Risk factors of recipient site infection in head and neck cancer patients undergoing pectoralis major myocutaneous flap reconstruction.

The aim of this study was to investigate the factors associated with infection at the recipient site of pectoralis major myocutaneous flap (PMMF) of head and neck cancer patients. We retrospectively reviewed head and neck cancer patients who underwent PMMF reconstruction and identified those with recipient site infection. Variables of patients with and without infection were compared and associated factors were investigated by logistic regression model. A total of 478 patients were included in the final analysis and 183 patients (38.3%) developed recipient site infection. Lower margin of skin island, concurrent tracheotomy, diabetes mellitus, mandibular plate reconstruction, prior radiation, and peri-operative blood transfusion were independent factors associated with recipient site infection of PMMF. Skin island of PMMF beyond the eighth intercostal space markedly increased the risk of recipient site infection after major head and neck cancer surgery. Recognition of relevant factors associated with infection may help surgeons to identify those at risk.

The association between surgical site infection and previous operation in oral cavity cancer patients.

We investigated the post-operative surgical site infection (SSI) rate in oral cavity cancer patients who had previous operation in the oral cavity region and compared it with that of patients without previous operation. We retrospectively reviewed over 1,000 chart records of oral cavity cancer patients from January 2004 to November 2010 and relevant data were collected. Statistical methods included descriptive statistics, bivariate analyses, and a multiple logistic regression model for investigating the relevant factors of post-operative SSI. A total of 894 patients were enrolled in the final analyses. The overall post-operative SSI rate was 20.8%. Previous history of operation was identified in 173 patients (19.4%). There was no significant difference in post-operative SSI rate between the patients with previous operation and those without (22.5 vs. 20.4%, P = 0.601). Previous operation in the oral cavity region was not associated with increased post-operative SSI rate in oral cavity cancer patients.

Voice low tone to high tone ratio, nasalance, and nasality ratings in connected speech of native Mandarin speakers: a pilot study.

OBJECTIVE: Voice low tone to high tone ratio (VLHR) is defined as the power ratio of a voice spectrum with a specific cut-off frequency. Previous studies have shown that there are significant correlations between VLHR and nasalance and hypernasality ratings in vowels. The correlation was investigated in this study using connected speech material. DESIGN: The Zoo Passage, the Rainbow Passage, the English Nasal Sentences, the Mandarin Nonnasal Sentences, and the Mandarin Nasal Sentences were used to acquire VLHRs, nasalance scores, and perceptual judgments of nasality. Each passage was recorded twice for averaging, and the cut-off frequencies from 200 Hz to 1200 Hz were used to survey for the presence of optimal correlations with VLHR. Participants : Ten native Mandarin speakers with an English learning history of over 8 years were enrolled. Main outcome measures : VLHRs, nasalance scores, and hypernasality ratings. RESULTS: The correlations of VLHR with nasalance (rho  =  .76, p < .001, Spearman rank correlation) and nasality ratings (rho  =  .81, p < .001) were significant using a cut-off frequency of 300 Hz for the English passages. For the Mandarin Sentences, the optimal correlations of VLHR with nasalance (rho  =  .83, p < .001) and nasality ratings (rho  =  .79, p < .001) were identified using a cut-off frequency of 500-Hz. CONCLUSION: The significant correlations of VLHR with nasalance and perceptual ratings of nasality using connected speech show that these approaches have a potential value in terms of basic and clinical application.

A Pilot Study of the Waterless Empirical Taste Test.

OBJECTIVES: This study was performed to test the clinical applicability of a new taste test-the waterless empirical taste test (WETT). METHODS: Sixty healthy volunteers and 20 patients with oral cancer were enrolled. They all received the conventional solution-based whole-mouth suprathreshold taste test (WMTT), which contained sucrose, citric acid, sodium chloride, and caffeine solutions for tastants, along with the WETT. The WETT used plastic strips to deliver tastants. The strip was embedded with sucrose, citric acid, sodium chloride, caffeine, or monosodium glutamate taste enhancer in 4 different concentrations. Each strip was tested twice. Thirty of the healthy volunteers received the WETT again to measure a retest reliability. Case-control matching by age and gender was used to compare the scores of WMTT and WETT between 13 healthy volunteers and 13 patients with oral cancer. RESULTS: The correlation was not high between the WMTT and WETT (r < 0.7) whether in the healthy volunteers or in patients with oral cancer. In terms of retest reliability of the WETT, the mean total score was 24.9 ± 7.3 for the first test and 25.8 ± 8.4 for the second test. The intraclass correlation coefficient was 0.85 (P < .001). When case-control matching was performed, the WMTT scores were not significantly different between 13 healthy volunteers and 13 patients with oral cancer (P = .266), but the WETT scores were significantly lower in patients with oral cancer (P = .017). CONCLUSION: This study showed that the results of the WETT were not highly correlated with those of the WMTT. However, its retest reliability was high, and its results were significantly different between the healthy volunteers and the patients with oral cancer.

