Patterns of alaryngeal voice adoption and predictive factors of vocal rehabilitation failure following total laryngectomy.

OBJECTIVE: We aimed to determine patterns of alaryngeal voice acquisition and predictive factors of vocal rehabilitation (VR) failure following total laryngectomy (TL) at a large Canadian tertiary care center. METHODS: All consecutive patients having undergone a TL between January 1st, 2011 and December 31st, 2019, at the Centre Hospitalier de l'Université de Montréal were included. RESULTS: One hundred and ninety-seven laryngectomized patients were identified. Successful VR was achieved in 86 (59.0%) patients, while 59 (41.0%) failed to use a method of alaryngeal voice as their principal means of communication at 1 year postoperatively. The use of tracheoesophageal puncture (TEP) was associated with higher VR success rates (70.6%) when compared with the artificial larynx (48.6%), and esophageal voice (18.8%). The only independent predictor of VR failure on multivariate analysis at all time points was a low socioeconomic status. CONCLUSION: Failure to adopt an alaryngeal voice following TL is highly prevalent, despite comprehensive and free speech language pathologist services being offered at our center. A low resort to TEP at our institution and a poor acceptability and accessibility of alternative VR methods may contribute to this trend. The challenges of VR may be further exacerbated by the barriers linked to a lower socioeconomic status, which in turn may contribute to reduced candidacy for TEP.

Practice patterns for positive sentinel lymph node in head and neck melanoma.

BACKGROUND: An international survey was conducted to investigate the preferences for completion lymph node dissection (CLND) in head and neck melanomas. METHODS: A questionnaire was sent through the American Society of Head & Neck Surgery (AHNS) and Canadian Society of Otolaryngology-Head and Neck Surgery (CSO). RESULTS: Hundred and forty-nine surgeons completed the survey. Response rate was 6.3% and 9.7% from AHNS and CSO members, respectively. When presented the scenario of a 47-year-old male with a clinical T3bN0 cheek melanoma, with 1/1 positive sentinel lymph node (SLN) with nodal deposit <2 mm, 72 of respondents (48.3%) would perform a CLND. Reasons for CLND included multiples positive SLN (64.1%), size of nodal deposits (54.2%), and perceived lack of compliance to follow-up (54.2%). Surgeons with access to immunotherapy treatment were less likely to recommend CLND (p = 0.025). CONCLUSIONS: Following SLN biopsy, nearly half of the surveyed head and neck surgeons would recommend CLND, which contrasts with the current melanoma practice patterns in other anatomic locations. However, compared with an earlier study in the literature it does seem that there has been a shift away from completion neck dissection. Further investigation into understanding practice variations is warranted.

Evaluating contralateral neck failure in patients with lateralized OPSCC treated with transoral robotic surgery and neck management based on pre-operative SPECT-CT lymphatic mapping.

BACKGROUND: Risk of contralateral nodal metastases in oropharyngeal squamous cell carcinoma (OPSCC) is relatively low, however, many OPSCC patients receive bilateral neck treatment. This study evaluates the oncological outcomes with management of the contralateral cN0 neck based on lymphatic mapping with single photon emission computed tomography (SPECT-CT). METHODS: Retrospective evaluation of patients with lateralized cT1-2 and contralateral cN0 OPSCC treated with primary surgery between December 2017 and October 2019. All patients underwent pre-operative lymphatic mapping using SPECT-CT. Clinical parameters including demographics, tumor characteristics and oncological outcomes were recorded. RESULTS: Thirteen patients underwent primary site resection with transoral robotic surgery (TORS) and ipsilateral neck dissection with or without adjuvant therapy. Twelve patients (92.3%) had ipsilateral drainage on SPECT-CT, whereas 1 (7.7%) patient had bilateral neck lymphatic drainage. Four patients (30.8%) underwent post-operative radiation therapy (PORT). Three patients with unilateral drainage on SPECT-CT underwent PORT with unilateral neck irradiation, and 1 patient with bilateral drainage underwent PORT with bilateral neck irradiation. Seven (53.8%) patients were staged as pT1, 6 (46.2%) patients as pT2, 6 (46.2%) patients were pN0, 3 (23.1%) patients were pN1, 1 (7.7%) patient was pN2a for and 3 (23.1%) patients were N2b. The median distance of the tumor from midline was 1.05 cm (0.0-1.58). Primary sites included tonsil (n = 10, 76.9%) and tongue base (n = 3, 23.1%). The median follow-up time was 15.4 months. All patients were disease free at the latest follow-up with no contralateral neck failures. CONCLUSIONS: Pre-operative mapping of lymphatic drainage in early stage OPSCC with SPECT-CT is a promising tool which can reduce treatment to the contralateral neck potentially without compromising oncological outcomes.

