The pericranial flap for inner lining of full-thickness nasal defects: a retrospective cohort study.

BACKGROUND: Effective nasal reconstruction requires skin and soft tissue cover, cartilage or bone structure, and mucosal lining. Ideal lining is thin, pliable and vascularised, making reconstruction challenging. This paper presents the first case series with long-term outcomes of pericranial flaps used as inner lining for nasal reconstruction. METHODS: Patients undergoing paramedial forehead flaps from 2007 to 2019 were identified using second-stage nasal reconstruction billing codes. Patients with pericranial flaps for lining, for whom there were data on resulting outcomes and complications, were identified. RESULTS: Sixty-six patients underwent second-stage nasal reconstruction. Eighteen patients had paramedian forehead and pericranial flaps for inner lining reconstruction. The flap lining had no immediate post-operative complications. Three patients suffered partial to major reconstructive failure post radiotherapy. Other complications included nasal stenosis and orocutaneous fistula. CONCLUSION: Combined with paramedian forehead flaps, the pericranial flap is reliable as inner lining for nasal reconstruction. It is easily accessible and useful in resections with limited mucosal options.

Haemostatic devices in parotid surgery: a systematic review.

OBJECTIVE: The Harmonic Scalpel and Ligasure (Covidien) devices are commonly used in head and neck surgery. Parotidectomy is a complex and intricate surgery that requires careful dissection of the facial nerve. This study aimed to compare surgical outcomes in parotidectomy using these haemostatic devices with traditional scalpel and cautery. METHOD: A systematic review of the literature was performed with subsequent meta-analysis of seven studies that compared the use of haemostatic devices to traditional scalpel and cautery in parotidectomy. Outcome measures included: temporary facial paresis, operating time, intra-operative blood loss, post-operative drain output and length of hospital stay. RESULTS: A total of 7 studies representing 675 patients were identified: 372 patients were treated with haemostatic devices, and 303 patients were treated with scalpel and cautery. Statistically significant outcomes favouring the use of haemostatic devices included operating time, intra-operative blood loss and post-operative drain output. Outcome measures that did not favour either treatment included facial nerve paresis and length of hospital stay. CONCLUSION: Overall, haemostatic devices were found to reduce operating time, intra-operative blood loss and post-operative drain output.

Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma.

OBJECTIVE: Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN: Retrospective case series and subsequent prospective cohort study SETTING: Tertiary care academic teaching hospital SUBJECTS AND METHODS: Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 - December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 - December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost. RESULTS: Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD. CONCLUSION: Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments.

The abscopal effect in head-and-neck squamous cell carcinoma treated with radiotherapy and nivolumab: a case report and literature review.

Introduction: The abscopal effect is a rarely observed outcome of radiotherapy wherein there is a reduction in metastatic disease burden outside of the targeted treatment area. Likely due to an in situ vaccine effect of radiotherapy, the abscopal effect may be augmented by immunotherapy. This report is the first case of the abscopal effect observed in metastatic head-and-neck squamous cell carcinoma (hnscc) treated with concurrent radiotherapy and single-agent nivolumab. Case Description: An otherwise healthy 57-year-old man underwent craniofacial resection and adjuvant chemoradiotherapy for advanced sinonasal squamous cell carcinoma. Distant metastatic disease developed shortly after primary treatment, and immunotherapy in the form of nivolumab was initiated. Subsequent oligometastatic progression despite immunotherapy prompted palliative radiotherapy to a single metastasis due to pending symptomatology. Post-radiotherapy, the abscopal effect was observed with all distant sites of metastatic disease shrinking. Five months following treatment, a sustained reduction in disease burden has been demonstrated. Summary: We present the first case of the abscopal effect in a patient with metastatic hnscc treated with palliative radiotherapy concurrent with single-agent nivolumab immunotherapy, and only the third case of the abscopal effect in metastatic head-and-neck cancer. Dual treatment with immunotherapy and radiotherapy may be an important treatment option in the future, mediated through the abscopal effect.

Oncological and functional outcomes after repeat transoral laser microsurgery for the treatment of recurrent early glottic cancer.

