The use of the submental island flap in reconstructing palatal and facial defects in a surgical camp in East Africa.

BACKGROUND: The goals of successful reconstructive surgery are to restore function and cosmesis; however, limitation of resources can become an important consideration in low-middle income countries. METHODS: We describe our experience using the submental island flap in two cases during a short-term surgical camp in East Africa. RESULTS: The submental island flap was utilized as an excellent alternative to a free flap to reconstruct a subtotal maxillectomy and a parotidectomy defect in two patients. CONCLUSIONS: We demonstrate the successful use of this flap and describe some necessary modifications to achieve optimal results in a resource limited setting.

Post-operative MRSA infections in head and neck surgery.

PURPOSE: Surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus (MRSA) is a serious post-operative complication, with head and neck cancer patients at greater risk due to the nature of their disease. Infection with MRSA has been shown to be costly and impart worse outcomes on patients who are affected. This study investigates incidence and risks for MRSA SSIs at a tertiary medical institution. MATERIALS AND METHODS: This study reviewed 577 head and neck procedures from 2008 to 2013. Twenty-one variables (i.e. tumor characteristics, patient demographics, operative course, cultures) were analyzed with SPSS to identify trends. A multivariate analysis controlled for confounders (age, BMI, ASA class, length of stay) was completed. RESULTS: We identified 113 SSIs of 577 procedures, 24 (21.23%) of which were MRSA. Of all analyzed variables, hospital exposure within the preceding year was a significant risk factor for MRSA SSI development (OR 2.665, 95% CI: 1.06-6.69, z statistic 2.086, p=0.0369). Immunosuppressed patients were more prone to MRSA infections (OR 14.1250, 95%CI: 3.8133-52.3217, p<0.001), and patients with a history of chemotherapy (OR 3.0268, 95% CI: 1.1750-7.7968, p=0.0218). Furthermore, MRSA SSI resulted in extended post-operative hospital stays (20.8±4.72days, p=0.031). CONCLUSIONS: Patients who have a history of chemotherapy, immunosuppression, or recent hospital exposure prior to their surgery are at higher risk of developing MRSA-specific SSI and may benefit from prophylactic antibiotic therapy with appropriate coverage. Additionally, patients who develop MRSA SSIs are likely to have an extended postoperative inpatient stay.

Use of concurrent chemoradiation in advanced staged (T4) laryngeal cancer.

HYPOTHESIS: Patients with advanced laryngeal cancer sometimes desire organ preservation protocols even if it portends a worse outcome. BACKGROUND: To assess outcomes of patients with T4 laryngeal cancer treated with chemoradiation therapy. METHODS: Case series with chart review at a tertiary university hospital. Twenty-four patients with T4 laryngeal cancer all declined total laryngectomy with adjuvant radiation as the primary treatment modality and alternatively received concurrent chemoradiation therapy. The primary outcome was overall survival. Secondary outcomes were rates of tracheotomy dependence, gastric tube dependence, and need for salvage laryngectomy. RESULTS: All patients had T4 laryngeal disease, 71% had cartilage invasion and 59% had regional metastasis to the neck. Kaplan-Meier analysis determined 2-year and 5-year overall survival to be 64% and 59% respectively. The locoregional recurrence rate was 25%. The distant metastasis rate was 21%. The rate of salvage laryngectomy was 17%, which occurred at a mean of 56.5months after the original diagnosis. The rate of tracheotomy dependence was 33% while gastric tube dependence was 25%. CONCLUSION: Advanced T4 laryngeal cancer, particularly with cartilage invasion, remains a surgical disease best treated with total laryngectomy and adjuvant radiation. This data may help guide patients and practitioners considering concurrent chemoradiation therapy for definitive treatment of advanced laryngeal cancer.

Outcomes of microvascular free tissue transfer in twice-irradiated patients.

BACKGROUND: Patients may require microvascular free tissue transfer (MFTT) following re-irradiation for recurrent cancer or radiation complications. The objective of this study was to describe the indications for and outcomes of free flaps performed in twice-radiated patients. METHODS: A retrospective chart review identified the indications for and outcomes of 36 free flaps performed on 29 twice-irradiated patients. RESULTS: The free flap success rate was 92%. The most common indications requiring MFTT were cancer recurrence and osteoradionecrosis. Sixty-one percent experienced postoperative complications, most commonly wound infection (33%). Twenty-five percent of the procedures required return to the operating room due to postoperative complication. CONCLUSIONS: MFTT can be successfully performed in the twice-irradiated patient population with a success rate comparable to singly-radiated patients. Despite a high success rate, there is also a high rate of surgical site complications, especially infection.

