Comparison between the radial forearm and superficial circumflex iliac artery perforator free flaps for oral soft tissue reconstruction.

The radial forearm free flap (RFFF) is widely used for oral reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap is an increasingly utilized alternative. The cases of 165 patients who received either an RFFF or SCIP flap for oral reconstruction at Chris O'Brien Lifehouse, Sydney were reviewed. The aim was to report on patient, pathology, treatment, and outcome variables and to compare these between the two flap groups. A RFFF was used in 126 patients and a SCIP flap in 39 patients. SCIP flap patients were younger (P < 0.001) and had shorter operative times (P < 0.001), shorter anaesthetic times (P < 0.001), and more frequent recipient site dehiscence (P = 0.005) when compared to RFFF patients. The SCIP flap was significantly less frequently used for composite resections including bone when compared to the RFFF (P < 0.001). The primary site distribution was more even for RFFF patients (P < 0.001). There were no SCIP flap failures; three RFFF failures occurred. SCIP flaps performed comparably in terms of operative and clinical outcomes. Most SCIP flaps were utilized in younger patients with partial glossectomy defects.

A pilot study of intensive intervention using a novel trismus device.

PURPOSE: Trismus secondary to head and neck neoplasm treatment impacts upon quality of life, nutrition, oral hygiene, and dentition. Current treatment options for trismus apply unquantified force to the jaw, and in many cases, the device costs are prohibitive. This study aimed to prospectively evaluate the impact of a novel trismus device. METHOD: This single arm cohort study prospectively evaluated the impact of a novel trismus device on maximal incisal opening (MIO), trismus-related function and quality of life scores. Seventeen patients diagnosed with trismus were recruited to undergo a 10-week program using a novel device. The effect of the intervention was assessed by comparing pre- vs post-intervention validated measures. RESULT: A significant improvement in MIO was observed post the 10-week intervention period (12.6 mm). This was associated with an improvement in patient reported trismus symptomology including quality of life, swallowing, speech, and jaw pain. CONCLUSIONS: This pilot study demonstrates the feasibility of a novel device in the treatment of trismus. Further evaluation of this device is warranted to assess efficacy, safety, and cost-effectiveness in a larger cohort with appropriate controls.

Phosphaturic Mesenchymal Tumors in the Head and Neck Demonstrate a Broad Clinical and Morphologic Spectrum.

Phosphaturic mesenchymal tumour (PMT) is a rare tumour that occurs in bone or soft tissue and is associated with production of fibroblast growth factor 23 (FGF23) leading to tumor-induced osteomalacia. We report three cases of PMT involving the head and neck that highlight the broad spectrum of clinical and histologic features of PMT. One of these lesions from the hard palate demonstrated an admixture of epithelial and mesenchymal elements, a feature that can pose a diagnostic challenge. The diagnostic utility of immunohistochemistry including FGF23, somatostatin receptor 2A, SATB2, ERG and CD56 is discussed. The biochemical pathway in the development of PMT associated tumor induced osteomalacia and its role in investigations and management of PMT is also described.

Institutional-based and commercial virtual surgical planning in maxillomandibular reconstruction - Comparing the digital plan and postoperative scan.

BACKGROUND: Virtual surgical planning (VSP) is increasingly used in maxillomandibular osseous free flap reconstruction. Non-commercial ('in-house') VSP may offer the same level of accuracy and other benefits, without the inflated costs and time delays inherent in using commercial providers. Comparisons between commercial and in-house methods are lacking. This study aims to determine the accuracy of VSP, compare in-house and commercially planned cases, and explore predictors of the reconstruction error. METHODS: Seventy-six patients who had a virtually planned maxillomandibular reconstruction between January 2012 and July 2020 were retrospectively identified. The preoperative digital plan was compared to the postoperative CT scan in terms of length of bone segments, angle between adjacent segments and intercondylar, and intergonial angle distances (mandibular reconstructions only). RESULTS: Forty-four patients fulfilled the inclusion criteria. The mean intergonial and intercondylar distances error was 1.7 ± 1.01 mm, mean segment length error was 1.3 ± 1.40 mm, and mean angles error was 1.9 ± 2.32°. The difference in error of in-house VSP compared to commercial VSP was not statistically significant for intercondylar and intergonial distance (p = 0.76), segment length (p = 0.15), or angle between segments (p = 0.92). The increased error was associated with osteoradionecrosis as the indication for surgery, greater number of segments, and secondary reconstructions. CONCLUSION: VSP is an accurate method of maxillary and mandibular reconstruction. In-house VSP may be similar in accuracy to commercial VSP options. Higher levels of inaccuracy are likely to occur in more complex reconstructions, particularly secondary reconstructions, and in the setting of osteoradionecrosis.