BACKGROUND: Transoral laser microsurgery for glottic squamous cell carcinoma is the standard of care at many institutions. Repeat transoral laser microsurgery for recurrence may avoid the need for radiotherapy and total laryngectomy. This study aimed to identify oncological and functional outcomes in a cohort of patients who had undergone repeat transoral laser microsurgery procedures. METHOD: A retrospective review of prospectively collected data of patients treated with transoral laser microsurgery for carcinoma in situ or tumour stages T1 or T2 glottic cancer, from 2003 to 2018. RESULTS: Twenty patients were identified. Additional treatment was not needed in 45 per cent of patients. The five-year overall survival rate was 90 per cent. The disease-specific survival rate was 100 per cent. The laryngeal preservation rate was 85 per cent. There was improvement in mean Voice Handicap Index-10 scores following repeat transoral laser microsurgery treatment, when comparing the pre- and post-operative periods (mean scores = 15.5 vs 11.5, p = 0.373). CONCLUSION: Repeat transoral laser microsurgery can be an oncologically safe alternative to other salvage therapies for glottic squamous cell carcinoma recurrence, without sacrificing functional outcomes.

Bacterial contamination of surgical loupes and headlights.

BACKGROUND: Medical equipment can transmit pathogenic bacteria to patients. This single-institution point prevalence study aimed to characterise the types and relative amount of bacteria found on surgical loupes, headlights and their battery packs. METHOD: Surgical loupes, headlights and battery packs of 16 otolaryngology staff and residents were sampled, cultured and quantified. Plate scores were summed for each equipment type, and the total was divided by the number of users to generate mean bacterial burden scores. Residents completed a questionnaire regarding their equipment cleaning practices. RESULTS: The contamination rates of loupes, headlights and battery packs were 68.75 per cent, 100 per cent and 75 per cent, respectively. Battery packs cultured more bacteria (1.58 per swab ± 1.00) than loupes (0.75 per swab ± 0.66; p = 0.024). Headlights had non-significantly greater growth (1.50 per swab ± 0.71) than loupes (p = 0.052). Bacterial growth was significantly higher from inner surfaces of loupes (p = 0.035) and headlights (p = 0.037). Potentially pathogenic bacteria were cultured from the equipment of five participants, including: Pantoea agglomerans, Acinetobacter radioresistens, Staphylococcus aureus, Acinetobacter calcoaceticus baumannii complex and Moraxella osloensis. CONCLUSION: This study demonstrates that surgical loupes and headlights used in otolaryngology harbour non-pathogenic skin flora and potentially pathogenic bacteria.

Longitudinal analysis of Voice Handicap Index in early glottic cancer patients treated with transoral laser microsurgery: age, gender, stage and time dependence.

OBJECTIVES: Transoral laser microsurgery is an increasingly common treatment modality for glottic carcinoma. This study aimed to determine the effect of age, gender, stage and time on voice-related quality of life using the Voice Handicap Index-10. METHODS: Primary early glottic carcinoma patients treated with transoral laser microsurgery were included in the study. Self-reported Voice Handicap Index testing was completed pre-operatively, three months post-operatively, and yearly at follow-up appointments. RESULTS: Voice Handicap Index improvement was found to be dependent on age and tumour stage, while no significant differences were found in Voice Handicap Index for gender. Voice Handicap Index score was significantly improved at 12 months and 24 months. Time versus Voice Handicap Index modelling revealed a preference for non-linear over linear regression. CONCLUSION: Age and stage are important factors, as younger patients with more advanced tumours show greater voice improvement post-operatively. Patient's Voice Handicap Index is predicted to have 95 per cent of maximal improvement by 5.5 months post-operatively.

Laryngeal recurrence sites in patients previously treated with transoral laser microsurgery for squamous cell carcinoma.

