An extended toboggan technique for resection of substernal thyroid goiters.

We describe our technique for the safe resection of substernal thyroid goiters. Early mobilization of the thyroid gland from tracheal attachments anteriorly and laterally facilitates extraction of the goiter from the mediastinum. Retrograde dissection through the ligament of Berry on the ipsilateral side can also facilitate identification of the recurrent laryngeal nerve and delivery of the substernal portion of the gland. We describe 2 representative cases in which we successfully used this technique.

Outcomes in head and neck reconstruction by surgical site and donor site.

OBJECTIVES/HYPOTHESIS: Define surgical outcomes of specific donor sites for free tissue transfer in head and neck reconstruction. STUDY DESIGN: Retrospective cohort review at an academic tertiary care center. METHODS: A review was made of free tissue transfer procedures performed at a university-based tertiary care facility from October 2004 to April 2011. A total of 1,051 patients underwent six types of free flaps: fasciocutaneous radial forearm (53%), osteocutaneous radial forearm (16%), rectus abdominis (11%), fibula (10%), anterior lateral thigh (7%), and latissimus dorsi (2%). Demographic data were collected, and outcomes measured were: length of hospital stay, flap viability, and major complications (infection, fistula, and hematoma). RESULTS: Of the 1,051 flaps performed, the most common operative site was oral cavity (40%, n = 414) followed by hypopharynx/larynx (22%, n = 234), cutaneous (20%, n = 206), oropharynx (9%, n = 98), midface (7%, n = 76), and skull base (2%, n = 23). The median hospital stay was 7.9 days (range, 1-76), and the overall failure rate was 2.8%. Cutaneous defects required the shortest length of hospitalization (5.8 days, P < .0001), a low free flap failure rate (1.5%, n = 3), and limited major complications (6%, n = 12). Conversely, oropharynx defects were associated with the longest hospitalization (8.9 days). Midface defects had a high incidence of complications (15%, n = 11, P = .10). Defects above the angle of the mandible had higher overall complications when compared to below. Similarly, reconstruction for primary or recurrent cancer had a total failure rate of 2.5%, whereas secondary reconstruction and radionecrosis had a failure rate of 4.0% (P = .29). Additionally, there was no statistical difference between outcomes based on donor site. CONCLUSIONS: This review demonstrates that certain subsets of patients are at higher risk for complications after free tissue transfer. Patients undergoing free flap reconstruction for cutaneous defects have substantially shorter hospital stays and are at lower risk of flap complications, whereas reconstruction for radionecrosis and secondary reconstruction tend to have higher overall flap failure rates.

Primary versus delayed tracheoesophageal puncture for laryngopharyngectomy with free flap reconstruction.

OBJECTIVES: To determine whether postoperative complication rates and speech outcomes differ between patients undergoing primary versus secondary tracheoesophageal puncture following total laryngectomy with free flap reconstruction. STUDY DESIGN: Retrospective clinical study in a tertiary academic center. METHODS: Between November 2004 and June 2010, 137 patients underwent total laryngectomy or laryngopharyngectomy with pharyngeal free flap reconstruction for malignant disease. Data was collected on patient and operative demographics, early postoperative complications, speech outcomes, and predictive factors for tracheoesophageal puncture failure. RESULTS: Thirty patients (22%) had a primary tracheoesophageal puncture performed at the time of laryngectomy, 27 patients (20%) received secondary punctures (>3 months postlaryngectomy), and 80 patients (58%) never received a puncture. Patient and operative demographics were similar between groups (P < .05), apart from proportionately more hypopharyngeal tumors in the "no puncture" group (P < .002). Similar numbers of patients in primary and secondary puncture groups achieved intelligible speech (67% vs. 71%, P = .82) and both groups reported good patient-perceived voice-related quality of life. Salvage surgery and nonpatch radial forearm free flap reconstruction both trended toward increased early postoperative complication rates (P = .09). CONCLUSIONS: There is no difference in the early postoperative complication rate for primary versus secondary tracheoesophageal puncture following total laryngectomy with concurrent free flap reconstruction. Radial forearm patch free flap reconstruction achieves good speech outcomes.

