Regional metastasis to anatomies beyond traditional neck dissection boundaries: a multi-institutional analysis focused on unconventional metastases in oral cancer patients.

BACKGROUND: Regional metastasis sometimes occurs in anatomies that are not included in traditional neck dissections. The purpose of this study was to evaluate the treatment outcomes of squamous cell carcinoma of oral cavity (SCCOC) patients with unconventional metastatic lymph nodes (UMLNs) in sublingual, buccinator, and parotid anatomies. METHODS: This retrospective multi-institutional analysis of squamous cell carcinoma of oral cavity patients with unconventional metastatic lymph nodes was performed from January 2008 to December 2015. All the included patients received surgical treatment for unconventional metastatic lymph nodes. The end point of the study was to determine the factors influencing these patients' survival and the corresponding solutions to improve survival. Pathological grade, contralateral metastasis, extranodal extension, and other factors were collected and analyzed by logistic regression and the Cox model. RESULTS: A total of 89 patients were identified. Among these patients, 25 (28.1%) received primary treatment, 28 (31.5%) received staged (therapeutic) neck dissections, and 36 (40.4%) had recurrent or residual diseases. Altogether, 45 patients (51%) had buccinator node metastases, 31 (35%) had sublingual metastases, 12 (14%) had parotid metastases, and 1 had both buccinator and parotid metastases. Regarding regional metastases, 31 patients (34.8%) had isolated unconventional metastatic lymph nodes. Adjuvant therapies were administered to 72 (80.9%) patients, 25 (28.1%) of whom were treated with radio-chemotherapies. The overall survival rate was 38.2%. Multivariate analysis found that the subsites of unconventional metastatic lymph nodes (P = 0.029), extranodal extension in both unconventional metastatic lymph nodes (P = 0.025) and cervical lymph nodes (P = 0.015), sites of primary or recurrent squamous cell carcinoma of oral cavity (P = 0.035), and types of neck dissections (P = 0.025) were significantly associated with overall survival. CONCLUSIONS: Unconventional metastatic lymph nodes are uncommon, yet awareness of potential unconventional metastatic lymph nodes should be heightened. Early surgical interventions are warranted in patients with sublingual or buccinator metastases, while caution should be given to those with parotid metastases. Aggressive en bloc (in-continuity) resections may be mandatory in advanced oral cancer cases for close anatomic locations with possible buccal or sublingual metastases.

Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak.

Endoscopic skull base surgery continues to rapidly evolve, requiring comparable advances in reconstructive techniques. While smaller skull base defects with low intraoperative CSF flow have been successfully managed with a variety of avascular and/or noncellular techniques, larger defects with high CSF flow require more robust repairs often in the form of vascularized flaps, which confer excellent success rates in this setting. Despite these successful outcomes, a paucity of data describing specific patient and operative characteristics and their effects on repair exist. Therefore, a retrospective, consecutive chart review was performed on patients who underwent endoscopic skull base reconstruction with a vascularized flap in the setting of intraoperative CSF leaks. In this series, 151 patients with a mean age of 51 years underwent 152 vascularized flap skull base reconstructions for an array of benign and malignant pathologies. These vascularized flaps included 144 nasoseptal flaps, 6 endoscopic-assisted pericranial flaps, 1 facial artery buccinator flap, and 1 inferior turbinate flap that were used throughout all regions of the skull base. Perioperative (< 3 months) and postoperative (> 3 months) flap complications were assessed and revealed 3 perioperative flap defects (2.0%) defined as a visualized defect within the substrate of the flap and a total of 5 perioperative CSF leaks (3.3%). No patient experienced flap death/complete flap loss in the cohort. Assessed postoperative flap complications included 1 case (0.7%) of mucocele formation, 8 cases (5.3%) of prolonged skull base crusting, and 2 cases (1.3%) of donor-site complication, specifically septal perforation secondary to nasoseptal flap harvest. Among the 152 cases identified, 37 patients received radiation therapy while 114 patients did not undergo radiation therapy as part of the treatment profile. No significant association was found between perioperative complication rates and radiation therapy (p = 0.634). However, a significant association was found between postoperative complication rates and radiation therapy, primarily accounted for by an increased risk for prolonged (> 6 months) skull base crusting (p = 0.025). It is clear that larger skull base defects with high intraoperative CSF flow require thoughtful approach and strong consideration for vascularized repair.

