Elective Irradiation of Retropharyngeal Lymph Nodes as an Indication for Adjuvant Radiation Therapy After Transoral Surgery for Tonsil Cancer.

Treatment of squamous cell carcinoma of the tonsil involves primary radiation therapy (RT) or surgical resection. Historically, if RT was the primary or adjuvant treatment modality, most of the bilateral retropharyngeal lymph nodes (RPLNs) were treated electively with a therapeutic dose for subclinical disease, regardless of whether radiographically pathologic lymph nodes were seen on initial diagnostic imaging. De-escalation strategies include the incorporation of transoral surgery with the goal to either eliminate or reduce the dose of adjuvant RT or chemotherapy. Transoral surgery does not include elective removal of the RPLNs, and no guideline or outcome paper recommends adjuvant RT specifically to electively treat RPLNs. In this Topic Discussion, we discuss pertinent literature and suggest management decisions. The management decisions discussed in this Topic Discussion pertain to only tonsillar primaries and not those of the soft palate or base of the tongue.

Utility of Tracheostomy in Patients With COVID-19 and Other Special Considerations.

INTRODUCTION: Patients who become severely ill from coronavirus disease 2019 (COVID-19) have a high likelihood of needing prolonged intubation, making tracheostomy a likely consideration. The infectious nature of COVID-19 poses an additional risk of transmission to healthcare workers that should be taken into consideration. METHODS: We explore current literature and recommendations for tracheostomy in patients with COVID-19 and look back at previous data from severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1), the virus responsible for the SARS outbreak of 2003. RESULTS: Given the severity and clinical uncertainty of patients with COVID-19 and the increased risk of transmission to clinicians, careful consideration should be taken prior to performing tracheostomy. If tracheostomy is performed, we recommend a bedside approach to limit exposure time and number of exposed personnel. Bronchoscopy use with a percutaneous approach should be limited in order to decrease viral exposure. CONCLUSION: Thorough preprocedural planning, use of experienced personnel, enhanced personal protective equipment where available, and a thoughtful anesthesia approach are instrumental in maximizing positive patient outcomes while successfully protecting the safety of healthcare personnel. Laryngoscope, 130:2546-2549, 2020.

Prognostic significance of venous invasion in node-negative head and neck squamous cell carcinoma.

BACKGROUND: Venous invasion (VI) is not frequently evaluated on routine histologic examination of head and neck squamous cell carcinoma (HNSCC), and the prognostic significance is largely unknown. Studies have shown that extramural venous invasion is an adverse prognostic factor in colorectal carcinoma. To our knowledge, this is the first study evaluating the prognostic significance of venous invasion in node-negative (without clinical or pathologic evidence of lymph node involvement) HNSCC, utilizing the elastic stain. METHODS: A total of 105 consecutive lymph node-negative (N0) HNSCC were evaluated for the presence of venous channel invasion by tumor utilizing the elastin stain. Clinical, demographic, and follow-up data were recorded. RESULTS: Of 37 patients with venous invasion, 19% had loco-regional recurrence, as opposed to 12% of those without. Univariate analysis revealed statistically significant decreased recurrence-free survival in the presence of venous invasion (log-rank [Mantel-Cox] test P-value .025). CONCLUSION: Identification of VI is greatly aided by elastic stain. In patients with node-negative HNSCC, presence of VI resulted in decreased recurrence-free survival on univariate analysis. The impact of VI as a prognostic marker should be further evaluated.

Maximizing outcomes in a Gustilo-Anderson type IIIB open tibia fracture with segmental bone loss: A case report and review of the literature.

INTRODUCTION: Gustilo-Anderson type IIIB open fractures are severe injuries associated with multiple complications and threaten the viability of the limb. In addition, large segmental bone defects pose reconstructive challenges when treating open fractures and outcomes can be unpredictable. This case report highlights a good outcome in a patient with a type IIIB open tibia fracture with segmental bone loss that was successfully treated with a staged induced membrane technique and latissimus dorsi free flap. CASE REPORT: A 17-year-old female sustained a Gustilo-Anderson type IIIB open tibia fracture with segmental bone loss after a motor vehicle collision. While amputation seemed inevitable, her extremity was able to be salvaged using the staged induced membrane technique and free flap coverage. She made an exceptional recovery and at 24-month follow-up, her short form-12 scores and foot and ankle outcome scores were close to the average for a healthy adult. CONCLUSION: Our patient's outcome represents the benefits of a shared decision-making process with a multidisciplinary approach and highlights the benefit of limb salvage in a healthy patient.