Minimally invasive parathyroidectomy: use of intraoperative parathyroid hormone assays after 2 preoperative localization studies.

OBJECTIVES: To review minimally invasive parathyroidectomy (MIP) in patients undergoing initial surgical management of primary hyperparathyroidism (HPT) with preoperative, localizing sestamibi scanning (MIBI), and concordant ultrasonography (US) to determine if intraoperative parathyroid hormone (iPTH) is necessary in these cases. Minimally invasive parathyroidectomy has become an acceptable therapeutic option in treating primary HPT. Preoperative MIBI scanning, high-resolution US with color Doppler flow, and iPTH monitoring have refined this technique. DESIGN: Retrospective review. PATIENTS: The medical records of 738 consecutive patients who had undergone surgery for HPT. After excluding revision surgical procedures, secondary and tertiary HPT, unavailable intraoperative parathyroid (PTH) data, concomitant thyroid disease requiring thyroidectomy, and patients without preoperative MIBI or US, 428 patients (58%) were included in the study. RESULTS: The mean decrease in PTH level was 85%. Of the 428 patients with primary HPT included in the study, 209 patients (49%) had localizing, concordant preoperative MIBI and US. A decline of more than 50% in iPTH levels was observed in 202 patients (97%) after removal of parathyroid tissue localized by MIBI and US. The procedures for 4 patients were converted to bilateral neck explorations after the postexcision PTH level failed to drop less than 50%. CONCLUSIONS: Our results show that iPTH monitoring may be eliminated in MIP surgery in a carefully selected group of patients who have preoperative, localizing MIBI with concordant US. This potentially allows an increase in operating room efficiency and a decrease in costs while performing MIP.

Zygomatic-maxillary buttress reconstruction of midface defects with the osteocutaneous radial forearm free flap.

BACKGROUND: The purpose of this study was to evaluate morbidity, functional, and aesthetic outcomes in midface zygomatic-maxillary buttress reconstruction using the osteocutaneous radial forearm free flap (OCRFFF). METHODS: A retrospective review of 24 consecutive patients that underwent midface reconstruction using the OCRFFF was performed. All patients had variable extension of maxillectomy defects that requires restoration of the zygomatic-maxillary buttress. After harvest, the OCRFFF was fixed transversely with miniplates connecting the remaining zygoma to the anterior maxilla. The orbital support was given by titanium mesh when needed that was fixed to the radial forearm bone anteriorly and placed on the remaining orbital floor posteriorly. The skin paddle was used for intraoral lining, external skin coverage, or both. The main outcome measures were flap success, donor-site morbidity, orbital, and oral complications. Facial contour, speech understandability, swallowing, oronasal separation, and socialization were also analyzed. RESULTS: There were 6 women and 18 men, with an average age of 66 years old (range, 34-87). The resulting defects after maxillectomy were (according to the Cordeiro classification; Disa et al, Ann Plast Surg 2001;47:612-619; Santamaria and Cordeiro, J Surg Oncol 2006;94:522-531): type I (8.3%), type II (33.3%), type III (45.8%), and type IV (12.5%). There were no flap losses. Donor-site complications included partial loss of the split thickness skin graft (25%) and 1 radial bone fracture. The most significant recipient-site complications were severe ectropion (24%), dystopia (8%), and oronasal fistula (12%). All the complications occurred in patients with defects that required orbital floor reconstruction and/or cheek skin coverage. The average follow-up was 11.5 months, and over 80% of the patients had adequate swallowing, speech, and reincorporation to normal daily activities. CONCLUSIONS: The OCRFFF is an excellent alternative for midface reconstruction of the zygomatic-maxillary buttress. Complications were more common in patients who underwent resection of the orbital rim and floor (type III and IV defects) or external cheek skin.

Fluorescent detection of rat parathyroid glands via 5-aminolevulinic acid.

