Closure of post-laryngectomy pharyngocutaneous fistulae.

BACKGROUND: Closure of salvage laryngectomy defects with vascularized tissue remains controversial. METHODS: We evaluate outcomes in patients who required repair of a fistula after attempted primary closure of salvage laryngectomy defect and assess risk factors for persistent fistula. Between 2001 and 2010, 20 patients were treated for pharyngocutaneous fistulae after primary closure of a salvage laryngectomy. All patients required free flap repair for definitive fistula management. RESULTS: Patients presented with fistulae from one to 18 months in duration; median time to closure was seven days. Radial forearm free flap was used in 86% of patients. With free flap alone 50% of patients achieved fistula closure. Additional procedures improved closure rate to 85%. Recipient vessels were used in the neck in 54.5%, compared to internal mammary vessels in 45.5%. Hypothyroidism was identified as a risk factor for persistent fistula (p = 0.01). Chronic steroid use (p = 0.08) did not reach significance as a risk factor for fistula closure. Gastroesophageal reflux disease was newly diagnosed or noted as a comorbidity in 14 patients (70%) in this study. It did not reach statistical significance as a risk factor in refistulization (p = 0.12). Complications included leak, carotid blowout, infection, free flap loss, and late refistulization. Overall flap failure in this study was 4.5%. CONCLUSIONS: Delayed secondary repair of pharygocutaneous fistulas after salvage laryngectomy is associated with a higher complication rate and poor success rates compared to use of vascularized tissue at the time of salvage laryngectomy. Prolonged wound healing in these patients is associated with hypothyroidism.

Management of the N0 neck in recurrent laryngeal squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: To evaluate the utility of neck dissections in patients undergoing salvage laryngectomy with a clinically negative neck. STUDY DESIGN: Retrospective cohort study. METHODS: This retrospective review identified 71 patients with N0 necks who underwent salvage laryngectomy from 2001 to 2007. The standard practice of surgeons within our institution was different, thus neck dissections were performed on approximately one half of the patients, creating two groups for comparison. The number of neck dissections with positive metastasis were examined. Postoperative complications, overall survival, and site of recurrence were compared between patients with neck dissection and no neck dissection. RESULTS: Thirty-eight patients underwent 71 neck dissections concurrently with salvage laryngectomy. A total of 33 patients had salvage laryngectomy without neck dissection. Only three of 71 neck dissections (4%) had positive nodal metastasis. The rate of fistula, wound infection, hematoma/bleeding, chyle leak, wound dehiscence, and flap failure did not reveal any statistical differences. However, the overall complication rate in neck dissections patients was higher (42.2 %) than no neck dissections (21.3%; P = .04). Neck dissection patients had a higher proportion of fistulas (32%) than no dissections (18%; P = .2). Regional failure occurred in 7.9% of the patients with neck dissections and 15% of patients without neck dissection (P = .5). There was no survival advantage for patients who underwent neck dissection compared to no neck dissection (P = .47). CONCLUSIONS: There was no survival advantage gained by performing neck dissection in the clinically negative neck. However, a trend toward reduced regional failure with neck dissection must be balanced by the increased potential for complications and fistulae.

Indications and outcomes of double free flaps in head and neck reconstruction.

OBJECTIVE: This study describes the clinical setting and operative outcomes for simultaneous double free flap treatment of extensive composite head and neck cancers. METHODS: A retrospective review at two tertiary referral centers was performed. Patient demographics, cancer characteristics, reconstruction methods, and postoperative course were recorded. All patients were assessed for diet, speech, esthetics, socialization, and satisfaction using specific evaluation scales. RESULTS: A total of 30 patients underwent double free flap reconstruction between 2001 and 2007. There were 19 men and 11 women, mean age of 62 years (range, 42-79). Comorbidities were present in 67% of the cases and 70% smoked. Most frequently the cancer was a squamous cell carcinoma (90%), in advanced stage (87%), and recurrent (67%), affecting the oral cavity (43%), larynx (23%) or pharynx (20%). The fibula osteoseptocutaneous/radial forearm fasciocutaneous flap combination was most commonly used (n = 13), followed by the jejunum-radial forearm flap (n = 10). Three flaps required early anastomosis revision and only two partial flap losses were observed. In 11 cases, there was a severe recipient site complication: wound dehiscence (n = 3), oral incompetence (n = 4), fistula (n = 2), and stenosis (n = 2). Two patients died in the postoperative period due to medical problems (7%). The mean follow up was 15.3 months. Patient satisfaction was poor to moderate and the overall functional evaluation score was low. CONCLUSIONS: Double free flaps for one-stage reconstruction of extensive head and neck defects should be used in selected cases. Although a reliable procedure, immediate postoperative morbidity and mortality is high, and the long-term functional and esthetic results are modest. Realistic outcomes should be discussed with patients during planning and consent.

