analysis of predictive factors using multivariate analysis.

Salivary bypass tubes (SBT) are increasingly used to prevent pharyngocutaneous fistula (PCF) following laryngectomy and pharyngolaryngectomy. There is minimal evidence as to their efficacy and literature is limited. The aim of the study was to determine if SBT prevent PCF. The study was a multicentre retrospective case control series (level of evidence 3b). Patients who underwent laryngectomy or pharyngolaryngectomy for cancer or following cancer treatment between 2011 and 2014 were included in the study. The primary outcome was development of a PCF. Other variables recorded were age, sex, prior radiotherapy or chemoradiotherapy, prior tracheostomy, type of procedure, concurrent neck dissection, use of flap reconstruction, use of prophylactic antibiotics, the suture material used for the anastomosis, tumour T stage, histological margins, day one post-operative haemoglobin and whether a salivary bypass tube was used. Univariate and multivariate analysis were performed. A total of 199 patients were included and 24 received salivary bypass tubes. Fistula rates were 8.3% in the SBT group (2/24) and 24.6% in the control group (43/175). This was not statistically significant on univariate (p value 0.115) or multivariate analysis (p value 0.076). In addition, no other co-variables were found to be significant. No group has proven a benefit of salivary bypass tubes on multivariate analysis. The study was limited by a small case group, variations in tube duration and subjects given a tube may have been identified as high risk of fistula. Further prospective studies are warranted prior to recommendation of salivary bypass tubes following laryngectomy.

Endoscopic resection of a giant fibrovascular polyp of the oesophagus with the assistance of ultrasonic shears.

Giant fibrovascular polyps of the oesophagus are rare benign tumours originating from the upper oesophagus. A 58-year-old woman presented with a 6-week history of a sore throat, odynophagia and progressive dysphagia, managing only a soft diet. CT of the neck and thorax, and barium swallow, both demonstrated a giant fibrovascular polyp measuring approximately 7 cm in length arising from the proximal oesophagus. The patient underwent endoscopic resection of the polyp with the assistance of ultrasonic shears. We present the case of a giant fibrovascular polyp and describe our novel technique for successful endoscopic resection using ultrasonic shears.

Papillary thyroid carcinoma nodal surgery directed by a preoperative radiographic map utilizing CT scan and ultrasound in all primary and reoperative patients.

BACKGROUND: To study the diagnostic accuracy of physical examination (PE), ultrasonography (US), contrastenhanced computed tomography (CT) and in preoperative detection of macroscopic nodal metastasis in primary/recurrent papillary thyroid carcinoma (PTC) patients to determine if the routine addition of CT would be beneficial in accurate preoperative lymph-node surgery planning. METHODS: In a tertiary center prospective study, 162 PTC patients underwent preoperative lymph-node evaluation by PE, US, and CT. Sensitivity, specificity, positive/negative predictive value (PPV/NPV) of each nodal detection technique were calculated in central/lateral cervical compartments. The gold standard for diagnostic-accuracy was surgical pathology. RESULTS: In patients undergoing primary (Group I)/revision (Group II) surgical treatment for PTC, combined US/CT yielded significantly higher sensitivity for macroscopic lymph-node detection in both lateral and central neck, most marked in Group I-central compartment. CONCLUSIONS: Combined preoperative US/CT provides reliable, objective, preoperative macroscopic nodal metastasis map to design rational nodal surgery in primary/revision PTC patients.

Orbital floor abscess secondary to sinusitis in an immunocompromised patient.

A 65-year-old man with a history of renal transplantation presented with facial pain, purulent nasal discharge, and periorbital swelling. Signs of optic nerve compromise developed and persisted despite medial orbital wall decompression. Further imaging revealed an orbital floor abscess secondary to direct communication of a maxillary pseudomonal sinusitis. Full recovery was achieved after further surgical drainage via an endoscopic endonasal approach. Failure to improve after surgical decompression is an indication for repeat imaging. Immunocompromised patients can present atypically. Orbital floor abscess secondary to sinusitis without an underlying odontogenic or traumatic cause has not previously been reported. The authors highlight the importance of clinical vigilance, serial imaging, microbiological investigations, and early surgical intervention in high-risk patients.

Endoscopic airway management of laryngeal sarcoidosis.

OBJECTIVE: To report the results of treating laryngeal sarcoidosis with intralesional steroids and minimally invasive laser surgery. Sarcoidosis is a rare multisystem inflammatory disorder of unknown cause. Laryngeal involvement is extremely rare, and its optimal management remains controversial. DESIGN: Retrospective medical chart review. Settings Tertiary care center/national referral airway reconstruction center. PATIENTS: Ten consecutive patients treated for laryngeal sarcoidosis between 2004 and 2008. MAIN OUTCOME MEASURES: Demographic and clinical information including extralaryngeal manifestations obtained from patient records, laryngeal anatomic subsite manifestation of disease, intraoperative findings, and scores from the Medical Research Council (MRC) dyspnea outcome assessment instrument (which was administered preoperatively, at the first postoperative outpatient visit 4-6 weeks later, and at last follow-up). RESULTS: The patients included 9 women and 1 man, a total of 2.8% of the unit's adult surgical airway case mix (10 of 353). Mean (SD) age at presentation was 37 (17) years. All patients presented with dyspnea and dysphonia; 2 required emergency tracheostomy prior to treatment. Six patients presented with isolated laryngeal sarcoid. Supraglottis and arytenoids were affected in all patients. The median number of endoscopic treatments was 2 (range, 1-4). Significant improvement in MRC dyspnea grading was found postoperatively (P < .05), and patients with tracheostomy were successfully decannulated. The mean (SD) follow-up time was 24 (18) months. There were no adverse effects of surgery. Nine patients had a substantial dose reduction or discontinuation of their systemic corticosteroid therapy following endoscopic treatment. CONCLUSIONS: Minimally invasive endoscopic surgery with intralesional corticosteroid injection and laser reduction is an effective method of controlling laryngeal sarcoid. It improves symptoms immediately with minimal morbidity and, most importantly, reduces the need for systemic steroid administration in most patients. This study supports early recognition and endoscopic intervention in the management of laryngeal sarcoidosis.

Balloon Sinuplasty: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis.

More than 100 million patients worldwide suffer from chronic rhinosinusitis, and a considerable amount of money has been spent on research and treatments by healthcare providers. In the northern hemisphere, damp, temperate climates, along with higher concentrations of pollen, are associated with a higher prevalence of chronic rhinosinusitis. Owing to its persistent nature, the disease can become a significant cause of morbidity. If untreated, it can reduce quality of life and productivity. When medical treatment is not effective, surgery may offer an excellent outcome. Although functional endoscopic surgery has proven to be effective, many cases could be managed medically. Recent research has suggested that optimal medical treatment is as effective as surgery in patients with chronic rhinosinusitis at the end of 1 year. Balloon Sinuplasty (Acclarent, Inc., CA, USA) is a new technique in the management of sinusitis and is a hotly debated topic. It is a delicate, minimally invasive tool, and early research demonstrates promising outcomes in terms of safety and effectiveness. This novel technique has been approved by the US FDA. Recently, NICE raised no concerns regarding its safety and efficacy but will continue to review this procedure.

Securing tracheal stents: a new and simple method.

Indwelling silastic stents have been used in the subglottis and upper trachea to manage laryngotracheal abnormalities. A number of methods of fixation have been described. The authors describe a quick and simple method of fixing endoluminal tracheal stents using a single suture.