The association of lymph node volume with cervical metastatic lesions in head and neck cancer patients.

The aim of this study was to determine if volume of cervical lymph node measured via computed tomography (CT) could differentiate metastatic from benign lesions in head and neck cancer patients. We conducted a retrospective review of chart and images in a tertiary referring center in Taiwan. Patients with head and neck cancers underwent radical, modified radical or functional neck dissection were enrolled. The CT images before operation were reassessed by a radiologist and were compared with the results of pathological examination. A total of 102 patients were included for final analyses. Most patients were male (n = 96, 94%) and average age was 50.1 years. Although the average nodal volume in patients with cervical metastases was higher than those of patients without cervical metastases, it was not an independent factor associated with cervical metastasis after controlling for other variables; however, central nodal necrosis on enhanced CT image [odds ratio (OR) 18.95, P = 0.008) and minimal axial diameter >7.5 mm (OR 6.868, P = 0.001) were independent factors correlated with cervical metastasis. Therefore, the volume of cervical lymph node measured from CT images cannot predict cervical metastases in head and neck cancer patients. Measurement of minimal axial diameter of the largest lymph node is a simple and more accurate way to predict cervical metastasis instead.

Migrating fish bone presenting as acute onset of neck lump.

We encountered a 62-year-old woman with a progressively worsening sore throat and a sharp lump located in her left upper neck, which appeared several hours before admission. After questioning, she underwent rigid esophagoscopy at a local hospital for suspected fish bone impaction but this gave a negative result. Unusual signs caused us to arrange a computed tomography scan, which showed that a foreign body had penetrated the left sternocleidomastoid muscle to the subcutaneous layer, with extensive emphysema in the neck. We extracted the foreign body with a 1-cm horizontal incision of the neck under general anesthesia. The patient returned to a normal diet and was discharged on day 5 of hospitalization without further morbidity. This is another rare case of a migrating foreign body presenting as a neck lump. On reviewing the literature, most cases involving subcutaneously migrating fish bones show development of a neck lump several weeks to months after ingestion, with relatively stable conditions. However, our case showed a neck lump 1 day after ingestion with acute toxic symptoms.

Saliva Pepsin Detection and Proton Pump Inhibitor Response in Suspected Laryngopharyngeal Reflux.

OBJECTIVES/HYPOTHESIS: To evaluate the prediction value of saliva pepsin detection for an 8-week proton pump inhibitor (PPI) response in patients with a Reflux Symptoms Index (RSI) score ≥13, which indicates possible laryngopharyngeal reflux. STUDY DESIGN: Prospective individual single-cohort study. METHODS: Patients were recruited who had experienced chronic laryngopharyngeal symptoms (RSI score ≥13) for more than 3 months after excluding other etiologies. The patients received PPI (40 mg of esomeprazole once daily) treatment for 8 weeks. Prior to treatment, the patients submitted saliva/sputum samples that were collected during the time symptoms were observed. The samples were taken for pepsin detection, and performed using the commercially available Peptest lateral flow device. The association of the Peptest results and PPI response were statistically analyzed with the χ2 test. RESULTS: Seventy-four patients completed the study, and upon completion of PPI treatment, the mean RSI score was significantly reduced from 19.22 ± 5.18 to 8.99 ± 5.69. Forty-four (59.5%) patients exhibited a good response as defined by an RSI score reduction ≥50%. The results of the Peptest were semiquantitatively graded as 0, 1, 2, 3 (negative, weak positive, moderate positive and strong positive, respectively) based upon the visual intensity of the test sample line as compared to the control line. Twenty-four patients (32.4%) exhibited grade 3 strong positive results. The Peptest strong positive results (P < .05) were significantly associated with a good PPI response, with the positive predictive value being 79.2%. CONCLUSIONS: Analysis of strong positive results for pepsin detection in saliva/sputum samples may be a useful, noninvasive method for predicting better PPI response in patients with suspected reflux induced chronic laryngopharyngeal symptoms. LEVEL OF EVIDENCE: 2 Laryngoscope, 129:709-714, 2019.