Systematic review and meta-analysis of the complications of salvage total laryngectomy.

BACKGROUND AND OBJECTIVES: Management paradigms in laryngeal cancer have shifted to "organ preservation" chemoradiotherapy protocols. In the event of treatment failure, salvage total laryngectomy remains the only curative treatment option. However a comprehensive review of the complications of this procedure has not been reported. METHODS: A systematic review of the literature was performed using keywords "salvage laryngectomy" to retrieve relevant publications between January 2000 and August 2015. RESULTS: Of the 407 articles retrieved from the literature search, 50 studies encompassing 3292 patients were included. Forty-nine studies reported pharyngocutaneous fistula which occurred in 859 patients (pooled incidence 28.9%; 95% confidence intervals 25.5-32.5%). Twenty-four studies reported complications in addition to PCF and these included wound complications (infection, dehiscence and necrosis), dysphagia, bleeding, and pharyngeal and stomal stenosis. CONCLUSIONS: Overall complication rate was 67.5%, Pharyngocutaneous fistula was the commonest complication with a pooled incidence of 28.9%.

Endoscopic vocal fold injection using a 25-gauge butterfly needle.

OBJECTIVE: To describe a useful technique for infiltrating a bulking agent using a butterfly needle, as part of a transoral endoscopic vocal fold medialisation procedure. METHODS: This paper describes the procedure of grasping the needle with phonosurgery forceps and administering the injectate to the vocal fold through careful application of the syringe plunger via a length of rubber tubing from outside the mouth. RESULTS: This procedure is performed routinely in our institution without complication. The advantages of this technique are discussed. CONCLUSION: This is a safe and easy method of injecting into a vocal fold.

Quality of life assessment in patients treated for metastatic cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: Treatment for metastatic cutaneous head and neck squamous cell carcinoma is usually multimodal and associated with morbidity. This study aimed to evaluate the impact of treatment on patients' quality of life. METHOD: Cross-sectional survey of 42 patients (35 men, 7 women) at least 6 months after metastatic cutaneous head and neck squamous cell carcinoma treatment, using two standardised quality of life questionnaires: the Functional Assessment of Cancer Therapy - Head and Neck questionnaire and the Facial Disability Index, with statistical analysis to identify potential predictors of outcome. RESULTS: Female gender correlated with significantly lower Facial Disability Index physical function scores (p = 0.017). Alcohol consumption correlated with significantly better scores for Functional Assessment social well-being (p = 0.016), general total score (p = 0.041) and overall total score (p = 0.033), and for Facial Disability Index physical function (p = 0.034). Marital status, education, employment, chemotherapy, time from last treatment, parotidectomy and facial nerve sacrifice did not affect quality of life. The commonest patient complaints were dry mouth (76 per cent), altered voice quality and strength (55 per cent), and physical appearance (45 per cent). CONCLUSION: Female gender predicts worse quality of life, while alcohol consumption (versus none) predicted for better quality of life.

In patients with metastatic cutaneous head and neck squamous cell carcinoma to cervical lymph nodes, the extent of neck dissection does not influence outcome.

BACKGROUND: This study aimed to compare recurrence and survival in patients undergoing either selective neck dissection or modified radical neck dissection to treat metastatic cutaneous head and neck squamous cell carcinoma to the cervical lymph nodes (levels I-V) only. METHODS: Twenty-eight year, retrospective analysis of a prospectively maintained database from a tertiary referral hospital, with a minimum follow up of two years. RESULTS: There were 122 eligible patients: 96 males (79 per cent) and 26 (21 per cent) females (median age, 66 years). Sixty-six patients (54 per cent) underwent selective neck dissection and 56 (46 per cent) modified radical neck dissection. The former patients had a lower rate of regional recurrence compared with the latter (17 vs 23 per cent, respectively). There was no significant difference in five-year overall survival (61 vs 57 per cent, respectively) or five-year disease-free survival (74 vs 60 per cent, respectively), comparing the two groups. Overall survival and disease-free survival were significantly improved by the addition of adjuvant radiotherapy. CONCLUSION: We found no difference in outcome in patients undergoing selective versus modified radical neck dissection. Adjuvant radiotherapy significantly improved outcome.

Endoscopic treatment of glottic stenosis: a report on the safety and efficacy of CO2 laser.