BACKGROUND: The laryngeal framework provides a natural barrier preventing tumour spread to extralaryngeal structures. Transoral laser microsurgery (TLM) for laryngeal squamous cell carcinoma (SCC) may violate these boundaries, altering the pathways of tumor spread for potential recurrences. Our project objective is to describe laryngeal SCC recurrence patterns and overall survival in patients requiring total laryngectomy (TL) after TLM. METHODS: Patients undergoing TLM for laryngeal SCC requiring salvage TL were identified from a prospective CO2 laser database containing all patients undergoing TLM for head and neck malignancies at the QEII Health Sciences Center in Halifax, Nova Scotia between March 2002 - May 2014. Surgical pathology reports were analyzed for tumor characteristics, extent of recurrence and invasion of local structures. Kaplan-Meier analyses were performed to evaluate overall survival, disease specific survival (DSS) and locoregional control. RESULTS: Fifteen patients were identified from the database as receiving salvage TL for recurrent disease after initial TLM resection for laryngeal SCC. Final pathology reports demonstrated that 67% (10/15) of patients had thyroid cartilage involvement while 53% (9/15) of patients had cricoid cartilage involvement on salvage TL pathology. 33% (5/15) of patients had perineural invasion and 27% (4/15) had lymphovascular invasion. Mean and median follow-up times were 36.7 months and 26.8 months respectively (range 3.9-112.6). The Kaplan-Meier estimate for overall survival at 36 months was 40% post TL with a standard error (SE) of 13.6%. DSS was 47% (SE 14.2%), and locoregional control was 55% (SE 14.5%) post TL. CONCLUSIONS: Laryngeal recurrence sites following TLM seem to be consistent with historical data at known laryngeal sites of vulnerability. Treatment with TLM does not predispose patients to a lower rate of locoregional control and overall survival after total laryngectomy and salvage outcomes are consistent with literature values.

Transoral laser surgery for laryngeal carcinoma: has Steiner achieved a genuine paradigm shift in oncological surgery?

Transoral laser microsurgery applies to the piecemeal removal of malignant tumours of the upper aerodigestive tract using the CO2 laser under the operating microscope. This method of surgery is being increasingly popularised as a single modality treatment of choice in early laryngeal cancers (T1 and T2) and occasionally in the more advanced forms of the disease (T3 and T4), predominantly within the supraglottis. Thomas Kuhn, the American physicist turned philosopher and historian of science, coined the phrase 'paradigm shift' in his groundbreaking book The Structure of Scientific Revolutions. He argued that the arrival of the new and often incompatible idea forms the core of a new paradigm, the birth of an entirely new way of thinking. This article discusses whether Steiner and colleagues truly brought about a paradigm shift in oncological surgery. By rejecting the principle of en block resection and by replacing it with the belief that not only is it oncologically safe to cut through the substance of the tumour but in doing so one can actually achieve better results, Steiner was able to truly revolutionise the management of laryngeal cancer. Even though within this article the repercussions of his insight are limited to the upper aerodigestive tract oncological surgery, his willingness to question other peoples' dogma makes his contribution truly a genuine paradigm shift.

Orbital mass as first presentation of metastatic p16-positive oropharyngeal squamous cell carcinoma.

We describe a case in which a 67-year-old man was diagnosed with a metastatic recurrence of p16-positive oropharyngeal squamous cell carcinoma after presenting with a medial orbital mass in the region of the nasolacrimal apparatus. A review of the literature revealed that metastasis to the orbit from any malignancy is an uncommon occurrence, and no cases of p16-positive oropharyngeal squamous cell carcinoma have previously been reported. Our case highlights the importance of maintaining a high index of suspicion during surveillance visits with such patients.

Outcomes of transoral laser microsurgical management of T1b stage glottic cancer.

OBJECTIVE: This study aimed to evaluate the oncological and voice outcomes of transoral laser microsurgery for tumour stage T1b stage glottic cancer patients. METHODS: A prospective cohort study in a tertiary care head and neck cancer centre included tumour-node-metastasis stage T1bN0M0 glottic cancer patients scheduled to undergo transoral laser microsurgery from January 2002 until June 2014. Kaplan-Meier five-year analyses of local control, overall survival, disease-specific survival and laryngeal preservation were performed. Voice Handicap Index-10 scores and maximum phonation times were also recorded. RESULTS: Twenty-one participants with a mean age of 66.8 years were enrolled. The mean follow up was 56.5 months. Kaplan-Meier 5-year survival analysis illustrated a local control rate of 82 per cent, overall survival of 88 per cent, disease-specific survival of 100 per cent, and laryngeal preservation of 100 per cent. The pre-operative Voice Handicap Index-10 score was 19.1 ± 9.47 (mean ± standard deviation (SD)) and the post-operative scores were 13.5 ± 9.29 at three months, 10.44 ± 9.70 at one year and 5.83 ± 4.91 at two years. The pre-operative maximum phonation time was 16.23 ± 5.46 seconds (mean ± SD) and the post-operative values were 14.44 ± 6.73 seconds at three months, 15.27 ± 5.71 seconds at one year and 14.33 ± 6.44 seconds at two years. CONCLUSION: Transoral laser microsurgery yields relatively high rates of oncological control and acceptable voice outcomes, and thus shows utility as a primary treatment modality for T1b glottic cancer.