OBJECTIVE: Anatomic identification of parathyroid glands during surgery is challenging and time consuming. We sought to determine whether 5-aminolevulinic acid (5-ALA) could produce parathyroid gland fluorescence to improve their detection in a preclinical model. METHODS: Thirty-two rats were administered 0 to 700 mg/kg of 5-ALA by intraperitoneal injection prior to neck exploration under the illumination of a blue light (380-440 nm). Tissue fluorescence was assessed at 1, 2, or 4 hours postinjection and then removed for histologic confirmation of parathyroid tissue. RESULTS: Rat parathyroid glands could not be visualized under ambient light. At dosages of 300 mg/kg or greater, bilateral parathyroid glands were visualized in 18 of 19 rats using blue light illumination. At dosages less than 300 mg/kg, parathyroid gland fluorescence was detected in only 1 of 13 rats. At 2 hours after 5-ALA administration, the net mean intensity of parathyroid gland fluorescence was optimal with a dose of 500 mg/kg. At both 1 and 4 hours after 5-ALA injection, the net mean intensity of parathyroid gland fluorescence was optimal at the highest dose (700 mg/kg) and positively correlated with dosage increases. CONCLUSION: 5-ALA can be used to selectively detect parathyroid tissue from surrounding tissue in a preclinical model. Our data support the use of this technique in the clinical setting.

Locoregionally advanced head and neck cancer treated with primary radiotherapy: a comparison of the addition of cetuximab or chemotherapy and the impact of protocol treatment.

PURPOSE: The addition of platinum-based chemotherapy (ChRT) or cetuximab (ExRT) to concurrent radiotherapy (RT) has resulted in improved survival in Phase III studies for locoregionally advanced head and neck cancer (LAHNC). However the optimal treatment regimen has not been defined. A retrospective study was performed to compare outcomes in patients who were treated definitively with ExRT or ChRT. METHODS: Cetuximab with concurrent RT was used to treat 29 patients with LAHNC, all of whom had tumors of the oral cavity, oropharynx, or larynx. All patients were T2 to T4 and overall American Joint Committee on Cancer Stage III to IVB, with a Karnofsky Performance Status (KPS) score of 60 or greater. ChRT was used to treat 103 patients with similar characteristics. Patients were evaluated for locoregional control (LRC), distant metastasis-free survival (DMFS), disease-specific survival (DSS), and overall survival (OS). Median follow-up for patients alive at last contact was 83 months for those treated with ExRT and 53 months for those treated with ChRT. Cox proportional hazard models were used to assess independent prognostic factors. RESULTS: The LRC, DMFS, and DSS were not significantly different, with 3-year rates of 70.7%, 92.4%, and 78.6% for ExRT and 74.7%, 86.6%, and 76.5% for ChRT, respectively. The OS was significantly different between the two groups (p = 0.02), with 3-year rates of 75.9% for ExRT and 61.3% for ChRT. OS was not significant when patients who were on protocol treatments of ExRT or ChRT were compared. Also, OS was not significant when multivariate analysis was used to control for potential confounding factors. CONCLUSION: In our single-institution retrospective review of patients treated with ExRT or ChRT, no significant differences were found in LRC, DMFS, DSS, or OS.

The role of ultrasonography in parathyroid surgery.

OBJECTIVE: To assess the role of high-resolution ultrasonography in the preoperative evaluation of patients with hyperparathyroidism. DESIGN: Retrospective cohort. SETTING: Tertiary care university hospital. PATIENTS: Three hundred seventeen patients with hyperparathyroidism who underwent preoperative assessment with ultrasonography and/or sestamibi scan and surgical treatment between October 2003 and October 2006. MAIN OUTCOME MEASURES: Descriptive statistics of localization imaging studies and detection of concomitant thyroid disease in patients presenting with hyperparathyroidism. RESULTS: Ultrasonography correctly localized the parathyroid adenoma(s) in 148 (69.4%) of the 229 patients with these lesions. Sestamibi scans correctly localized the parathyroid adenoma(s) in 133 (58.1%) of the 229 patients. The agreement between the 2 imaging procedures was moderate (kappa = 0.23; 95% confidence interval, 0.12-0.36). Of 317 patients with hyperparathyroidism, 96 (30.3%) had clinically significant concomitant thyroid disease requiring partial or total thyroidectomy. Histopathologic examination revealed benign thyroid disease in 80 (83.0%) of the 96 patients and thyroid carcinoma in 16 (16.6%). CONCLUSION: Ultrasonography is a useful tool in the preoperative evaluation of patients with hyperparathyroidism both for localization of parathyroid adenomas and for the diagnosis of concomitant thyroid disease.