BACKGROUND: Treatment of glottic stenosis is a considerable challenge to the otolaryngologist. Glottic airway patency can be compromised by bilateral vocal fold palsy, anterior webbing or a posterior segment scar, which may be significant enough to impair arytenoid movement. METHOD: A retrospective analysis of a prospective database of patients (n = 34) treated by a specialist airway surgeon. All patients underwent endoscopic treatment with a CO(2) laser in an attempt to improve airway calibre and, in 12 patients, to decannulate tracheostomy tubes. RESULTS: Twenty-one patients had bilateral vocal fold palsy and 13 had predominantly posterior glottic stenosis. A variety of pathology-directed treatment approaches were used to achieve good functional results. Four patients required a second endoscopic procedure. The overall revision rate was 5 per cent for bilateral fold palsy and 23 per cent for posterior glottic stenosis (p < 0.05). All patients had an adequate functional airway calibre, and all 12 tracheotomised patients were decannulated. DISCUSSION: Pathology-directed endoscopic laser surgery is safe and effective treatment for glottic stenosis. Rather prescriptive use of unilateral or bilateral cordotomy or combined cordo-arytenoidectomy, clinicians must perform the procedure that will treat the lesion most adequately. Our success rate compared favourably with the best reported results.

Metastatic cutaneous squamous cell carcinoma of the external ear: a high-risk cutaneous subsite.

INTRODUCTION: Patients with cutaneous squamous cell carcinoma of the external ear may develop metastatic spread to the nearby ipsilateral parotid and/or upper cervical lymph nodes. The literature suggests that the external ear is a high-risk subsite for such tumours, due to nodal metastasis and its associated morbidity and mortality. METHODS: Between 1980 and 2007, 43 patients with a diagnosis of metastatic cutaneous squamous cell carcinoma of the external ear were treated with surgery alone, surgery plus adjuvant radiotherapy, or radiotherapy alone. RESULTS: Patients comprised 39 men and four women. Their median age at diagnosis was 72 years, with a median follow up of 35 months. The median size of the primary lesion was 21 mm, with a median thickness of 7 mm. Fifteen patients presented concurrently with nodal metastases. Thirty patients developed parotid metastases (with positive cervical nodes in six patients), while 13 developed cervical metastases only. Eight patients underwent surgery alone, 32 underwent surgery plus adjuvant radiotherapy, and three received radiotherapy alone. At the last follow up, 15 patients had relapsed and nine had died of their disease, with a median survival after relapse of 5.5 months. CONCLUSION: Patients with metastatic cutaneous squamous cell carcinoma of the external ear have a relatively poor outcome, with a significant number of patients experiencing nodal relapse and death after treatment.

Evaluating the effects of oral prednisolone on recovery after tonsillectomy: a prospective, double-blind, randomized trial.

OBJECTIVES: To investigate the role of a 7-day course of oral prednisolone on recovery from tonsillectomy. STUDY DESIGN: Double-blind, randomized, placebo-controlled trial of 50 consecutive patients, aged 5 years and older, who had no previous or known contraindications to steroid therapy. METHODS: The patients were randomized at the time of surgery to either a 7-day course of daily placebo or prednisolone (dosage: 10 mg per day in patients aged 5-11 y, 0.5 mg/kg in those aged 12 and older). Age, sex, weight, diagnosis, tonsil size (in cm2), additional adenoidectomy, performing surgeon, method of dissection, length of procedure, total blood loss, intraoperative fluid requirement, and length of hospitalization were documented for each patient. During the first postoperative day, morning pain score, paracetamol use, oral fluid intake, temperature, presence of nausea and vomiting, level of activity (low, moderate, or normal), and type of diet (liquid, soft, or normal) were recorded. RESULTS: The steroid group consisted of a greater number of diathermy dissection cases and had significantly less intraoperative blood loss (P value = .022 and .017, respectively). On postoperative days 4 to 7, the steroid group experienced less nausea and vomiting (P value = .01, .04, .04, and .04, respectively). Paracetamol use was less in the steroid group on days 2, 7, and 8 (P value = .03, .02, and .02, respectively). There was no difference between the two groups for the other data measured. CONCLUSION: A 7-day course of corticosteroids may play a limited role in patients' recovery from tonsillectomy.

Fish bones at the cricopharyngeus: a comparison of plain-film radiology and computed tomography.