Complex Microbiome in Brain Abscess Revealed by Whole-Genome Culture-Independent and Culture-Based Sequencing.

Brain abscess is a severe infectious disease with high mortality and mobility. Although culture-based techniques have been widely used for the investigation of microbial composition of brain abscess, these approaches are inherent biased. Recent studies using 16S ribosomal sequencing approaches revealed high complexity of the bacterial community involved in brain abscess but fail to detect fungal and viral composition. In the study, both culture-independent nanopore metagenomic sequencing and culture-based whole-genome sequencing using both the Illumina and the Nanopore platforms were conducted to investigate the microbial composition and genomic characterization in brain abscess. Culture-independent metagenomic sequencing revealed not only a larger taxonomic diversity of bacteria but also the presence of fungi and virus communities. The culture-based whole-genome sequencing identified a novel species in Prevotella and reconstructs a Streptococcus constellatus with a high GC-skew genome. Antibiotic-resistance genes CfxA and ErmF associated with resistance to penicillin and clindamycin were also identified in culture-based and culture-free sequencing. This study implies current understanding of brain abscess need to consider the broader diversity of microorganisms.

Prospective, randomized, controlled trial of tranexamic acid in patients who undergo head and neck procedures.

OBJECTIVES: To determine if tranexamic acid could reduce the drainage duration after head and neck procedures. STUDY DESIGN: Prospective, randomized, controlled trial. METHODS: Patients who underwent head and neck operations were included. The study group was treated with tranexamic acid during the perioperative period whereas the control group received normal saline solution. Blood samples were also collected. RESULTS: The study and control groups consisted of 26 and 29 patients, respectively. Although there was a significant difference in the drainage amount between the two groups, (49.7 vs 88.8 mL, P = 0.041), no significant difference could be found in the drainage duration between the two groups (2.69 vs 3.07 days, P = 0.146). There was also no significant difference in the coagulation profiles between the two groups. CONCLUSION: We did not find a meaningful effect in reducing the drainage duration after head and neck procedures with the use of prophylactic tranexamic acid.

Treatment outcomes of unknown primary squamous cell carcinoma of the head and neck.

BACKGROUND: Treatment modality of unknown primary squamous cell carcinoma of the head and neck (SCCHN) remains controversial. OBJECTIVES: To evaluate the treatment outcomes and prognostic factors of unknown primary SCCHN. MATERIALS AND METHODS: Patients with unknown primary SCCHN from April 1995 to March 2013 were recruited retrospectively. RESULTS: Sixty-nine patients were enrolled. The median time of follow-up was 55.5 months. The 2-year loco-regional control rate of all the patients was 60.4%. Multivariate Cox regression analysis revealed that N3 stage, extracapsular spread, distant metastasis, and treatment modality were significantly associated with neck recurrence. The actuarial 5-year disease-specific survival rates of neck dissection, neck dissection plus adjuvant therapy, radiotherapy alone, and combined therapy were 80.0%, 61.7%, 33.3%, and 68.8%, respectively (p = 0.046). The 5-year disease-specific survival rates of N1/N2a, N2b/N2c, and N3 stage were 83.9%, 64.3%, and 36.7%, respectively (p = 0.013). Univariate regression analysis revealed that neck recurrence, supraclavicular node involvement, distant metastasis, N3 stage, and unhealthy lifestyle habits were correlated with disease-specific mortality, especially the first three parameters. Patient's occupation and comorbidity were not significantly correlated with survival. CONCLUSIONS: Composite therapy is mandatory for advanced unknown primary SCCHN. Supraclavicular node involvement and unhealthy lifestyle habits, such as betel nut chewing, indicate a poor prognosis.

Risk factors for wound infection after surgery in primary oral cavity cancer patients.

OBJECTIVES: Few studies have discussed the predictive factors of surgical wound infection (WI) in primary oral cavity cancer patients. Therefore, we aimed to determine the relevant factors associated with postoperative WI in a large group of patients with oral cavity cancers. STUDY DESIGN: Retrospective chart review. METHODS: We retrospectively reviewed 1,693 chart records of oral cavity cancer patients. Twenty variables were obtained from chart review. Statistical methods included descriptive statistics, bivariate analyses, and a multiple logistic regression model for investigating the predictive factors for WI. RESULTS: Postoperative WI rate was 19.8%. Diabetes mellitus (odds ratio [OR]: 2.511, 95% confidence interval [CI]: 1.409-4.475), perioperative blood transfusion (OR: 4.293, 95% CI: 2.448-7.529), reconstruction with free flap or pectoris major myocutaneous flap (OR: 3.682, 95% CI: 1.909-7.102), and postoperative serum albumin level less than 2.8 g/dL (OR: 2.853, 95% CI: 1.928-4.221) were all independent factors associated with postoperative WI. CONCLUSIONS: Recognition of relevant factors can help surgeons to identify those at high risk of WI after surgery for primary oral cavity cancer and can enable better management of such cases.