Free tissue transfer to manage salvage laryngectomy defects after organ preservation failure.

OBJECTIVE: Salvage laryngectomy to treat organ preservation failures results in significantly higher local wound complications. Even in the absence of extralaryngeal disease, primary closure of laryngeal defects can result in protracted wound care problems. We hypothesize that even when sufficient mucosa is present to close the defect primarily, introduction of vascularized tissue to close the defect may improve outcomes. DESIGN: Retrospective case-control study. SETTING: Two academic tertiary care centers. PATIENTS AND METHODS: Patients undergoing salvage surgery for laryngeal squamous cell carcinoma between 2000 to 2006 were considered for this study. Patients requiring total laryngopharyngectomy or partial pharyngectomy were excluded. There were 37 patients who met study criteria: 17 patients underwent free flap reconstruction (16 radial forearm flaps and 1 rectus flap), and 20 patients underwent primary closure. The median follow-up was 12 (range, 4-60) months. Previous treatment consisted of chemoradiation for 41% of the reconstruction group and 35% of the primary closure group; the remainder were treated with primary radiation alone. MAIN OUTCOME MEASURES: Pharyngocutaneous fistula, stricture, length of hospitalization, feeding tube dependence. RESULTS: The free flap reconstruction group had a lower rate of fistula (18%) compared with the primary closure group (50%). A lower rate of stricture formation (18% vs. 25%) and feeding tube dependence (23% vs. 45%) was observed in the free flap reconstruction group compared with the primary closure group. The development of a fistula in either group resulted in a prolonged hospital stay (mean, 19 vs. 7 days) and additional procedures. CONCLUSION: Planned reconstruction of salvage laryngectomy defects with vascularized tissue is associated with a lower fistula rate and may improve outcomes.

Expandable tracheal stenting for benign disease: worth the complications?

OBJECTIVES: To characterize the limitations of self-expandable stents in the management of benign tracheal stenosis, we performed a retrospective review at a tertiary care medical center. METHODS: Patients who underwent tracheal stenting were assessed for the cause and severity of tracheal stenosis, comorbidities, stent-related complications, and follow-up airway procedures. RESULTS: Sixteen adults (12 women, 4 men; mean age, 47 years) had a total of 26 stents placed for benign disease. Intubation-related stenoses were most frequent (81%). The average follow-up time was 20 months (range, 1 to 40 months). Each stent remained functional for an average of 12.4 months. In the study group, 87% had a complication that required surgical intervention to maintain a patent airway. The most common problem was granulation tissue formation at the ends of the stent causing airway restenosis (81%), and 5 patients (31%) required tracheotomy as a result of restenosis around the stent. Fourteen of the stents (56%) were removed or expelled from the patients. CONCLUSIONS: The implantation of self-expandable stents is a minimally invasive method of managing benign tracheal stenosis. Although a small subset of patients may benefit from placement, the majority of patients have complications that require intervention to maintain a patent airway. Thoughtful discretion is critical in selecting patients for this intervention.

Preemptive vessel dilator cricothyrotomy aids in the management of upper airway obstruction.

PURPOSE: Our objective was to demonstrate that preemptive vessel dilator cricothyrotomy may be useful when managing the patient with airway obstruction. METHODS: An Institutional Review Board approved retrospective study was undertaken in 88 patients for whom this technique was selected. The anesthesiologists and surgeons identified as authors were directly involved in the care of these patients. All vessel dilator cricothyrotomies were performed in the operating rooms of University Hospital, UAB, Medical Center. The patients selected for this airway management technique were afflicted with some type of supraglottic lesion, usually squamous cell carcinoma, which was obstructing their airways to an extent that complete airway obstruction during induction of anesthesia was a significant possibility. Prior to induction of anesthesia, the vessel dilator was inserted into the tracheal lumen through the cricothyroid membrane as described. Oxygenation was maintained with jet ventilation from a Sanders jetting device. Age, sex, weight, initial and lowest O(2) saturation, first recorded ETCO(2), blood pressure and duration of jet ventilation were recorded. RESULTS: The airways were successfully managed in all 88 patients with this technique. There were no deaths, and no postoperative hypoxic sequelae; also complications were minor. CONCLUSION: Vessel dilator cricothyrotomy as a preemptive procedure in the management of patients with significant supraglottic airway obstruction may be a useful addition to the anesthesiologists' armamentarium of airway management devices.