Buccinator-based myomucosal flaps in intraoral reconstruction: A review and new classification.

The buccinator-based myomucosal flaps are axial pattern flaps that are suitable in reconstruction of medium sized oral soft tissue defects; they are rich in blood supply, have appropriate thickness and considerable mucosal paddle, and they can secrete saliva. The present study describes surgical anatomy and blood supply of these flaps and demonstrates all possible modifications of these flaps (9 modifications). Many terms (> 10) have been used to refer to buccinator-based myomucosal flaps in the literatures. This report introduces a new classification system mainly based on the remaining attachments of buccinator muscle after flap elevation in pedicle variants and axial blood supply orientation in island variants.

Atividade exacerbada do músculo bucinador em sujeitos com má oclusão de Angle Classe III / Exacerbated activity of the buccinator muscle in subjects Angle Class III malocclusion

Introdução: Estudos descrevem a função do músculo bucinador como controlador do bolo alimentar durante a mastigação. Pouco se sabe, entretanto, sobre seu comportamento em sujeitos com distintos padrões dentário e esquelético, o que contribuiria para o desenvolvimento dos tratamentos ortodônticos e ortognático. Objetivo: Este estudo tem como objetivo investigar a atividade eletromiográfica do músculo bucinador, em sujeitos Classe III de Angle, durante a mastigação. Material e Método: A amostra foi constituída por 32 sujeitos saudáveis, sem Disfunção Temporomandibular durante a mastigação, sendo 16 sujeitos Classe I e 16 sujeitos Classe III. Para garantir a fidedignidade da captação do sinal, foram utilizados eletrodos diferenciais, além de testes de função, correlação e normalização dos dados. Na medida em que os dados revelaram uma distribuição não normal (teste de Shapiro-Wilk), realizou-se teste da mediana, sendo estabelecido o nível de significância em 5%. Resultado: Na comparação dos dados normalizados da variável Root Means Square (RMS) (µV), do período ativo, não foram encontradas diferenças significativas (Classe I: 0,469 ± 0,355; Classe III: 0,531 ± 0,355 - p: 0,4812). Entretanto, em relação às variáveis RMS (µV) do período inativo (Classe I: 0,359 ± 0,355; Classe III: 0,641 ± 0,355 - p: 0,0016), duração do período ativo (ON) (Classe I: 0,313 ± 0,180; Classe III: 0,687 ± 0,180 - p: 0,0368) e razão entre o RMS do período inativo e RMS do período ativo (RIA) (Classe I: 0,391 ± 0,355; Classe III: 0,609 ± 0.355 - p: 0,0137), foram observadas diferenças significativas. Conclusão: A partir dos dados obtidos, pôde-se constatar uma atividade exacerbada do músculo bucinador nos sujeitos Classe III de Angle.

Introduction: Studies describe the role of the buccinators muscle as controlling the bolus during mastication. Little is known, however, about its behavior in subjects with different dental and skeletal standards, which would contribute to the development of orthodontic and orthognathic treatments. Objective: The purpose of this study was to investigate the electromyographic activity of the buccinator muscle, in subjects Class III Angle, during mastication. Material and Method: The sample was composed by 32 healthy subjects, without Temporomandibular Disfunction, during mastication, being 16 Class I and 16 Class III. In order to guarantee the reliability of the caption of the signal, differential electrode were used, as well as function tests, correlation and normalization of data. As the data revealed a non-normal distribution (Shapiro-Wilk test), the median test was carried out, establishing then the level of significance in 5%. Result: In the comparison of the normalized data of the variable Root Means Square (RMS) (µV), from the active period, no significant differences were found (Classe I: 0,469 ± 0,355; Classe III: 0,531 ± 0,355 - p: 0,4812). Nonetheless, in comparison to the variables RMS (µV) from the inactive period (Classe I: 0,359 ± 0,355; Classe III: 0,641 ± 0,355 - p; 0,0016), duration of the active period (ON) (Classe I: 0,313 ± 0,180; Classe III: 0,687 ± 0,180 - p: 0,0368) and the result between the RMS of the inactive period and the RMS of the active period (RIA) Classe I: 0,391 ± 0,355; Classe III: 0,609 ± 0.355 - p: 0,0137) significant differences were found. Conclusion: Based in the results of the data analysis, we could to comprove the existence of exacerbated activity of the buccinator muscle in Angle's Class III subjects.