Preoperative Protective Endovascular Covered Stent Placement Followed by Surgery for Management of the Cervical Common and Internal Carotid Arteries with Tumor Encasement.

Objective The objective of this study was to report the outcomes on a preliminary cohort of patients with tumor encasement of either, or both, the cervical internal carotid artery (ICA) and common carotid artery (CCA) following preoperative covered stent placement and surgical resection. Setting This study was set at the University of Florida College of Medicine, Jacksonville, FL. Participants Subjects who received preoperative stenting of the cervical ICA/CCA before surgical resection of head and neck tumors between April 1, 2015, and July 31, 2015 were participated. Main Outcome Measures The outcomes assessed were resectability of tumors after stenting, histopathological assessment of specimen margins, complications associated with stenting. Results Five subjects received preoperative covered stent placement of the ICA/CCA before surgical resection. The mean age was 65.2 years. Median follow-up was 3.5 months. Excision of the adventitia from the stent was performed in all subjects. No intraoperative complications occurred. One vascular-related complication occurred in one subject who suffered occlusion of the stent, sustaining a ministroke. No involvement of tumor at the deep margin (inner surface of adventitia) of the resection was seen in any subjects. Conclusions Preoperative covered stent placement of the cervical ICA/CCA in the management of subjects with head and neck tumors who display encasement on preoperative imaging may represent a safe and effective treatment.

Clinical Pathway Implementation Improves Efficiency of Care in a Maxillofacial Head and Neck Surgery Unit.

PURPOSE: Clinical pathways have become an important and simple method of improving patient outcomes and decreasing health care resource usage. The purpose of this study was to evaluate early outcomes associated with the implementation of a clinical pathway in a maxillofacial head and neck surgery unit. MATERIALS AND METHODS: This investigation is a retrospective cohort study of patients who underwent microvascular reconstruction of the head and neck from January 1, 2014 through December 31, 2014. Continuous variables were compared among 4 groups using analysis of variance or Kruskal-Wallis test, and categorical variables were compared using χ2 test or Fisher exact test where appropriate. The primary predictor variable was use of the clinical pathway. Groups included patients treated by surgeon A during periods before and after implementation of a postoperative clinical pathway. Two groups treated by surgeon B also were evaluated during the same periods and served as external controls. Each period covered a span of 6 months. Outcome variables across groups were evaluated, including length-of-stay metrics, infection rates, transfers to the intensive care unit, and unplanned return to the operating room. RESULTS: Sixty-six patients who underwent microvascular head and neck reconstruction were included. There was a significant decrease in the average length of stay (P = .0364) and an increase in the rate of discharge within 7 days (P = .0416) in the group treated with the clinical pathway. Other outcomes, including infection rate, transfer to the intensive care unit, and unanticipated return to the operating room, showed no relevant difference among groups. CONCLUSIONS: The results of this study suggest that implementation of a clinical pathway can be beneficial for efficient management of postoperative care in the setting of microvascular head and neck reconstruction. More predictable and shorter lengths of stay are achievable and the clinical pathway serves as a valuable means of improving communication of the clinical care team.

Microvascular Free Tissue Transfer for Head and Neck Reconstruction in Children: Part I.