Lateral arm microvascular free tissue reconstruction of a large neck keloid.

Keloid scars pose a surgical challenge in the region of the head and neck. We present a rare case of a large infected and recurrent neck keloid that failed multiple prior reconstructive attempts. Ultimately, the tissue was resected and the surgical bed was repaired with a lateral arm microvascular free flap. This repair emphasizes the need for adequate coverage of the defect while maintaining neck mobility, ease of swallowing, and cosmesis. This is the second report in the literature of free tissue transfer as treatment for a large keloid scar, and the first to show the feasibility of early post operative low dose irradiation of the surgical bed.

Fibula Free Flap Reconstruction of Cervical Spine Defects: A Multi-Institutional Study.

INTRODUCTION: Cervical spine defects result in spinal instability, putting the spinal cord and vertebral arteries at risk of damage and possibly devastating neurological injuries. The fibula free flap can span the spinal defects for stability. There is a paucity of literature on this technique. METHOD: Multi-institutional retrospective case series reviewing patients who underwent cervical spine reconstruction with a fibula free flap. Patient demographic information, comorbidities, characteristics of cervical spine defects, and free flap complications were collected. RESULTS: A total of 1187 fibula free flaps across 10 different institutions were reviewed. Thirteen patients (1.09%) underwent cervical spine reconstruction with a fibula free flap. Average age was 52.3 years old with an age range of 12-79 years. There were six males (46.1%) and seven females (53.8%). The most common defect etiology was infection (n = 6, 46.1%). Most commonly involved cervical spine level of the defect was C5 (n = 10) followed by C6 (n = 9) and C4 (n = 8). The majority of reconstructed defects spanned three or more cervical levels, (n = 9, 69.2%). Facial artery was the most common arterial anastomosis (n = 8). Eight patients (61.5%) required a tracheostomy during their postoperative course. None of the patients had symptomatic or radiographic nonunion. CONCLUSION: This case series demonstrates that a vascularized fibula flap is a potential reconstructive option for cervical spine defects, especially in defects greater than three cervical levels, in the setting of infection, and previously radiated patients. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2024.

Free Flap Donor Sites in Head and Neck Reconstruction.

Microvascular free tissue transfer, also referred to as free flaps surgery, is a reconstructive technique that has become a foundational component of complex head and neck reconstruction. There have been considerable advancements in the field over the last 30 years including the number and variety of free flaps. Each of these free flaps has unique characteristics that must be considered for the defect when selecting a donor site. Here, the authors focus on the most common free flaps used in head and neck reconstruction.

Managing Oromandibular Hardware Failure after Free Flap Surgery.

Hardware failure after oromandibular reconstruction using free tissue transfer can delay additional therapies directed at cancer treatment and prevent patients from returning to normal oral function. Understanding and strict adherence to principles of rigid fixation is critical in preventing complications. Early surgical intervention for hardware exposure as well as utilization of locoregional flaps may prevent the need for more extensive revision surgery.

Association of Neoadjuvant Pembrolizumab for Oral Cavity Squamous Cell Carcinoma With Adverse Events After Surgery in Treatment-Naive Patients.