Projected cutting guides using an augmented reality system to improve surgical margins in maxillectomies: A preclinical study.

BACKGROUND: Positive margins have been reported up to 80% in advanced maxillary cancers. Intraoperative navigation (IN) aims to improve margins, but provides a two-dimensional view of a registered instrument without anticipating any cutting directions, and the information is displayed in monitors outside surgical field. Augmented Reality (AR) can delineate margins while addressing the gaze-toggling drawback of IN. In a preclinical setting, we implemented preoperative-planned osteotomies needed for maxillectomies and projected this information on the surgical field using AR. We aimed to improve negative margin rates while retaining the benefits of AR. METHODS: Five maxillary tumor models were built. Five fellowship-trained surgeons completed virtual unguided and AR-guided maxillectomies. Comparisons in terms of intratumoral cuts, close, adequate, and excessive distances from the tumor were performed. Differences between "ideal" cutting-plan and the AR-guided virtual osteotomies was obtained. Workload questionnaires to evaluate the technology were completed. RESULTS: 115 virtual osteotomies were analyzed. Intra-tumoral and "close" margins were lower for the AR-assisted osteotomies (0.0% vs 1.9% p < 0.0001 and 0.8% vs 7.9% p < 0.0001). Proportion of "adequate" margins were higher in the AR simulations (25.3% vs 18.6%, p = 0.018). The AR osteotomies had high similarity with the pre-planned with interclass correlation index close to 1 in "adequate" margins 0.893 (95% CI: 0.804-0.949). Workload scores were better for AR-guided simulations for the domains of mental demand, performance, effort and frustration. CONCLUSION: The projector-based AR method improved margin delineation, and preoperative planning was accurately translated to the simulations. Clinical translation will aim to consolidate our preclinical findings to improve outcomes.

Achieving negative resection margins in oral cavity cancer with masticator space involvement-Is it feasible? International collaborative study.

BACKGROUND: Masticator space involvement in oral cavity squamous cell carcinoma (OCSCC) is considered an unresectable disease. Nevertheless, achieving negative resection margins is feasible in limited masticatory space involvement. MATERIALS AND METHODS: A multi-institutional study on OCSCC patients with masticator space invasion who underwent surgical resection. Margin status was assessed according to anatomic tumor involvement of the inframandibular and supra-mandibular notch. RESULTS: One-hundred and thirty-two patients met the inclusion criteria. Then, 67 patients (50.8%) were diagnosed with a supra-notch tumor and 65 (49.2%) with an infra-notch disease. Negative margins were more common in the infra-notch group (43.3 vs. 23.1%, p = 0.014), and positive margins were more common in the supra-notch group (41.5 vs. 23.9%, p = 0.041). Multivariable analysis demonstrated that supra-notch tumors had an increased likelihood for involved resection margins (odds ratio = 2.46, p = 0.036). CONCLUSION: OCSCC patients with masticator space involvement are prone for positive surgical margins in tumors extending above the supra-mandibular notch.