A retrospective review in the management of T3 laryngeal squamous cell carcinoma: an expanding indication for transoral laser microsurgery.

BACKGROUND: The purpose of this study was to evaluate the functional and oncological outcomes of patients treated for T3 laryngeal squamous cell carcinoma. Specifically comparing transoral laser microsurgery and radiotherapy/chemoradiotherapy treatment modalities. METHOD: A retrospective review of patients treated for T3 laryngeal SCC between 2002 and 2010 was undertaken. RESULTS: Forty-nine patients were included. 15 cases were glottic, (9 treated with TLM, 6 with RT/CRT), 33 supraglottic (6 treated with TLM, 27 with RT/CRT) and 1 subglottic subsite (treated with RT/CRT). There was no statistical difference between treatment groups for 24 month locoregional control (72.3 %), overall survival (glottis 86.7 %, supraglottic 70.4 %) and disease specific survival (glottic 93.3 % and supraglottic 74.1 %). Overall laryngeal preservation (84.9 %) was also similar in both groups. CONCLUSION: Our institution is expanding the application of TLM to selected patients with T3 laryngeal carcinoma. Oncological outcomes have not been jeopardized by this approach and the treatment is well tolerated by patients with few complications.

Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis.

BACKGROUND: In Canada, 4,400 cases of oral cancer are diagnosed yearly. Surgical resection is a key component of treatment in many of these cancers. Reconstruction of defects, with the goal of preserving function, is of utmost importance. Several choices are possible for reconstruction of larger defects, including both free and pedicled flaps. Free flap reconstruction is reliable and effective, but requires additional personnel and peri-operative resources. Pedicled flaps remain an important alternative to free flaps, and are less resource intensive. This paper reviews our inaugural experience with the submental island flap (SIF) and compares costs incurred to a matched cohort of oral cancer patients reconstructed with forearm free flaps. METHODS: Charts of patients who underwent SIF and RFFF reconstruction from January 1st 2013 to April 1st 2015 were retrospectively examined. Associated costs were obtained via online database and previously reported costs at the study institution. RESULTS: Mean length of ICU stay in glossectomy RFFF reconstruction was 4.7 days. Only one patient required ICU stay for one night in the SIF group. Mean length of hospital stay was not significantly different in SIF patients vs RFFF patients (12.4 vs 15.4 days, p > 0.05). Mean operative time was significantly lower in the SIF group compared to the RFFF group (347 vs 552 min, p < 0.05). Total mean intraoperative costs were found to be $4780.59 for RFFF operations, versus $2307.94 for SIF. Total mean cost of post-operative stay was $18158.40 in the SIF group and $43617.60 in the RFFF group. Total cost savings were therefore $27931.85 per patient for the SIF group. CONCLUSIONS: We have demonstrated the use of the submental island flap as an alternative to radial forearm free flaps, showing both decreased hospital costs and comparable patient outcomes. Pedicled flaps are making a resurgence in head and neck reconstruction, and the submental island flap offers an excellent alternative to more labour intensive and costly free flap alternatives.

The association of warthin tumor with salivary ductal inclusions in intra and periparotid lymph nodes.

A predominant theory of the much debated histogenesis of Warthin tumor (WT) is that it arises from heterotopic salivary ductal inclusions (SDI) in parotid lymph nodes (LN). If this were the case, we might expect to see an increased number of SDI in the lymph nodes of patients with WT compared to controls. To test this, we compared the prevalence of SDI in patients with WT versus those with pleomorphic adenoma (PA). Cases of WT and PA were retrieved from the case files of the Department of Pathology at the QEII Health Science Centre, Halifax, NS, Canada. We then compared the prevalence of SDI in parotid LN between patients diagnosed with WT versus PA. 46 WT and 52 PA met our inclusion criteria. WT was significantly associated with an older age at surgery (62.5 years vs 50.2 years, p = 0.001). 71.7 % of WT and 32.7 % of PA had inclusions in any LN. The presence of inclusion is a significant predictor for WT versus PA (p = 0.019). Where smoking status was available, 92.5 % of WT patients were smokers/ex-smokers, versus. 55.1 % of PA (p = 0.034 for current smokers). Among PA, 44 % of smokers had inclusions compared with 22.7 % of non-smokers. SDIs are more frequent in parotid LN from patients with WT than PA. The high proportion of smokers among WT patients is consistent with prior studies. The results support the hypothesis that WT arises from SDIs. Individuals with more SDIs may be predisposed to WT.

