Submental island flap versus radial forearm free flap for oral tongue reconstruction: a comparison of complications and functional outcomes.

OBJECTIVE: This study compared the complications and functional outcomes of patients with oral tongue cancer who had undergone reconstruction using a submental island flap or a radial forearm free flap. METHOD: Of the 54 patients, 29 underwent reconstruction with a submental island flap and 25 patients with a radial forearm free flap. The complications and outcomes of speech and swallowing were evaluated. RESULTS: In the submental island flap group, all the flaps were successfully transferred with no donor site complications. In the radial forearm free flap group, partial skin graft loss and arm function restriction were recorded. Mean operative time and duration of hospital stay were significantly shorter in the submental island flap group. Speech and swallowing function were comparable between the two groups. There was no significant difference in locoregional recurrence between the groups. CONCLUSION: The submental island flap is reliable and is suitable for oral tongue reconstruction. It has a lower complication incidence when compared to the radial forearm free flap, while maintaining speech and swallowing function.

Deep neck infection in patients with and without human immunodeficiency virus: a comparison of clinical features, complications, and outcomes.

We retrospectively studied the clinical features, complications, and outcomes of deep neck infections in 31 adult patients with the human immunodeficiency virus (HIV) (HIV group) and 192 patients without (non-HIV group). In the HIV group, the cause was more likely to be odontogenic (21 (68%) compared with 90 (47%); odds ratio (OR) 2.38; 95% CI 1.06 to 5.32). In both groups, the parapharyngeal, submandibular, and masticator spaces, were those most often involved. However, in the HIV group, Ludwig's angina was common, and was the main cause of airway obstruction. Streptococcus pneumoniae, Staphylococcus aureus, and Pseudomonas aeruginosa were most often isolated in the HIV group. Upper airway obstruction tended to be more common in the HIV group (5/31 compared with 13/192). These patients also had a higher risk of other complications (sepsis, mediastinitis, jugular vein thrombosis, and pneumonia) (6/31 compared with 12/192; OR 3.60; 95% CI 1.24 to 10.45), a higher mortality rate (3/31 compared with 2/192), and longer hospital stay (19days compared with 16 days). Factors associated with an increased risk of complications in this group were an age of 55 years or over and a CD4 count of less than 350 cells/mm3. Deep neck infections in these patients are more severe. Dental health care, appropriate empirical antibiotics, early detection, and management of the airway and complications, may improve outcomes.

Prevention of pharyngocutaneous fistula in salvage total laryngectomy: role of the pectoralis major flap and peri-operative management.

OBJECTIVE: This study aimed to evaluate the impact of an onlay pectoralis major flap in reducing the incidence of pharyngocutaneous fistula after salvage total laryngectomy and determine the complications of pectoralis major flap reconstruction. METHODS: A retrospective study was conducted of consecutive patients who underwent salvage total laryngectomy between 1995 and 2016. The pharyngeal defects were primarily closed with or without the pectoralis major flap. RESULTS: Of 64 patients, 34 had primary pharyngeal closure alone (control group) and 30 received an onlay pectoralis major flap (pectoralis major flap group). The overall fistula rate was 15.6 per cent, with 17.6 per cent occurring in the control group and 13.3 per cent in the pectoralis major flap group (p = 0.74). The incidence rates of voice failure (p = 0.02) and shoulder disability (p < 0.001) were significantly higher in the pectoralis major flap group. CONCLUSION: The pectoralis major flap in salvage total laryngectomy did not decrease the pharyngocutaneous fistula rate, and the incidence of flap-related complications was high. Appropriate surgical technique and post-operative care may reduce the incidence of pharyngocutaneous fistula.

Submental island flap reconstruction in oral cavity cancer patients with level I lymph node metastasis.