OBJECTIVES: To compare and contrast the use of plain film radiology and computed tomography (CT) scanning in the detection of fish bones at the level of the cricopharyngeus. STUDY DESIGN: Prospective study of 30 different fish bones placed at the level of the cricopharyngeus in a fresh human cadaver head and neck specimen and imaged using both plain films and CT scans. METHODS: Thirty different bones from 10 different local species of fish were selected and grouped as small, medium, or large in size. Both plain-film and CT images of the bones were reported by a radiologist as A, easily seen; B, seen on close inspection; or C, not seen. Results were analyzed using McNemar's test. RESULTS: CT scanning was superior to plain-film radiology in demonstrating the presence of fish bones at the level of the cricopharyngeus (P < .0001, McNemar's test, df = 1 when comparing report type A with B and C). CONCLUSION: The superior usefulness of CT scans in demonstrating the presence of fish bones lodged at the cricopharyngeus has been clearly shown in this study; therefore we advocated its use in selected cases.

[A study of seismic storms occurred from October 1989 to June 1990, in the neighborhood of Pico El Aguila and Piñango, Venezuelan Andes]. / Estudio de unas tormentas sísmicas en la región de El Aguila y de Piãnago, Andes Venezolanos, entre Octubre de 1989 y Abril de 1990.

Between October 1989 and June 1990 there were a large number of microearthquakes in the neighborhood of Pico El Aguila and Piñango, Mérida State, Venezuela. The epicenters form two clearly separated groups. The first one comprises events which occurred between October 1989 and March 1990. Their epicenters were located between 8.75 degrees N and 8.88 degrees N and between 70.75 degrees W and 70.88 degrees W. They are lined up in a northwest-southeast trend. The zone is crossed in its center by the Boconó fault zone, and the Valera fault is the northwest limit of the epicentral distribution. The second group of microearthquakes was recorded during April 1990, and its epicenters were located between 8.85 degrees N and 9.00 degrees N, and between 70.75 degrees W and 70.90 degrees W. They are lined up in a trend parallel to the first group. The Valera fault forms its southwest border, and the Piñango fault its northwest one. Based on the polarities, six composite focal mechanisms were constructed, three for the first group of events and three for the second one. In the first group, two mechanisms, one in each side of the Boconó fault zone, correspond to reverse faulting. A third mechanism, obtained from events close to the Boconó fault zone, correspond to a right-lateral strike-slip displacement. In the second group, two mechanisms correspond to reverse faulting and the third, located in the southwestern end of the lineation, close to the Valera fault, shows a left-lateral strike-slip mechanism. The Angelier graphical method was applied to the six mechanisms, which produced a range of acceptability for the orientation of the maximum stress axes between N 24 degrees W and N 51 degrees W. These characteristics can be explained by a mechanical model, postulated in this work for the study area, which explain the coexistence of reverse, right lateral strike slip and left lateral strike slip faulting under the same stress regime, assuming that this faulting occurs on preexisting faults. Some 25 Km northeast of the study area, the azimuth of the Boconó fault zone is approximately N 49 degrees E. In case that the orientation of the compression axis remains constant, this would mean, from the mechanics point of view, that the Boconó fault zone is a "weak" one, just as other strike-slip faults such as San Andreas Fault and the Big Sumatra Fault.

Model parameter optimization for site - dependent simulation of ground motion by simulated annealing : Re - evaluation of the Ashigara Valley prediction experiment

More than 40 groups from 10 different countries participated n a weak- and strong- motion prediction experiment at Ashigara Valley which required the blind prediction of time series, spectra and spectral ratios for selected and instrumented sedimentary sites with well-known geotechnical properties. The wide scatter of the results of this experiment have raised a number of questions as to how to model high-frequency ground motion in the presence of available geootechnical and geophysical data. The critical re-evaluation of our own prediction which was based on

Plasma 6-keto prostaglandin F1 alpha and thromboxane B2 in sick preterm neonates.