Use of negative pressure dressings in head and neck reconstruction.

BACKGROUND: Head and neck microvascular surgery commonly requires management of complex wounds of the upper aerodigestive tract and donor sites. Negative pressure dressings have been reported to promote healing in compromised wounds. METHODS: Between February 2001 and June 2004, data were collected in a retrospective manner on 23 patients who underwent treatment with negative pressure dressings at two tertiary care institutions. RESULTS: Twenty-three patients underwent negative pressure wound treatment for donor site complications (n = 9) or head and neck wounds (n = 14) with a minimum of 5 months follow-up. Average duration of treatment was 6.5 days. Indications for use in wound complications included wound breakdown (n = 3), fistula with carotid exposure (n = 4), tendon exposure of donor site (n = 6), and others (n = 3). On average, granulation tissue was promoted in across 93% of the wound bed over the course of treatment. Two patients with anterior mandibular hardware exposure were managed successfully with negative pressure dressings. Large split-thickness skin grafts (average size, 135 cm2) at mobile sites were bolstered with negative pressure dressings in seven patients with an overall take rate of 74%. CONCLUSION: Although of limited use as a bolster for split-thickness skin grafts, negative pressure dressings are safe and effective in the management of complex head and neck wounds and in the treatment of donor site complications.

Extracellular matrix metalloprotease inducer-expressing head and neck squamous cell carcinoma cells promote fibroblast-mediated type I collagen degradation in vitro.

Until recently, tumor progression has been considered a multistep process defined by tumor cell mutations and the importance of the surrounding stroma poorly understood. It is now recognized that matrix-degrading enzymes that promote tumor cell invasion are elaborated by both tumor cells and fibroblasts in vivo. To determine the relative role of tumor cell-derived proteases compared with fibroblast-derived proteases, coculture experiments were done with each cell type using an in vitro model of type I collagen degradation. Head and neck squamous cell carcinoma cells in coculture with normal dermal fibroblasts showed matrix degradation, but neither cell type alone produced this effect. Manipulating the in vitro coculture environment showed that collagenolysis in this model was a result of fibroblast-derived matrix metalloproteases (MMP). To explore the possible role of extracellular matrix metalloprotease inducer (EMMPRIN) in this interaction, transfection of EMMPRIN into a cell line with low endogenous EMMPRIN expression was done and showed a significant increase in collagenolysis. Inhibition of collagenolysis with a tissue inhibitor of metalloprotease-2 (TIMP-2) and a synthetic furin inhibitor was observed but not with TIMP-1, which suggested a possible role for membrane type-1 MMP. These results suggest that fibroblast-derived MMPs but not those from tumor cells are important for in vitro collagenolysis and that this process is promoted by tumor cell-expressed EMMPRIN.

Expression of proteolytic enzymes in head and neck cancer-associated fibroblasts.