BACKGROUND: Limited outcome data exist regarding the survival of microvascular free flaps for head and neck reconstruction in children. The objectives of this study were to perform a systematic review of the literature and meta-analysis comparing the survival of the most commonly used free flaps used for head and neck reconstruction in children. METHODS: A systematic search of PubMed, Embase, and Scopus was conducted using various keywords up to January 1, 2015. Meta-analysis was used to compare the survival of the most commonly used free flaps. The primary predictor variable was free flap type. The primary outcome variable was flap failure. The pooled relative risk (RR) with 95% confidence intervals (CIs) was estimated using a Mantel-Haenszel, fixed-effects model. RESULTS: The authors reviewed 25,303 abstracts. Five studies met inclusion criteria. A total of 646 children received a total of 694 free flaps. The pooled survival rate among all free flaps was 96.4%. The fibula free flap (fibula) and subscapular system free flaps (scapula) were the most commonly used flaps. There was no difference in survival when comparing the scapula (RR = 0.59, 95% CI: 0.26, 1.56, P = 0.29), or fibula (RR = 1.91, 95% CI: 0.55, 6.65, P = 0.31) to other free flaps, or when comparing the scapula to the fibula (RR = 2.29; 95% CI: 0.40, 13.08, P = 0.35). CONCLUSIONS: Free tissue transfer is highly successful in children. Although data are limited, there appears to be no difference in survival among various free flaps used for head and neck reconstruction in children.

Maxillofacial Gunshot Injuries: A Comparison of Civilian and Military Data.

PURPOSE: To compare military with civilian gunshot wounds (GSWs) in the maxillofacial region in order to establish differences in presentation, morbidity, and surgical management. MATERIALS AND METHODS: A cross-sectional study design was used. The University of Florida at Jacksonville oral and maxillofacial surgery operating room census and hospital trauma registry were both reviewed to identify maxillofacial GSW cases from 2005 through 2011. Military GSW data (2005 through 2011) were obtained from the US Department of Defense (DOD). The predictor variables were civilian versus military GSW events. The outcome variables of interest included the region of the face involved, race, gender, death during admission, hospital length of stay, and number of days in the intensive care unit (ICU). Descriptive statistics were computed. RESULTS: The sample was divided into military maxillofacial GSWs (n = 412) and civilian maxillofacial GSWs (n = 287 treated of 2,478 presented). A significant difference was measured between study groups regarding the region of the face involved (P = .0451), gender (P ≤ .0001), and race (P ≤ .0001). No significant relationship was measured regarding deaths during admission (P = .6510) for either study group. No standard deviation values for hospital length of stay or number of ICU days were provided by the DOD. The mean hospital length of stay for the military group was within the 95% confidence interval of the civilian group findings (6.0-7.6). The mean number of ICU days for the military group was not within the civilian group's 95% confidence interval (1.9-2.9). CONCLUSIONS: These data showed important differences in anatomic location, gender, and race distribution of maxillofacial GSWs between military and civilian populations. Limited analysis of hospital length of stay and number of ICU days might indicate no meaningful difference in hospital length of stay, although there was a statistical difference in the number of ICU days between the 2 populations. Future research comparing surgical strategies in these 2 environments could assist maxillofacial surgeons in providing optimal care to their patients.

Survival of microvascular free flaps in mandibular reconstruction: A systematic review and meta-analysis.

BACKGROUND: Free tissue transfer is commonly used in the reconstruction of post-ablative defects of the mandible. Due to lack of statistical power, comparing the survival of various free flaps, even in large studies, is challenging. The purpose of this study was to perform a meta-analysis comparing the survival of the most commonly used free flaps for mandibular reconstruction. METHODS: We searched PubMed, EMBASE, and SCOPUS for relevant studies. A meta-analysis using the Peto one-step odds ratio (OR) with 95% confidence intervals (CI) was used to compare the pooled survival of the most commonly used free flaps for mandibular reconstruction. RESULTS: Of the 25,303 studies reviewed, 17 were selected for data extraction. A total of 1,221 subjects received 1,262 free flaps. Sixty-five free flaps failed. The pooled survival of all free flaps used for mandibular reconstruction was 94.8%. The deep circumflex iliac artery (DCIA) flap was associated with a seven-fold increase in failure when compared to the radial forearm free flap (Peto OR 7.40; 95% CI 1.38, 39.75, P = 0.02). There was no difference in survival when comparing other commonly used free flaps. CONCLUSIONS: The results of this study suggest that free flap reconstruction of the mandible is highly successful. With the exception of the increased survival of the radial forearm when compared to the DCIA, there is no difference in recipient site survival when comparing various free flaps for mandibular reconstruction.