Visual screening of oral cavity cancer: The role of otolaryngologists.

OBJECTIVES: Because most screening was done by dentists, the purpose of this prospective cohort study was to evaluate the effectiveness of oral visual screening by otolaryngologists. In addition, we wanted to determine which group of enrolled patients was at potential risk of contracting oral cancer. METHODS: All male patients age > or =18 years who visited our clinic received oral mucosal screening. Basic data, including personal habits, were also obtained. A multivariate logistic regression model was devised to determine relevant risk factors for developing oral cancer. RESULTS: A total of 5,825 patients were enrolled in this study. Positive findings were found in 226 patients (3.9%). One hundred seventy-two patients received biopsy and 131 patients were proven to have oral cancer (sensitivity rate: 76.2%). The results showed that those who smoked, consumed alcohol, and chewed betel quid on a regular basis were most likely to contract oral cancer (odds ratio = 49.81, 95% confidence interval = 29.38-84.42). CONCLUSIONS: The otolaryngologists involved in this study successfully performed the oral screening. The sensitivity and specificity rates were both satisfactory. We suggest that those who are habitual cigarette smokers, alcohol consumers, and betel quid chewers should receive oral mucosal screening regularly so that potential oral cancer can be detected as early as possible.

Laryngeal tuberculosis: a review of 26 cases.

OBJECTIVES: To review the clinical characteristics of laryngeal tuberculosis. STUDY DESIGN: Retrospective case series. SUBJECTS AND METHODS: Medical records of 26 histopathology-confirmed cases in a tertiary medical center from 1992 to 2006. RESULTS: The female patients were significantly younger than male patients. Hoarseness is the most common symptom (84.6%) because true vocal fold is most commonly involved (80.8%). Infection usually involves unilateral (66.7%) and right-side larynx but multiple subsites of the larynx (57.7%). The appearance of the affected larynx may have mixed features and change before diagnosis. Laryngeal tuberculosis is usually misdiagnosed as laryngeal cancer, especially in patients with malignant signs such as enlarged cervical lymph nodes and vocal fold immobility. Chest film is better than sputum examinations for screening. CONCLUSION: We should be especially alert about TB infection when facing young female patients with unusual laryngeal lesions. Extensive laser excision before diagnosis should be avoided because after antituberculous treatment, prognosis is usually good and vocal fold immobility could be reversible.

Lipoma of the palatine tonsil.

Lipomas are benign tumors composed of mature fat cells. They occur frequently in subcutaneous tissue but rarely in the upper aerodigestive tract. Tonsillar lipomas are rare. To our knowledge, there are only six documented cases in the English literature. Here, we present the case of a 46-year-old Taiwanese female with a submerged oval yellowish mass in her left palatine tonsil. She received tonsillectomy and the pathologic diagnosis was tonsillar lipoma. The clinical presentation, management and literature review are also presented.

Cervical sympathetic chain schwannoma.

Schwannomas are benign, slow-growing tumors that arise from Schwann cells of the nerve sheath. Those originating from the sympathetic cervical chain are rare. Herein, we present three cases of cervical sympathetic chain schwannoma (CSCS) and describe our experience with the clinical presentation, surgical management, and outcomes of patients with this pathology. All three patients were found to have a pulsatile, non-tender mass located at the level of the angle of the mandible without cervical nerve function deficit. On imaging study, the location of the mass between the prevertebral muscle and carotid artery with outward displacement of the carotid sheath is a typical characteristic of CSCS. Operative excision and sacrifice of a portion of the sympathetic chain remains the treatment of choice. Postoperative Horner's syndrome is predictable and vagus nerve dysfunction or first bite syndrome is also possible.

Castleman's disease of the neck.

Castleman's disease is an uncommon benign disease of unknown etiology that induces reactive lymph node hyperplasia. There are 2 histologic subtypes of Castleman's disease: hyaline vascular type and plasma cell type. Tissue biopsy is necessary for a definitive diagnosis. Castleman's disease of the neck occurs rarely. On reviewing the literature, most Castleman's disease of the neck presented with a single mass. We report here an 80-year-old man with 2 neck masses of 1 year's duration. A 4-cm firm movable mass in the left submandibular area and another 2-cm firm movable mass in the left level IV area were noted. The patient was diagnosed with Castleman's disease of the neck after resection of 1 of the masses. There was no evidence of progression or recurrence of the disease after 21 months of follow-up. We suggest that this was a rare case of multicentric cervical Castleman's disease.