The submental island flap is useful as an alternative to microvascular free tissue transfer for the reconstruction of defects after resection of oral cancer because it is simple to harvest, reliable, and is associated with good oral function and low morbidity. However, because cancer of the oral cavity carries a risk of level I nodal metastases, the oncological safety of the flap remains controversial. Between April 2012 and September 2016, we studied patients with squamous cell carcinoma of the oral cavity who had surgical resection with submental island flap reconstruction for viability of the flap, signs of recurrence, and complications. Thirty-five patients (22 men and 13 women) were enrolled in the study and the mean (range) duration of follow-up was 23 (11-48) months. Six patients had local recurrences of their tumours, none of which was considered to be related to the flap. No flap was lost completely, but there were 10 cases of partial skin loss that healed with conservative management. There were no orocutaneous fistulas, haematomas, or marginal mandibular nerve palsies. We conclude that the submental island flap can be used safely in selected patients with level I lymph node metastases when the flap has been harvested meticulously.

Induction chemotherapy with paclitaxel, ifosfamide, and cisplatin followed by concurrent chemoradiotherapy for unresectable locally advanced head and neck cancer.

OBJECTIVE: Induction chemotherapy (IC) and concurrent chemoradiotherapy (CCRT) for locally advanced head and neck cancer has been studied in many clinical trials. This study was conducted to determine the response rate of IC with paclitaxel, ifosfamide, and cisplatin followed by CCRT with cisplatin for this group of patients, and the effect of the entire treatment on survival and time to disease progression. METHODS: Thirty patients with advanced and unresectable head and neck cancer were treated with 2 cycles of induction paclitaxel/ ifosfamide/ cisplatin. If the primary tumor had a complete or partial response, patients were treated with 2 more cycles of IC followed by radiotherapy 70 Gy plus 3 cycles of cisplatin. For those with less than partial response or disease progression were treated according to the discretion of the physicians. RESULTS: Ninety percent of patients had stage IV disease and 40% of them had primary tumor at maxillary sinus and nasal cavity. One patient (3%) achieved complete response (CR) and 18 patients had partial responses (PR) to IC. CCRT enhanced the response rate, resulting in a total of 3 CR (10%) and 16 PR (53%) to treatment. The median time to progression was 11.5 months. The median overall survival was 27 months. The most severe hematologic toxicity occurred during IC was grade3-4 neutropenia (40%). Grade 3-4 mucositis occurred in 68% of patients during CCRT. CONCLUSION: This novel combined-modality treatment program, is toxic but feasible, and can be administered for selected patients with advanced and unresectable head and neck cancer. © 2010 Biomedical Imaging and Intervention Journal. All rights reserved.

Total hypopharyngeal reconstruction.

In advanced hypopharyngeal carcinoma, the tumor may involve the entire hypopharyngeal mucosa and the larynx. After total laryngohypopharyngectomy is done, reconstruction of the circumferential defect of the hypopharynx is a challenge. We described our results of using a myomucosal tongue flap with dermal or skin graft (MTF) in 8 patients and using a tubed pectoralis major myocutaneous flap (TPMF) in 10 patients to reconstruct the total hypopharynx. There was no operative mortality. Fistula formation occurred in 3 patients of the MTF group and 4 in the TPMF group but all had spontaneous healing after conservative treatment. One in the MTF group and 4 in the TPMF group had stenosis of the anastomotic sites. Almost all responded well with periodic dilatation. Only one patient in the TPMF group who had been previously irradiated required gastrostomy for feeding. The 5-year actuarial survival rate of our patients was 32 per cent. These results show that total hypopharynx can be reconstructed with the above noted procedures. The survival rate is good, the morbidity rate is acceptable, and the perioperative mortality rate is zero.

The Amatsu tracheoesophageal shunt operation for voice restoration after total laryngectomy.

Vocal rehabilitation after total laryngectomy using tracheoesophageal shunt with sphincter mechanism or Amatsu's operation was performed in 12 patients at the department of Otolaryngology, Chiang Mai University from January 1993 to December 1998. Serviceable voice was attained within 10-14 days postoperatively. The success rate of voice restoration was 75 per cent with a good maximum phonatory time of 8 seconds. Tracheal aspiration which was found in 4 patients was managed conservatively without complication. The Amatsu tracheoesophageal shunt is a single stage operation which provides the patients with a good success rate of voice restoration, few complications, easy learning, and prosthesis free.

Esophageal foreign bodies.