Navigation-Guided Transnasal Endoscopic Delineation of the Posterior Margin for Maxillary Sinus Cancers: A Preclinical Study.

BACKGROUND: The resection of advanced maxillary sinus cancers can be challenging due to the anatomical proximity to surrounding critical anatomical structures. Transnasal endoscopy can effectively aid the delineation of the posterior margin of resection. Implementation with 3D-rendered surgical navigation with virtual endoscopy (3D-SNVE) may represent a step forward. This study aimed to demonstrate and quantify the benefits of this technology. MATERIAL AND METHOD: Four maxillary tumor models with critical posterior extension were created in four artificial skulls (Sawbones®). Images were acquired with cone-beam computed tomography and the tumor and carotid were contoured. Eight head and neck surgeons were recruited for the simulations. Surgeons delineated the posterior margin of resection through a transnasal approach and avoided the carotid while establishing an adequate resection margin with respect to tumor extirpation. Three simulations were performed: 1) unguided: based on a pre-simulation study of cross-sectional imaging; 2) tumor-guided: guided by real-time tool tracking with 3D tumor and carotid rendering; 3) carotid-guided: tumor-guided with a 2-mm alert cloud surrounding the carotid. Distances of the planes from the carotid and tumor were classified as follows and the points of the plane were classified accordingly: "red": through the carotid artery; "orange": <2 mm from the carotid; "yellow": >2 mm from the carotid and within the tumor or <5 mm from the tumor; "green": >2 mm from the carotid and 5-10 mm from the tumor; and "blue": >2 mm from the carotid and >10 mm from the tumor. The three techniques (unguided, tumor-guided, and carotid-guided) were compared. RESULTS: 3D-SNVE for the transnasal delineation of the posterior margin in maxillary tumor models significantly improved the rate of margin-negative clearance around the tumor and reduced damage to the carotid artery. "Green" cuts occurred in 52.4% in the unguided setting versus 62.1% and 64.9% in the tumor- and carotid-guided settings, respectively (p < 0.0001). "Red" cuts occurred 6.7% of the time in the unguided setting versus 0.9% and 1.0% in the tumor- and carotid-guided settings, respectively (p < 0.0001). CONCLUSIONS: This preclinical study has demonstrated that 3D-SNVE provides a substantial improvement of the posterior margin delineation in terms of safety and oncological adequacy. Translation into the clinical setting, with a meticulous assessment of the oncological outcomes, will be the proposed next step.

Bilateral radical neck dissection with immediate reconstruction of the internal jugular vein.

Head and neck surgery for advanced neck disease may require ablation of critical structures, including the internal jugular vein (IJV). Although unilateral ligation of the IJV is not commonly associated with a significant increase in morbidity, bilateral sacrifice of the internal venous system may cause severe complications. We present the case of a 60-year-old man with a T4N2cM0 tumour of the left and right hypopharynx. The evolution of the disease required a bilateral modified radical neck dissection and sacrifice of both IJVs. We describe a vein grafting technique for the IJV using the external jugular vein as a donor vessel. Postoperative computed tomography imaging confirmed adequate blood perfusion. This report describes two new and accessible surgical options for immediate IJV grafting. Although this modification slightly increases the surgery time and technical difficulty, it allows immediate restoration of venous perfusion, which may improve the prognosis and patient outcomes.

Delayed facial nerve decompression for severe refractory cases of Bell's palsy: a 25-year experience.