Importance: Pembrolizumab, a monoclonal antibody targeting programmed cell death 1, is currently approved by the US Food and Drug Administration for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC). The potential neoadjuvant role of programmed cell death 1 inhibitors in primary surgical management of HNSCC and effects on surgical outcomes are poorly understood. Objective: To evaluate the incidence of postoperative adverse events in treatment-naive patients with advanced oral cavity cancer receiving neoadjuvant pembrolizumab when compared with matched controls, as part of a window-of-opportunity multi-institutional clinical trial assessing neoadjuvant pembrolizumab for locally advanced HNSCC. Design, Setting, and Participants: This retrospective cohort study at a single tertiary academic institution included treatment-naive patients with local regionally advanced oral cavity squamous cell carcinoma (OCSCC) who were undergoing surgical resection. Exposures: Patients with local regionally advanced resectable OCSCC who received neoadjuvant pembrolizumab were retrospectively reviewed for postoperative adverse events. Controls were matched by age, race, smoking status, and overall cancer stage based on historical data at the same institution. Matched-cohort analysis was performed using a McNemar test to assess differences between the groups. Main Outcomes and Measures: Incidence of adverse events following surgical resection of advanced OCSCC within 30 days of surgery and on continued follow-up. Results: A total of 64 patients (32 as part of the prospective clinical trial and 32 as controls; mean [SD] age, 59.6 [10.3] years; 28 [44%] women) were included in the analysis. Postoperative adverse events in the 32 patients receiving pembrolizumab included lymphedema (n = 20 [63%]), trismus (n = 7 [22%]), return to operating room (n = 7 [22%]), wound infection (n = 7 [22%]), fistula (n = 6 [19%]), wound dehiscence (n = 4 [13%]), flap failure (n = 3 [9%]), and hematoma (n = 2 [6%]). The matched control group demonstrated similar complication rates without considerable differences, except for trismus (n = 16 [50%]), which was greater by a difference of 28.1% (95% CI, 5.6%-50.6%) in the control group. Conclusions and Relevance: This cohort study examined surgical complications among patients with local regionally advanced OCSCC treated with neoadjuvant pembrolizumab and found that serious adverse events were similar to those in patients who underwent standard-of-care treatment. This suggests that there is no increased perioperative morbidity in the use of preoperative treatment with immunotherapy. Further prospective studies are needed to validate these findings for oral cavity cancer and other subsites of the head and neck.

Cancellous Tibial Bone Graft for Malunion after Mandibular Reconstruction in Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: While nonunion after mandibular reconstruction for head and neck surgery is rare, literature exploring management is scarce. Our primary objective was to determine success rates of tibial bone graft (TBG) in achieving mandibular union. Secondary objectives include determining factors that contribute to failure of TBG. STUDY DESIGN: Retrospective Chart Review. METHODS: Retrospective chart review between January 1, 2008 and December 31, 2018. Patients who underwent a mandibulotomy or mandibulectomy with osteocutaneous free flap reconstruction were identified. Patients who were pursuing dental rehabilitation, subsequently diagnosed with mandibular nonunion and received a cancellous TBG were assessed. RESULTS: The 15 patients meeting inclusion criteria were mostly male (67%), white (87%), and nonsmokers (67%) with a median age of 64 (IQR = 60-73). Successful union occurred in 13 of 18 (72%) TBGs and the majority (63%) had a partial union documented at the time of surgery. Five patients (83%) who initially had a mandibulotomy achieved union compared to 78% of those with osteocutaneous reconstruction (P = 1.0). Postoperative radiation did not affect rates of union: 80% for both (P = 1.0). Patients with osteoradionecrosis (ORN) achieved union in 67% of cases compared to 75% of cases who did not have ORN (P = .86). There were similar rates of union for those who required perioperative antibiotics for infection and those without infection (67% vs. 75%, P = .86). Dental rehabilitation was achieved in 55% of patients, most commonly dentures. CONCLUSIONS: This study shows that TBG can be used to achieve union for patients with malunion after head and neck cancer reconstruction. We show its successful use within the reconstructive algorithm for patients regardless of postoperative radiation for very small defects. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1291-1296, 2021.

Trends in Number of Women Speakers at the American Head and Neck Society Meetings, 2007-2019.

Importance: The number of female speakers at American Head and Neck Society (AHNS) conferences should ideally be consistent with the number of women entering head and neck surgery fellowships to ensure gender equity in the field. Yet the presence of women speakers at the annual AHNS meetings, which is specific to the field of head and neck cancer, endocrine and microvascular reconstructive surgery, has yet to be studied. Objective: To determine whether the proportion of female speakers at the AHNS has increased in a manner consistent with the numbers of women entering fellowships since 2007. Design, Setting, and Participants: This qualitative study assessed 13 final meeting programs from AHNS national/international conferences from 2007 to 2019. The number of male and female participants in different roles throughout the meeting were retrospectively tracked. Participants were male and female speakers at AHNS national/international conferences who took part in the roles of scientific session presenter, scientific session moderator, expert panelist, miscellaneous moderator, and named lecturers/keynote speaker. Gender of the speaker was determined by searching names on the internet and using available published pronouns. Main Outcomes and Measures: Number of speaking opportunities for men and women in different roles from 2007 to 2019 as well as number of men and women entering AHNS fellowships since 2007 and new active AHNS members since 2012. Results: In this qualitative study, from 2007 to 2019, 4059 speakers were identified. Of these speakers, 902 (22%) were women and 3157 (78%) were men. Overall, there was a strong correlation between increasing years and number of women speakers from 2007 to 2019 (ρ = 0.75; 95% CI, 0.72-0.78). There were 2096 invited speaking roles that excluded research presentations, of which 400 were offered to female participants (19.1%) across the study period. There were 131 different women that made up all 400 of the opportunities that were offered to women in the years surveyed. There was a strong correlation in the proportion of women as presenters for oral abstracts, expert panelists, and miscellaneous moderators between the years but no correlation in scientific session moderators and named lecturers/keynote speakers. Of the 45 named lecturers/keynote speakers in the programs tracked, only 2 were women. Conclusions and Relevance: In this study, from 2007 to 2019, the presence of women at ANHS has increased overall, reflecting the changing demographic characteristics of those entering in head and neck oncology and microvascular surgery fellowships. However, a strong disparity continues to exist for preeminent speaking opportunities.