A retrospective study of 310 patients with foreign bodies in the esophagus was analyzed. The most common age of the esophageal foreign body patients was between 0 to 9 years old (32.6%), and a coin was the most common foreign object in children. Bone, fish bone and bolus of meat were found commonly in adults, while dentures were encountered in the old age group. History of foreign body ingestion, dysphagia and odynophagia were usually presented by the patients. Roentgenographic study was useful in diagnosis and plan of management. Rigid esophagoscopy under general anesthesia is recommended in all patients with suspected history of foreign body, even though plain films of the chest and neck failed to demonstrate any significant findings. Complications can be reduced if the treatment is conducted within 24 hours of foreign body impaction.

Acute external laryngeal injury.

A retrospective study of 35 patients with acute external laryngeal injury who were treated at Maharaj Nakorn Chiang Mai Hospital from January 1989 to 1998 was done. Eighty-six per cent of the patients with blunt trauma had been injured from a motor vehicle accident and the rest had a penetrating injury from a stab wound. The frequent signs and symptoms were hoarseness, skin contusion, pain and subcutaneous emphysema. The severity of the injury was classified into minor and major groups. There were 2 patients in the minor group and 33 in the major group. Both patients in the minor injury group had good result from conservative treatment. All patients in the major injury group, except one with left vocal cord paralysis, required surgical management. No airway problem was found in any patient and only one patient had unintelligible voice after treatment. Twenty-three per cent had minor complications and responded well to conventional treatment. Early diagnosis and proper management gave the best outcome of the patient's airway and voice.

Mandibular reconstruction: free flap vs AO plate.

The purpose of this study was to compare the use of the AO reconstruction plate with immediate free vascularized bone graft mandibular reconstruction. From April 1989 to December 1993 we performed 13 cases of mandibular reconstruction. Reconstruction plates were used in 4 and immediate free bone grafts were used in 9 patients. The overall success rate for use of the plate was 2 of 4 (50%). In one of the plate failure patients, the plate was removed eight months postoperatively. She was able to wear a dental prosthesis. Cancer destruction and microvascular anastomosis of the first seven free flaps were performed by one surgical team. Only 4 free flaps were successful (success rate was 44%). We found that the use of AO plate with flap for lateral defect was relatively safe, simple, functional, time-saving, cosmetically acceptable and could be used successfully in post-operative irradiated patients. Success rate of the free flap was better with two surgical teams. The long-term result of the free flap was more reliable than the AO plate.

Esophageal conduit in nearly hopeless corrosive esophageal stricture patient.

The case report of a 28 year old woman with strictured esophagus from corrosive esophagitis for 4 months is presented. Barium swallowing showed a strictured esophagus extending from T2 to the aortic knob and needed frequent dilatations. The patient had a perforated thoracic esophagus and mediastinitis on last dilatation. Cervical esophagostomy, transabdominal esophageal bandaging and jejunostomy feeding were done along with intravenous broad spectrum antibiotics. On esophagoscopy, there was complete stenosis of the cervical esophagus 2 cm from the postcricoid area. The large intestine from the caecum, transverse colon and descending colon was chosen as the esophageal conduit because of adequate length to pass subcutaneously. The caecum was anastomosed to the cervical esophagus and descending colon to the stomach. Seven days postoperatively, the patient could take liquids and soft porridge orally. There was a small leakage from the cervical anastomosed, spontaneous closure was achieved 3 weeks postoperatively. We chose the right side colon as the esophageal conduit because of adequate length to pass subcutaneously. Mediastinal and transhiatal routes could not be passed because of previous mediastinitis from thoracic esophageal perforation. This may be an alternative choice of operation for high cervical esophageal stenosis with previous mediastinitis.

Access to the superior mediastinum.

Surgical access for diseases that involve the superior mediastinum can be achieved without thoracotomy by utilizing the suprasternal approach with extension of the head and neck and transection of the interclavicular ligament, median sternotomy, resection of the medial third to one half of the clavicle, or resection of the manubrium sterni. There has been minimal morbidity and no operative or postoperative mortality in a review of 53 consecutive patients. There has been no significant disability. Combined with exposure at the base of the neck, the access to the superior mediastinum is good to excellent.