BACKGROUND: This study aims to assess the effectiveness of delayed facial nerve decompression for Bell's palsy (BP). METHODS: We performed a retrospective case review of all patients having undergone facial nerve decompression for severe refractory BP between 1984 and 2009 at our tertiary referral center. Demographics, timing between onset of symptoms and surgical decompression, degree of facial nerve dysfunction pre- and post-operatively, follow-up length after surgery and postoperative complications were recorded. Facial nerve dysfunction was assessed using the House-Brackmann (HB) scale. Electroneuronography, electromyography and imaging results were assessed when available. RESULTS: Eighteen patients had surgery between 21 and 60 days after onset of BP (group I), and 18 patients had surgery more than 60 days after onset of symptoms (group II). In group II, 11 patients had surgery between 61 and 89 days and 7 patients after 90 days. Groups I and II showed similar functional gain and rates of improvement to HB 3 or better (11/18 vs. 11/18, p > 0.05). In group II, patients operated 60 to 89 days after onset of BP showed a significantly higher rate of improvement to HB 3 or better (9/11 vs. 2/6, p = 0.049) with higher functional gain compared to those operated after 90 days (p = 0.0293). CONCLUSIONS: When indicated, facial nerve decompression for BP is usually recommended within the first 2 weeks of onset of facial paralysis. Nonetheless, our results suggest that patients with severe BP could benefit from decompression surgery within 90 days after onset of symptoms in the absence of an opportunity to proceed earlier to surgery. Further investigation is still required to confirm our findings. TRIAL REGISTRATION: Retrospective registered. IRB# 2016-6154, CE 15.154 - CA.

Superiorly based facial artery musculomucosal flap: A versatile pedicled flap.

BACKGROUND: The superiorly based facial artery musculomucosal (FAMM) flap is pedicled on the angular artery. This flap offers a well-vascularized mucosal surface allowing closure of medium size defects, most frequently within the oral cavity and intranasal region. METHODS: We describe a superiorly based harvest of the FAMM flap, which may be used for closure of multiple head and neck surgical defects. An operative technique video is provided, which can be viewed online. RESULTS: Our results demonstrate a fast and relatively straightforward harvest technique of the FAMM flap. This intraoral flap is a useful reconstructive tool, which also has the advantage to leave no visible external scars. CONCLUSION: The superiorly pedicled FAMM flap is a versatile and effective technique that may be integrated in the algorithm for reconstruction of head and neck defects.

Four PTEN-targeting co-expressed miRNAs and ACTN4- targeting miR-548b are independent prognostic biomarkers in human squamous cell carcinoma of the oral tongue.

The purpose of this study was to determine the prognostic value and oncogenic pathways associated to miRNA expression in squamous cell carcinoma of the oral tongue and to link these miRNA candidates with potential gene targets. We performed a miRNA screening within our institutional cohort (n = 58 patients) and reported five prognostic targets including a cluster of four co-expressed miRNAs (miR-18a, miR-92a, miR-103, and miR-205). Multivariate analysis showed that expression of miR-548b (p = 0.007) and miR-18a (p = 0.004, representative of co-expressed miRNAs) are independent prognostic markers for squamous cell carcinoma of the oral tongue. These findings were validated in The Cancer Genome Atlas (TCGA) cohort (n = 131) for both miRNAs (miR-548b: p = 0.027; miR-18a: p = 0.001). Bioinformatics analysis identified PTEN and ACTN4 as direct targets of the four co-expressed miRNAs and miR-548b, respectively. Correlations between the five identified miRNAs and their respective targeted genes were validated in the two merged cohorts and were concordantly significant (miR-18a/PTEN: p < 0.0001; miR-92a/PTEN: p = 0.0008; miR-103/PTEN: p = 0.008; miR-203/PTEN: p = 0.019; miR-548b/ACTN4: p = 0.009).

The Role of Conservative Management in Pneumosinus Dilatans Frontalis With Minimal Bony Deformity.

The authors describe the conservative management of 2 rare patients of uncomplicated pneumosinus dilatans of the frontal sinus with minimal bossing of the forehead. Regular nasal hygiene in combination with topical corticosteroids was administered with following complete resolution symptoms.

A Novel Minimally Invasive Approach for Surgical Septal Myectomy.