Heparin-mediated antibiotic delivery from an electrochemically-aligned collagen sheet.

BACKGROUND: Implantable medical devices and hardware are prolific in medicine, but hardware associated infections remain a major issue. OBJECTIVE: To develop and evaluate a novel, biologic antimicrobial coating for medical implants. METHODS: Electrochemically compacted collagen sheets with and without crosslinked heparin were synthesized per a protocol developed by our group. Sheets were incubated in antibiotic solution (gentamicin or moxifloxacin) overnight, and in vitro activity was assessed with five-day diffusion assays against Pseudomonas aeruginosa. Antibiotic release over time from gentamicin-infused sheets was determined using in vitro elution and high performance liquid chromatography (HPLC). RESULTS: Collagen-heparin-antibiotic sheets demonstrated larger growth inhibition zones against P. aeruginosa compared to collagen-antibiotic alone sheets. This activity persisted for five days and was not impacted by rinsing sheets prior to evaluation. Rinsed collagen-antibiotic sheets did not produce any inhibition zones. Elution of gentamicin from collagen-heparin-gentamicin sheets was gradual and remained above the minimal inhibitory concentration for gentamicin-sensitive organisms for 29 days. Conversely, collagen-gentamicin sheets eluted their antibiotic load within 24 hours. Overall, heparin-associated sheets demonstrated larger inhibition zones against P. aeruginosa and prolonged elution profile via HPLC. CONCLUSION: We developed a novel, local antibiotic delivery system that could be used to coat medical implants/hardware in the future and reduce post-operative infections.

The prefabricated supraclavicular artery flap in high-risk tracheal stenosis patients.

OBJECTIVES/HYPOTHESIS: Primary tracheal resection in appropriately selected patients with tracheal stenosis achieves >90% success rate. Risk factors for complications have been identified, making some patients high risk for this procedure. Herein is a review and discussion of a novel treatment method for tracheal stenosis utilizing a prefabricated composite auricular cartilage graft embedded in a supraclavicular artery island flap (pSCAIF) for tracheal reconstruction in high-risk patients. STUDY DESIGN: Retrospective case series. METHODS: After institutional review board approval, cases were analyzed after data collection. Between 2014 and 2016, eight patients underwent airway reconstruction using an auricular cartilage graft prefabricated within a supraclavicular artery island flap reconstruction; all of these were included in the study. Each case was reviewed, and relevant details of patient and disease characteristics, operative course, postoperative course, decannulation, and status at last follow-up were isolated and reported. RESULTS: Seven of eight patients were female. The most common cause of stenosis was iatrogenically induced multilevel stenosis (7/8 patients). All patients had undergone prior airway procedures, were high risk based on comorbid conditions, and underwent grafting and reconstruction with a composite supraclavicular island flap. All patients continue to follow up in a multidisciplinary clinic, and at last follow-up, eight of eight patients were successfully decannulated. CONCLUSIONS: The pSCAIF is a novel method for tracheal reconstruction. The analysis of the prefabricated locoregional approach cohort supports its utility for tracheal reconstruction in patients with complicated multilevel stenosis and adverse comorbidities and characteristics. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:641-648, 2020.

Sentinel Node Biopsy in Young Patients with Atypical Melanocytic Tumors of the Head and Neck.