Socio-demographic factors in the prognosis of oral cancer patients.

The aim of this study was to determine the survival rate of oral cancer patients treated in a medical center in central Taiwan and to investigate whether socio-demographic factors influence their survival. We retrospectively reviewed 1010 chart records of oral cancer patients. Survival was analyzed by the Kaplan-Meier method and Cox proportional hazard model was used for investigating the relationship between socio-demographic factors and survival. The overall 5-year survival rate was 63.24%. Multivariate analysis revealed that those without religious belief tended to have higher probability of death than those who had religious belief (relative risk (RR): 2.057, p<0.001). In addition, those who were single, widow/widower or divorced/separated had a poorer prognosis than those who were married (RR: 1.528, p=0.008). Apart from clinical features, socio-demographic factors also significantly influenced the survival of oral cancer patients. Therefore, care providers should take socio-demographic issues into consideration aside from ordinary clinical health care.

Voice low tone to high tone ratio: a potential quantitative index for vowel [a:] and its nasalization.

Hypernasality is associated with various diseases and interferes with speech intelligibility. A recently developed quantitative index called voice low tone to high tone ratio (VLHR) was used to estimate nasalization. The voice spectrum is divided into low-frequency power (LFP) and high-frequency power (HFP) by a specific cutoff frequency (600 Hz). VLHR is defined as the division of LFP into HFP and is expressed in decibels. Voice signals of the sustained vowel [a :] and its nasalization in eight subjects with hypernasality were collected for analysis of nasalance and VLHR. The correlation of VLHR with nasalance scores was significant (r = 0.76, p < 0.01), and so was the correlation between VLHR and perceptual hypernasality scores (r = 0.80, p < 0.01). Simultaneous recordings of nasal airflow temperature with a thermistor and voice signals in another 8 healthy subjects showed a significant correlation between temperature rate of nasal airflow and VLHR (r = 0.76, p < 0.01), as well. We conclude that VLHR may become a potential quantitative index of hypernasal speech and can be applied in either basic or clinical studies.

Transoral robotic surgery for early T classification hypopharyngeal cancer.

BACKGROUND: For hypopharyngeal cancer, transoral robotic surgery (TORS) has been reported as a new organ preserving treatment but outcomes are rarely reported. METHODS: From 2010 to 2013, 10 patients with early T classification pyriform sinus cancer were selected to receive TORS and conventional neck dissection. The clinical parameters, including rates of adjuvant radiotherapy, survivals, as well as organ and function preservation, were retrospectively analyzed. RESULTS: TORS was successful in all 10 patients, and 5 patients received adjuvant radiotherapy. After mean follow-up of 26 months, 1 patient died of distant metastasis and 1 patient died of other malignancy. There was no local recurrence and larynxes were all preserved. Eight surviving patients who were followed up continuously could receive oral intake and had a serviceable voice without tracheostomy or feeding tubes. CONCLUSION: TORS is a feasible transoral approach for selected patients with early T classification hypopharyngeal cancer. The reported oncologic/functional outcomes are satisfactory. © 2015 Wiley Periodicals, Inc. Head Neck 38: 857-862, 2016.

Osteoradionecrosis of mandible bone in patients with oral cancer--associated factors and treatment outcomes.

BACKGROUND: The purpose of this study was to investigate factors associated with osteoradionecrosis (ORN) of the mandible bone in a large cohort of patients with oral cancer. METHODS: We reviewed the medical records of patients with oral cancer and identified those with ORN of the mandible bone. Variables of patients with and without ORN were compared and associated factors were investigated by logistic regression model. RESULTS: A total of 1692 patients were included in the final analysis and 105 patients (6.2%) developed ORN in the mandible bone. Primary site, including mouth floor, buccal mucosa, retromolar trigone, or gum, segmental mandibulectomy, and total radiation dose to the primary site ≥75 Gy were independent factors associated with ORN. After aggressive treatment using surgical intervention with/without hyperbaric oxygen, 93.3% of the patients healed completely. CONCLUSION: Among patients with oral cancer after radiation, ORN is an uncommon and dreaded complication. Recognition of associated factors can help physicians to identify those at risk.