Digital measurements of 120 mandibular angles to determine the ideal fibula wedge osteotomy to re-create the mandibular angle for microvascular reconstruction.

PURPOSE: Mandibular reconstruction continues to be a challenge, even for the seasoned reconstructive surgeon. The present study sought to determine the normal anatomic mandibular angle and to establish a predictable angle of resection for the fibula bone cut to re-create the neomandibular body-ascending ramus angle. MATERIALS AND METHODS: A total of 30 random male and female panoramic radiographs were selected from our database. The selection criteria included age older than 21 years and a full or near total complement of teeth. The exclusion criteria were an edentulous mandible or maxilla, a history of trauma or maxillary or mandibular pathologic features, and age younger than 21 years. A total of 120 total measurements were performed. The angle measured was determined from a line coinciding with the posterior border of the ramus and the lower mandibular border. The measurements were taken from each side and from each gender group. The institutional review board of our institution approved the present study. RESULTS: The mean female mandibular right angle was 122.62°, and the left was 124.59° (average, 123.61°). The mean male mandibular right angle was 122.66°, and the left was 124.2° (average, 123.43°). The mean and median values were very similar. A statistically significant difference was identified between the left and right sides but not between the genders. Given this information, one can calculate a wedge cut in the fibula of about 56° to re-create the mean mandibular angle. CONCLUSIONS: This information can be used to make predictable fibula wedge closing osteotomies to re-create the normal mandibular ascending ramus body angle in a low-cost manner with the aid of an autoclavable metal wedge of 56°. This method would obviate the need for costly prefabricated guides.

Metastatic squamous cell carcinoma of an unknown primary site with cardiac involvement: case report.

Head and neck squamous cell carcinomas frequently metastasize to cervical lymph nodes. Distant metastasis by hematogenous dissemination pathways is less common. Cardiac involvement is a particularly rare occurrence. The first case of cardiac metastasis was reported in the early 18th century as a postmortem discovery. Since then, there have been sporadic reports of oropharyngeal cancer with cardiac metastasis. This report describes a case of metastatic squamous cell carcinoma of an unknown primary site involving the lungs, heart, and soft tissue of the bilateral paraspinal regions and lower extremity.

Versatility of supraclavicular artery island flap in head and neck reconstruction of vessel-depleted and difficult necks.

PURPOSE: The advent of microvascular free tissue transfer has given reconstructive surgeons a vast repertoire of treatment options for reconstruction of head and neck defects. However, the success of free flaps in head and neck reconstruction depends on the presence and quality of the recipient vessels in the neck for microvascular anastomosis. The supraclavicular artery island flap can be used to reconstruct a variety of head and neck defects, allowing the reconstructive surgeons to circumvent some of the problems inherent in vessel-depleted necks. The present study reports the use of the supraclavicular artery flap (SCAF) in the reconstruction of vessel-depleted neck and in difficult necks. MATERIALS AND METHODS: The present study was a retrospective study of patients who had undergone reconstruction with an SCAF and who also had a difficult neck or vessel-depleted neck in the head and neck surgery section from 2011 to 2012. Our inclusion criteria were patients treated at our institution with an SCAF who also had undergone multiple previous neck surgeries or patients with severely restricted donor options for soft tissue reconstruction. We excluded any patient for whom we did not have adequate follow-up or if the flap procedure was not performed by the faculty of the head and neck section. RESULTS: We identified 8 patients with a total of 9 SCAFs. One patient received bilateral SCAFs. Of the 8 patients, 6 were men and 2 were women. With the exception of 1 patient, all had received previous radiotherapy to the head and neck region. All the patients had undergone multiple surgical procedures. The flap survival was 100%. However, 2 patients had partial loss of the flap, and 2 had partial donor site wound dehiscence. Our overall complication rate was 38%, including dehiscence of the flap and partial loss of the flap. CONCLUSIONS: The SCAF is a sound option for reconstructing defects in the head and neck region in patients with previous radiotherapy and in multiple neck surgeries. The surgeon and patient should be aware of the high incidence of complications associated with this reconstructive option.