OBJECTIVE: To elucidate tumor-stromal interactions during tumor invasion by assessing the expression of proteolytic enzymes by carcinoma-associated fibroblasts (CAFs) in vivo using complementary DNA (cDNA) array analysis. METHODS: Tumor-associated stroma was isolated from tumor and adjacent mucosal specimens of the same patient by laser capture microdissection, and the messenger RNA (mRNA) was assessed by cDNA microarray specific for proteolytic enzymes and their inhibitors. Protein overexpression was then analyzed by immunoblotting of primary fibroblast isolates derived from skin, mucosa, and tumor specimens. RESULTS: Array analysis of 4 tumor and 4 adjacent mucosal samples demonstrated significant (2.6-fold) overexpression of membrane type 1 matrix metalloproteinase (MT1-MMP) but not of serine proteases or other matrix metalloproteinases. Analysis of normal dermal fibroblasts, normal mucosal fibroblasts, and CAFs similarly demonstrated up-regulation of MT1-MMP. CONCLUSIONS: These results suggest that MT1-MMP mRNA is specifically up-regulated in CAFs in vivo whereas MT1-MMP protein is specifically up-regulated in CAFs in vitro. Known to induce tumor cell invasion when expressed in tumor cells, CAF expression of MT1-MMP may be important in the stromal response to tumor cells that characterizes the desmoplastic reaction.

Expression of extracellular matrix metalloprotease inducer in laryngeal squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Head and neck cancer tumor cell invasion is responsible for both local destruction and distant metastasis. Invasion is largely mediated by matrix metalloproteases that are thought to be induced by tumor cell derived extracellular matrix metalloprotease inducer (EMMPRIN) in surrounding fibroblasts. We hypothesize that EMMPRIN is overexpressed in laryngeal cancer. STUDY DESIGN: Retrospective analysis of patients with supraglottic laryngeal cancer. METHODS: Total protein immunoblotting and immunohistochemical analysis of normal and malignant tissue were performed to determine EMMPRIN expression. EMMPRIN immunoreactivity in 33 patients was correlated with clinicopathological features and survival. RESULTS: Whole-tissue lysates of tumors (n = 8) and metastatic lymph nodes (n = 2), but not normal skin (n = 8) or mucosa (n = 6), expressed significant amounts of EMMPRIN by immunoblotting. EMMPRIN membrane immunoreactivity (transmembrane EMMPRIN score) was associated with nodal positivity (P =.07), and it was a borderline significant predictor of survival (Hazards Ratio = 2.4; 95% CI, 0.88-6.55). As a categorical variable, higher transmembrane EMMPRIN score was associated with higher mortality. CONCLUSIONS: The present study helps to establish EMMPRIN as a widely expressed protein in dysplastic mucosa and supraglottic laryngeal cancer, but not in normal epithelial counterparts.

Three-dose vs extended-course clindamycin prophylaxis for free-flap reconstruction of the head and neck.

BACKGROUND: Twenty-four hours of perioperative antibiotics provides effective prophylaxis for most head and neck cancer resections. Many reconstructive surgeons have been hesitant to apply this standard to free-flap reconstruction of the head and neck. This prospective clinical trial compared short-course and long-course clindamycin prophylaxis for wound infection in patients with head and neck cancer undergoing free-flap reconstruction. METHODS: Seventy-four patients were randomized to receive short-course (3 doses) or long-course (15 doses) clindamycin perioperatively. Wound infections, fistulas, and other postoperative complications were documented by faculty surgeons who were blinded as to treatment group. RESULTS: The differences in wound infections and other complications were statistically insignificant. No other independent predictors of wound complications emerged in this series of patients. CONCLUSIONS: Short-course clindamycin is as effective as long-course clindamycin in preventing wound infections after free-flap surgery for head and neck ablative defects.

Use of the endoscopic microdebrider in the management of airway obstruction from laryngotracheal carcinoma.

Endoscopic debridement of obstructing laryngotracheal carcinoma with the microdebrider is an alternative to CO2 laser excision or emergency tracheotomy. This is a retrospective study of 27 patients with advanced laryngotracheal carcinoma treated with the microdebrider for airway obstruction from 1998 to 2002. In 26 patients, the carcinoma was debrided successfully and tracheotomy was safely avoided. Postoperative bleeding was encountered in 1 patient with a coagulopathy. Two of the patients later required tracheotomy during radiotherapy secondary to radiation-induced laryngeal edema. Both were safely managed without acute airway compromise. Laryngeal debridement provided up to 3 months of stable airway until definitive oncological treatment was performed. Endoscopic microdebridement of obstructing carcinoma is a relatively simple and highly accurate approach to restoring a stable airway. It provides extra time for preoperative oncological, psychological, and nutritional planning.