BACKGROUND: Transaortic septal myectomy is the gold standard for the treatment of symptomatic hypertrophic obstructive cardiomyopathy that is refractory to medical therapy. The aim of this study was to assess early outcomes of minimally invasive septal myectomy performed through a right anterior minithoracotomy. METHODS: Between 2011 and 2014, 24 consecutive patients underwent isolated septal myectomy through a 4-5-cm right parasternal minithoracotomy. Perioperative clinical and echocardiographic outcomes in these patients were compared with those of a historical cohort of 26 consecutive patients who underwent isolated septal myectomy performed through a median sternotomy between 2002 and 2010. RESULTS: Age and sex distribution were similar between the groups. Median aortic cross-clamp time was 57 minutes in the minithoracotomy group vs 43 minutes in the sternotomy group (P = 0.149). There was no in-hospital mortality in either group. Intraoperative conversion to sternotomy was required in 1 patient. Postoperative permanent pacemaker implantation was required in 5 patients from each group (P = 0.999). Both groups demonstrated similar reductions in left ventricular outflow tract gradient and septal thickness. Residual obstructive systolic anterior motion of the mitral valve was observed in 2 patients (8%) in the minithoracotomy group and 1 patient (4%) in the sternotomy group (P = 0.602). CONCLUSIONS: This study demonstrates the feasibility of transaortic septal myectomy through a right minithoracotomy. Our early results suggest that this technique yields clinical and echocardiographic outcomes similar to those obtained with standard sternotomy.

Internal Jugular Vein Duplication: Anatomic Relationship With the Spinal Accessory Nerve.

Level II neck dissection is a commonly performed procedure in head and neck surgery. It carries the risk of injury to the spinal accessory nerve (SAN) and the internal jugular vein (IJV). Injury to any of these structures leads to increased intraoperative and postoperative complications and morbidity. Knowledge of the anatomic relation and possible variations from the norm is vital to decrease the morbidity of this frequently practiced procedure. This report describes 2 rare variations of the relation of the SAN to the IJV: 1) the IJV splitting with SAN passage through the IJV window and 2) the IJV splitting without SAN passage through the IJV window. Preoperative imaging and the pertinent literature regarding the variability in the relations of these structures are reviewed.

Successful management of a giant anterior sacral meningocele with an endoscopic cutting stapler: case report.

Anterior sacral meningoceles (ASMs) are rare defects in the sacrum with thecal sac herniations and symptoms that commonly include constipation, dysmenorrhea, and urinary disturbances. An ASM causing hydronephrosis and acute renal failure from compression of the lower portion of the urinary tract is a rare clinical entity. Only one other case has been reported. The authors present the case of a 37-year-old man admitted for obstructive renal failure and hydronephrosis due to a giant ASM that measured 25 × 12 × 18 cm and compressed the ureters and bladder. The ASM was successfully treated via an anterior transabdominal approach in which the authors used a novel technique for watertight closure of the meningocele pedicle with an endoscopic cutting stapler. The authors review the literature and discuss the surgical options for the treatment of ASMs, specifically the management of ASMs in the context of obstructive renal failure and hydronephrosis.

Endoscopic Mediastinal Staging in Lung Cancer Is Superior to "Gold Standard" Surgical Staging.

