Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects.

OBJECTIVES/HYPOTHESIS: Different reconstructive options are available for defects following total laryngectomy (TL) and circumferential (CH) or partial hypopharyngectomy (PH). We evaluated the flap success, pharyngocutaneous fistula, and pharyngoesophageal stenosis rates in two groups of patients treated by different policies. STUDY DESIGN: Comparison between two cohorts of patients treated by TL with PH/CH ± cervical esophagectomy and reconstructed according to different strategies. METHODS: Group A (historical) was composed of 89 patients reconstructed by pectoralis major myocutaneous (PMMC), radial forearm (RF), and anterolateral thigh (ALT) flaps. A salivary bypass stent (SBPS) was not routinely applied and left in place for a maximum of 14 days. Forty-four (49%) patients received preoperative radiotherapy/chemoradiotherapy (RT/CRT). Group B (prospective) included 105 patients reconstructed by RF or ALT with long-lasting SBPS left in place for a maximum of 45 days. Sixty-one (59%) received preoperative RT/CRT. RESULTS: In group A, flap failure occurred in four (4%) cases, and all were managed by PMMC. We encountered 22 (26%) fistulas and 14 (16%) stenoses. In group B, flap failure occurred in six (6%) cases and was managed by PMMC. We encountered seven (7%) fistulas and three (3%) stenoses. Comparing complications among the two groups, we encountered a statistically significant difference in favor of group B for both fistula (P < .001) and stenosis (P = .001). We did not evidence any significant difference in terms of flap success rate. CONCLUSIONS: First-line application of RF and ALT free flaps with long-lasting SBPS in reconstruction after PH/CH allows obtaining reduced incidences of both fistula and stenosis. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2731-2737, 2017.

Preoperative clinical predictors of difficult laryngeal exposure for microlaryngoscopy: the Laryngoscore.

OBJECTIVES/HYPOTHESIS: To identify a clinical predictor score for difficult laryngeal exposure (DLE) during operative microlaryngoscopy. STUDY DESIGN: Prospective cohort study in two academic institutions. METHODS: We evaluated 319 patients before microlaryngoscopy for benign and malignant glottic diseases by a standardized preoperative assessment protocol (Laryngoscore) that included 11 parameters: interincisors gap (IIG), thyro-mental distance, upper jaw dental status, trismus, mandibular prognathism, macroglossia, micrognathia, degree of neck flexion-extension, history of previous open-neck and/or radiotherapy, Mallampati's modified score, and body mass index (BMI). Each parameter was assessed to obtain a total score. Patients were divided into five classes according to the anterior commissure (AC) visualization: class 0, complete AC visualization with large-bore laryngoscopes in the Boyce-Jackson position; class I, as class 0 with external laryngeal counterpressure; class II, as class I in the flexion-flexion position; class III, as class II using small-bore laryngoscopes; and class IV, impossible AC visualization. RESULTS: Class 0-I-II (good/acceptable laryngeal exposure) presented a median score < 6. This value was chosen as cutoff for distinguishing favorable versus difficult/impossible laryngeal exposures. When the Laryngoscore was < 6, good laryngeal exposure was observed in 94% of patients, whereas when ≥ 6, DLE was encountered in 40%. When considering a Laryngoscore of ≥ 9, 67% of patients had a DLE. At univariate analysis, IIG, upper jaw dental status, macroglossia, micrognathia, degree of neck flexion-extension, and BMI statistically impacted on DLE (P < 0.05). CONCLUSIONS: The Laryngoscore is a good predictor of DLE and assists in selecting the ideal candidates for operative microlaryngoscopy. LEVEL OF EVIDENCE: 2b.

Role of narrow-band imaging and high-definition television in the surveillance of head and neck squamous cell cancer after chemo- and/or radiotherapy.

Narrow-band imaging (NBI) is an endoscopic technique enhancing mucosal vasculature and better identifying superficial carcinomas due to their neo-angiogenic pattern. NBI accuracy is increased by combination with a high-definition television (HDTV) camera. The aim of this report was to evaluate the diagnostic improvement of NBI +/- HDTV in the evaluation of head and neck squamous cell cancer (HNSCC) previously treated by chemo-radiotherapy (CHT-RT) or RT. A total of 390 patients affected by HNSCC were prospectively evaluated by NBI and white light (WL) endoscopy +/- HDTV between April 2007 and April 2009 at a single academic institution. Among them, we focused on 59 (15%) patients who received CHT-RT or RT as part of their treatment. Of 59 patients, 13 (22%) showed adjunctive preoperative NBI findings when compared to the standard WL examination. These findings were always confirmed by intraoperative HDTV NBI, while only eight (62%) were visible with HDTV WL. Of 13 lesions, 12 received histopathologic confirmation (from carcinoma in situ to invasive carcinoma). The sensitivity of flexible NBI, HDTV WL, and HDTV NBI was 100, 66 and 100%, respectively. The specificity was 98, 100, and 98%. The positive predictive value was 92, 100, and 92%. The negative predictive value was 100, 94, and 100%. The accuracy was 98, 91, and 98%. NBI +/- HDTV after CHT-RT or RT was of value in detecting tumor persistence (n = 2), early recurrences (n = 6), and metachronous tumors (n = 4). By contrast, only 1 of 59 (2%) patients was found to be false positive.