OBJECTIVE: To examine the diagnostic value of the sentinel lymph node biopsy in pediatric through young adult head and neck melanocytic tumors of unknown malignant potential. STUDY DESIGN: Retrospective case series. SETTING: Single academic institution. SUBJECTS AND METHODS: Demographics, histology, and outcomes were examined in 14 patients aged 4 to 24 years with head and neck melanocytic tumors of unknown malignant potential. Information on age at diagnosis, primary lesion characteristics, and sentinel lymph node biopsy were compared. RESULTS: Of 14 patients meeting criteria for head and neck melanocytic tumors of unknown malignant potential, 8 patients underwent sentinel lymph node biopsy (57%). Of those, 4 biopsies (50%) had positive sentinel nodes. All patients undergoing sentinel lymph node biopsy had primary lesions greater than 1 mm depth or mitotic rate of at least 1 mitosis per mm2. No patients had recurrence of their primary lesion at time of follow-up. CONCLUSION: Our data show a high rate of node-positive sentinel lymph node biopsy for pediatric and young adult head and neck patients with melanocytic tumors of unknown malignant potential, supporting the value of sentinel lymph node biopsy in this population.

Clinical Significance of Sarcopenia among Patients with Advanced Oropharyngeal Cancer.

OBJECTIVES: We investigated the prevalence and impact of sarcopenia on disease-free survival (DFS) and overall survival (OS) in advanced oropharyngeal cancer. STUDY DESIGN: Retrospective study. SETTING: Single-institution tertiary cancer care center. SUBJECTS AND METHODS: We identified patients with advanced oropharyngeal cancer with pretreatment positron emission tomography-computed tomography scans for image analysis. Data were collected on the following variables: age, sex, smoking and alcohol status, stage (TNM and American Joint Committee on Cancer), human papillomavirus (HPV) status, body mass index (BMI), and treatment modality. RESULTS: Of 113 patients identified with oropharyngeal cancer, 32 had sarcopenia: these patients were older (63.5 vs 57.6 years, P = .01), were less likely to be male (53.1% vs 76.5%, P = .03), and had a lower mean BMI (24.5 vs 28.4 kg/m2, P = .009). Eighty-five subjects had HPV-positive disease, and they had a higher BMI (28.2 vs 24.2 kg/m2, P = .01) than that of patients without HPV. Twenty-one subjects who were HPV positive had less cancer recurrence (24.7% vs 48.1%, P = .04) than that of their HPV-negative counterparts. Log-rank testing showed no difference in DFS ( P = .06) associated with sarcopenia but a significant difference in OS ( P = .049). There were differences in DFS ( P = .009) and OS ( P = .023) based on HPV status. According to univariable and multivariable models, HPV positivity exhibited improved DFS and OS. Sarcopenia was not statistically significant in survival models; however, it was associated with increased mortality and recurrence. CONCLUSION: Sarcopenia is a prognostic factor affecting OS independent of HPV status in advanced oropharyngeal cancer.

Long-term results of microvascular free-tissue transfer reanimation of the paralyzed face: three cases.

We conducted a retrospective case review at our tertiary care academic medical center to assess the long-term results of microvascular free-tissue transfer to achieve facial reanimation in 3 patients. These patients had undergone wide-field parotidectomy with facial nerve resection. Upper facial reanimation was accomplished with a proximal facial nerve-sural nerve graft, and lower facial movement was achieved through proximal facial nerve-long thoracic (serratus muscle) nerve anastomosis. Outcomes were determined by grading postoperative facial nerve function according to the House-Brackmann system. All 3 patients were able to close their eyes independent of lower facial movement, and all 3 had achieved House-Brackmann grade III function. We conclude that reanimating the paralyzed face with microvascular free-tissue transfer provides anatomic coverage and mimetic function after wide-field parotidectomy. Synkinesis is reduced by separating upper- and lower-division reanimation.

Clinical significance of tumor mitotic rate and lack of epidermal attachment in melanoma of the head and neck.

BACKGROUND: The primary purpose of this study was to identify the prognostic role of primary dermal melanoma and tumor mitotic rate in melanomas of the head and neck. METHODS: A retrospective review of the histopathologic, clinical, and demographic data of 256 patients was performed to investigate the impact of primary dermal melanoma and tumor mitotic rate on sentinel lymph node positivity, recurrence, and 5-year overall and disease-free survival. RESULTS: Increased tumor mitotic rate, but not primary dermal melanoma, is a significant predictor of sentinel lymph node positivity and higher likelihood of recurrence. Survival analysis demonstrated that both increased tumor mitotic rate and primary dermal melanoma decreased the 5-year overall and disease-free survival rates of patients with head and neck melanoma lesions. CONCLUSION: Tumor mitotic rate and primary dermal melanoma may have prognostic significance for both overall and disease-free survival in patients with head and neck melanoma. A larger prospective study is warranted to further elucidate prognostic factors for melanoma in the head and neck region.