BACKGROUND: The objective was to evaluate whether endobronchial ultrasonography (EBUS) or endoscopic ultrasonography (EUS) staging techniques of the mediastinum for lung cancer can change the treatment plan compared with the "gold standard" of surgical staging. METHODS: Patients were retrospectively identified from a prospectively collected database. Endoscopic staging was compared with the "gold standard" cervical mediastinoscopy (CM). In cases where mediastinoscopy was not performed, EBUS/EUS was compared with "ideal" CM, a virtual procedure, which was assumed to have 100% rates of sensitivity and specificity. RESULTS: EBUS was performed in 324 patients (99%), EUS in 295 patients (90%), and CM in 101 patients (31%); 226 patients (69%) were assumed to have undergone a virtual ideal CM and a virtual surgical mediastinal staging; 108 positive biopsies (33.0%) with endosonography had sampling of targets that were out of the scope of CM. Distant metastatic disease was diagnosed by EBUS/EUS in 7 patients (2.1%); 22 patients (6.7%) had positive targets outside the reach of the CM or virtual CM. If the 14 patients who had positive stations 5, 6, 10, and 11 are excluded (accessible with anterior mediastinotomy or extended cervical mediastinoscopy), there were 6 patients (1.8%) in whom endosonography upstaged the patient over ideal surgical mediastinal staging. In 20 patients (6.1%), ultrasound-guided biopsy made the diagnoses, which changed the treatment plan over CM and ideal CM. CONCLUSIONS: Combined EBUS- and EUS-guided biopsies can access more targets, including lung and distant metastasis, and thus have the potential to upstage patients compared with mediastinoscopy and change the treatment plan.

Voice and Functional Outcomes of Transoral Laser Microsurgery for Early Glottic Cancer: Ventricular Fold Resection as a Surrogate.

BACKGROUND: The aim of the study was to evaluate the oncological and functional outcomes with transoral laser microsurgery (TOLM) of patients with early glottic cancer. METHODS: We have prospectively evaluated patients treated with TOLM for Tis, T1 or T2 glottic squamous cell carcinoma. Evaluation of oncological outcomes, and voice and functional outcomes was assessed using voice-handicap index 10 (VHI-10) and performance status scale for head & neck cancer patients (PSS-H&N). Predictors of poor voice quality were evaluated using Student's t-test. RESULTS: Thirty patients were included, with 17.7 months mean follow-up. There were no cases of locoregional recurrence. Twelve patients (40%) were considered as having a problematic voice outcome. Four subjects out of 30 (13.3%) had significant problems with understandability of speech. Significant differences (P < 0.05) in VHI-10 score were found with tumor stage and partial resection of the ventricular fold. CONCLUSIONS: We report excellent oncological and functional outcomes in early glottic cancer treated with TOLM, with advanced tumors and partial resection of the ventricular fold as a surrogate predicting worse voice outcomes.

Active smoking status in chronic rhinosinusitis is associated with higher serum markers of inflammation and lower serum eosinophilia.

BACKGROUND: Smoking negatively affects postoperative evolution in patients with chronic rhinosinusitis (CRS); however, the mechanism remains incompletely described. In the lung, smoking increases expression of proinflammatory genes and is associated with an elevation of inflammatory serum markers. Our objective is to determine the impact of smoking on these biomarkers in CRS. METHODS: Two existing populations of patients previously phenotyped for genetic association studies (206 patients with refractory CRS and 408 patients with CRS and nasal polyposis) were stratified according to self-reported smoking status and available serum biomarkers (complete blood count [CBC], total immunoglobulin E [IgE]). Asthma and bacterial cultures were evaluated. RESULTS: Active smoking was low in both groups (genetics of chronic rhinosinusitis 1 [GCRS1]: 11.2%; genetics of chronic rhinosinusitis 2 [GCRS2]: 9.4%). Total white blood cell (WBC) count was significantly higher in active smokers than in those who had never smoked and ex-smokers. Serum eosinophilia and prevalence of self-reported asthma was lower in active smokers than never-smokers. In the GCRS2 population, endoscopically-collected cultures trended toward a lower recovery rate of Staphylococcus aureus in smokers (p = 0.07). Never-smokers and ex-smokers had similar levels of WBCs and eosinophils. CONCLUSION: Our study reveals that active tobacco smoking is associated with increases in markers of systemic inflammation in patients with CRS. The proinflammatory effect of smoking seems not only to act locally on sinus mucosa as previously described, but may also influence levels of inflammatory biomarkers systemically, suggesting that smoking-induced changes have profound implications for health. Nevertheless, these changes may be potentially reversible; thus smoking cessation in CRS patients is strongly advised, and may have an impact on response of CRS to therapy.