Outcomes of transoral laser microsurgery for recurrent head and neck cancer.

OBJECTIVE: To report our outcomes with salvage CO2 laser surgery following recurrence of laryngeal and oropharyngeal cancer after radiotherapy. METHOD: This study entailed a prospective review of patients treated with transoral laser microsurgery for recurrent laryngeal and oropharyngeal cancer between 2002 and 2010 at the Queen Elizabeth II Health Science Centre in Canada. RESULTS: Sixteen patients were identified, with a mean follow up of 30.6 months. Five patients died of recurrence. Complications were common in patients with oropharyngeal cancer. The overall survival and disease-free survival rates at an average of 29.8 months follow up were 50 per cent and 68.8 per cent respectively. CONCLUSION: Salvage surgery using transoral laser microsurgery should be considered in the management of patients with recurrent laryngeal and oropharyngeal cancer. This technique offers acceptable salvage rates with less comorbidity than other treatments.

Planned neck dissection following radiation treatment for head and neck malignancy.

Introduction. Optimal therapy for patients with metastatic neck disease remains controversial. Neck dissection following radiotherapy has traditionally been used to improve locoregional control. Methods. A retrospective review of 28 patients with node-positive head and neck malignancy treated with planned neck dissection following radiotherapy between January 2002 and December 2005 was performed to assess treatment outcomes. Results. Median interval to neck dissection was 9.6 weeks with a median number of 21 + 9 lymph nodes per specimen. Ten of 31 (32%) neck dissection specimens demonstrated evidence of residual carcinoma. Overall survival at two years was 85%; five-year overall survival was 65%. Concurrent chemotherapy did not impact the presence of residual neck disease. Conclusion. Based on the frequency of residual malignancy in the neck of patients treated with primary radiotherapy, a planned, postradiotherapy neck dissection should be strongly advocated for all patients with advanced-stage neck disease.

Complete spontaneous regression of metastatic merkel cell carcinoma: a case report and review of the literature.

Merkel cell carcinoma (MCC) is a rare aggressive primary cutaneous neuroendocrine neoplasm with a high rate of recurrence and metastasis. We report a case of a 94-year-old woman who experienced complete spontaneous regression of metastatic MCC. Nine months after complete excision of the primary MCC on her left eyebrow, metastatic MCC was confirmed with a fine-needle aspiration of a 4-cm mass on the left side of her neck. Three months later the mass had reduced in size to 2 cm and a neck dissection was performed. Her submandibular gland, thoracic duct and 25 lymph nodes were negative for MCC. Two of the lymph nodes, the larger measuring 1.3 cm, contained extensive amounts of fibrosis, with accumulation of macrophages and other chronic inflammatory cells. The literature documents 6 similar cases of complete spontaneous regression of metastatic MCC. The mechanism for regression is not well understood and is thought to involve T-cell-mediated immune response and apoptosis.

Frey's syndrome and parotidectomy flaps: A retrospective cohort study.

Gustatory sweating, also known as Frey's syndrome, is a recognized phenomenon after parotidectomy. The incidence of clinically significant gustatory sweating may be dependent on the thickness of the skin flap that is elevated at the time of surgery. Dissection in the subcutaneous level or the deeper sub-superficial musculoaponeurotic system level are 2 commonly used techniques in the operation. Twenty-eight patients were prospectively evaluated for Frey's syndrome after superficial parotidectomy. Thirteen patients underwent subcutaneous and 15 patients sub-superficial musculoaponeurotic system flap elevation. The overall incidence of gustatory sweating was determined, and a comparison of the two surgical techniques was assessed subjectively by patient interview-questionnaire and objectively evaluated with starch-iodine testing.