Modulation of tumor cell growth in vivo by extracellular matrix metalloprotease inducer.

OBJECTIVE: To investigate if loss of extracellular matrix metalloprotease inducer (EMMPRIN) will inhibit the growth of head and neck squamous cell carcinoma (HNSCC) tumor cell lines in vivo. Tumor cell-derived EMMPRIN is highly overexpressed in HNSCC and is thought to be induced by surrounding fibroblasts to stimulate matrix metalloproteases, which modulate tumor cell invasion, growth, and angiogenesis. DESIGN: In vivo study using FaDu tumor xenografts. SETTING: Academic research facility. SUBJECTS: Severe combined immunodeficiency (SCID) mice. INTERVENTIONS: The HNSCC cell line FaDu was transfected with EMMPRIN (FaDu/E), control vector (FaDu), or plasmid-expressing small-interfering RNA against EMMPRIN (FaDu/siE). Tumor cells combined with fibroblast cells were xenografted onto the flank of SCID mice. Tumors were measured biweekly over 4 weeks, at which time the mice were killed, and tumor samples were analyzed for proliferation (Ki-67 immunohistochemical analysis), vascularization (factor VIII staining), and apoptosis (TUNEL [terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling] assay). MAIN OUTCOME MEASURE: Growth of head and neck cancer cell lines genetically engineered to express variable levels of EMMPRIN. RESULTS: Tumor growth positively correlated and animal survival negatively correlated with increasing EMMPRIN expression. FaDu/E tumor growth was significantly larger at 4 weeks compared with FaDu tumors (P = .006). Similarly, the control vector-transfected FaDu tumors were significantly larger than FaDu/siE (P < .001). Immunohistochemical analysis demonstrated increased Ki-67 in EMMPRIN-transfected cells, without a significant change in the rate of apoptosis between groups. Vascular density and tumor formation rate also increased significantly with EMMPRIN expression. CONCLUSION: This study suggests that anti-EMMPRIN-targeted therapy may prove to be a novel treatment option in HNSCC.

Pretreatment swallowing exercises improve swallow function after chemoradiation.

OBJECTIVES/HYPOTHESIS: Swallowing dysfunction is a devastating complication of chemoradiation therapy (CRT) for head and neck squamous cell carcinoma. We have previously demonstrated that pretreatment swallowing exercises improve posttreatment swallowing-related quality of life. This study evaluates the effect of pretreatment swallowing exercises on posttreatment swallow function as measured by videofluoroscopy. STUDY DESIGN: Retrospective case control. METHODS: Eighteen patients with advanced squamous cell carcinoma of the oropharynx, hypopharynx, and larynx treated at University of Alabama at Birmingham with CRT were included in the study. Nine patients received pretreatment swallowing exercises prior to CRT, and nine patients received swallowing exercises during routine posttreatment management. Approximately 3 months after completing treatment, standard videofluoroscopy examinations were conducted. Outcomes measured by the videofluoroscopy examinations included hyoid elevation, epiglottis inversion, tongue base movement, cricopharyngeal opening, and Rosenbeck aspiration score. Percutaneous endoscopic gastrostomy (PEG) tube use was assessed at 12 months after treatment. RESULTS: Epiglottis inversion was better maintained (P = .05) in patients receiving pretreatment swallowing therapy. The position of the tongue base during swallowing was also significantly closer to the posterior pharyngeal wall (P = .025) for patients receiving pretreatment exercises. PEG tube removal rates did not significantly differ between groups. CONCLUSIONS: Performing pretreatment swallowing exercises produces measurable improvements in posttreatment swallowing function in patients who undergo organ-preservation CRT for head and neck cancer. This study provides an initial foundation for the development of noninvasive, cost-effective, evidence-based interventions in this group of vulnerable patients.