To determine if vascular abnormalities in preterm neonates might be related to vasoactive prostaglandins, stable prostacyclin (6-KPGF1 alpha) and thromboxane A2 (T X B2) metabolites in arterial blood were measured at less than or equal to 6 hours after birth and at 24, 48, and 72 hours using a radioimmunoassay. Neonates of less than 32 weeks gestation (N = 26) were diagnosed as having either the idiopathic respiratory distress syndrome (IRDS, N = 15) or pulmonary edema (PE, N = 11), and were also grouped according to the presence or absence of intracranial hemorrhage (ICH, N = 11) or patent ductus arteriosus (PDA, N = 10). Initial plasma 6-KPGF1 alpha was greater in neonates with ICH (0.23 +/- 0.04 ng/ml, mean +/- SE) than without ICH (0.11 +/- 0.04, p less than 0.05). Neonates with both ICH and IRDS (N = 8) had significantly elevated T X B2 at all sampling times compared to neonates with IRDS and no ICH (N = 7). Both T X B2 and 6-KPGF1 alpha increased with time in those with major ICH. Among neonates without ICH, 7 with IRDS had higher initial 6-KPGF1 alpha (0.19 +/- 0.07 ng/ml) and lower T X B2 (0.15 +/- 0.04 ng/ml) than 8 with PE (0.04 +/- 0.01 and 0.37 +/- 0.09 ng/ml, respectively). The initial 6-KPGF1 alpha (0.024 + 0.003 ng/ml), measured in neonates with PE and without PDA or ICH (N = 6), was significantly less than the corresponding value in the other neonates (0.201 +/- 0.036 ng/ml) (N = 20).

An evaluation of the efficiency of face masks in the resuscitation of newborn infants.

Five widely used neonatal face masks were tested on 44 babies for their efficiency in terms of degree of leakage and ease of cleaning. Leakage was measured indirectly. The mean peak pressure of ten breaths when babies were ventilated from a respirator via a mask was recorded; a low pressure was taken to indicate leakage. A triangular moulded rubber mask ('Rendell-Baker') leaked most and a circular silicone rubber mask ('Laerdal') leaked least. The ease of cleaning the masks was measured as the amount of bacteria removed from contaminated masks by wiping them with 70% ethanol. The Laerdal mask was significantly more effectively cleaned than the others. It is also the only one of the masks tested that can be boiled and autoclaved.

Effects of methylprednisolone on the response to group B streptococcal toxin in sheep.

The effects of pretreatment with methylprednisolone on the reaction to a toxin isolated from group B beta-hemolytic streptococci, type III, were studied in seven sheep instrumented for chronic measurements of pulmonary lymph flow and pulmonary artery and left atrial pressure. Each sheep was infused with toxin alone on one day and with methylprednisolone plus toxin on a different day in random order. The toxin alone caused a two-phase reaction. After the infusion of toxin, alone, in the initial phase, pulmonary artery pressure increased from 16 +/- 1 to 45 +/- 5 mm Hg and the rectal temperature rose from 39.5 +/- 0.14 to 40.8 +/- 0.18 degree C. During the second phase, the peripheral blood granulocyte count decreased to 10% of baseline values and the lung lymph protein clearance increased from 5.1 +/- 1.1 to 11.2 +/- 1.8 ml/h, suggesting increased pulmonary vascular permeability. Methylprednisolone pretreatment did not alter the initial phase of pulmonary hypertension or the febrile response but completely abolished the granulocytopenia and the increased pulmonary vascular permeability. These effects are unlikely to be related to inhibition of prostaglandin synthesis. Prevention of the lung vascular injury by methylprednisolone may be related to inhibition of granulocyte accumulation in the lung.

Recurrence of symptomatic patent ductus arteriosus in extremely premature infants, treated with indomethacin.

The administration of a single intravenous injection of indomethacin was followed by a major constrictive effect on the ductus in 36 of 42 very-low-birth-weight (less than or equal to 1000 gm) infants with symptomatic patent ductus arteriosus (PDA). In 26 of the 36 responders, the effect was sustained; symptomatic PDA recurred in the remaining 10. Infants who experienced a recurrence of symptomatic PDA had lower birth weights and had received indomethacin at an earlier postnatal age than did infants with a sustained effect. These results may be explained by differences in the production and clearance of prostaglandins or in the sensitivity of the ductus to prostaglandin effects between infants with a recurrence and infants with sustained constriction of PDA.

Preterm breech delivery. Early and late complications.

One hundred and ten singleton breech infants with a birth-weight less than 2 500 g have been delivered at Huddinge University Hospital during the years 1972-78. The cesarean section rate was 30.1 per cent. Vaginal and abdominal deliveries were compared with regard to perinatal mortality and asphyxial morbidity at birth. All infants born with reduced Apgar scores or traumatic birth injuries have been followed up. During a 6-year period 3 children born with low Apgar scores were found to have persistent sequelae. Two of these were considered to relate to the delivery. We conclude that cesarean section is of benefit for infants weighing 1 000-1 500 g. However, it is doubtful if abdominal delivery is of benefit for the fetus weighing 1 500-2 500 g. A high congenital anomaly rate (13.6 per cent) was found.