The transcervical-transparotid corridor for management of parapharyngeal space neoplasms: strengths and limits in a bi-institutional retrospective series.

BACKGROUND AND PURPOSE: Parapharyngeal space (PPS) neoplasms represent 1% of all head and neck tumors and are mostly benign. Surgery is the mainstay of treatment and the transcervical-transparotid (TC-TP) corridor still represents the workhorse for adequate PPS exposure. Our series investigates strengths and limits of this approach on a multi-institutional basis. METHODS: We reviewed consecutive patients submitted to PPS surgery via TC-TP route between 2010 and 2020. Hospital stay, early and long-term complications, and disease status were assessed. RESULTS: One hundred and twenty nine patients were enrolled. Most tumors were benign (79.8%) and involved the prestyloid space (83.7%); the median largest diameter was 4.0 cm. The TC-TP corridor was used in 70.5% of patients, while a pure TC route in about a quarter of cases. Early postoperative VII CN palsy was evident in 32.3% of patients, while X CN deficit in 9.4%. The long-term morbidity rate was 34.1%, with persistent CN impairment detectable in 26.4% of patients: carotid space location, lesion diameter and malignant histology were the main independent predictors of morbidity. A recurrence occurred in 12 patients (9.4%). CONCLUSIONS: The TC-TP corridor represents the benchmark for surgical management of most of PPS neoplasms, though substantial morbidity can still be expected.

Indocyanine green fluorescence video-angiography for flap perfusion assessment in head and neck reconstruction: a prospective study.

PURPOSE: Managing postoperative complications is crucial in reconstructive surgery. Indocyanine green fluorescence video-angiography (ICGA) aids in assessing flap vascularization intraoperatively, potentially reducing complications. METHODS: An ambispective study enrolled head and neck cancer patients undergoing ablative surgery with soft tissue reconstruction. An experimental arm (March 2021-May 2023) used ICGA, while a control arm (January 2017-December 2020) did not. Complications were graded by Clavien-Dindo classification. We also evaluated the effect of systemic inflammation on the sensitivity of ICGA in detecting hypoperfused areas of the flap. RESULTS: Complications were less frequent in the experimental arm, both overall (11.4% vs. 36.4%) and major ones (Clavien-Dindo ≥ 3) (8.6% vs. 30.9%). ICGA showed a protective effect in univariate and multivariate analyses. Previous radiation and ICGA were independent predictors of major complications. ICGA altered the surgical strategy in 25.7% of cases. CONCLUSIONS: Real-time perfusion assessment, particularly with ICGA, can improve outcomes in head and neck cancer patients undergoing soft tissue reconstruction by reducing complications. Further research with larger cohorts is warranted for validation.

The use of near-infrared autofluorescence during total laryngectomy with hemi- or total thyroidectomy.

PURPOSE: The aim of this study is to describe the use of near-infrared autofluorescence (NIR-AF) to identify and preserve parathyroid glands (PGs) in a group of patients with advanced hypopharyngeal/laryngeal cancer undergone total (pharyngo)laryngectomy with hemi- or total thyroidectomy. METHODS: At San Raffaele Hospital, Milan (Italy), from January 2021 to May 2021, 7 patients affected by cT4a laryngeal squamous cell carcinoma (SCC) underwent surgery using an autofluorescence detection system (Fluobeam-Fluoptics®). For proper surgical planning, the demolition phase envisaged extension of the intervention to 4 hemithyroidectomies and 3 total thyroidectomies associated, respectively, with homolateral or bilateral CCND. Serum calcium, ionized calcium, and parathyroid hormone (PTH) levels at post-operative day (POD) 1 and 2 and at 2 weeks after surgery were monitored. Finally, we compared the data obtained with a cohort of patients who underwent surgery without the adoption of NIR-AF. RESULTS: With the use of NIR-AF, 18/20 PGs were identified, of which 7/18 were preserved exclusively thanks to the use of autoflorescence. The technique also made it possible to identify and isolate three PGs from the surgical specimen, which were subsequently transplanted only after intraoperative histological confirmation. On POD-1, 3/7 patients (42.8%) were hypocalcemic; on POD-2 and after 2 weeks only 1/7 patient (14.2%) was hypocalcemic. Comparing the two groups, we highlighted that the utilization of NIR-AF was related to a significant decrease of median serum (p = 0.026) and ionized calcium levels (p = 0.017) 2 weeks after surgery. Using this new technology, in no case did definitive histological examination reveal the presence of PGs in the surgical specimen, reaching an accuracy of 100%. CONCLUSIONS: In our cohort of patients who underwent total (pharyngo)laryngectomy with hemi- or total thyroidectomy, the use of near-infrared autofluorescence improved medium term postoperative hypocalcemia rates. This new technology helps to achieve a better calcemic outcome compared to the standard naked eye approach, since it helps the surgeon to identify and preserve parathyroid glandular tissue with a lower incidence of post-operative hypocalcemia.

Current evidence on diagnosis and treatment of parotid gland lymphomas: a systematic review.

BACKGROUND AND PURPOSE: Parotid gland lymphoma (PGL) is a rare and challenging diagnosis. Different lymphomas can develop in the parotid gland, with the most common being the mucosa-associated lymphoid tissue (MALT) lymphoma, which originates directly from the glandular parenchyma. Other histologic subtypes arise from both intraglandular and extraglandular parotid lymph nodes. A consensus on diagnosis and treatment of PGL is still lacking, and published data is scarce and heterogeneous. METHODS: We performed a systematic review of the literature, including studies published after 2001, when the WHO classification of lymphoid tumours was introduced. RESULTS: Twenty retrospective studies were included in the analyses, eight of which focused exclusively on MALT lymphomas. Final analysis included 612 cases of PGL, with a 1.68:1 F/M ratio. MALT lymphoma was the most common histology, followed by follicular and diffuse large B-cell lymphoma. Most cases were low stages (IE/IIE acc. Ann Arbour, 76.5%) and only 10% of patients presented with symptoms, most commonly pain (4.8%) and B symptoms (2.2%). A high prevalence of associated autoimmune diseases was found, particularly Sjögren's syndrome, that affected up to 70% of patients with MALT lymphoma. In most cases diagnosis was achieved through parotidectomy (57.5%), or open biopsy (31.2%). Treatment strategies were either surgical, non-surgical or a combination of modalities. Surgery as a single-modality treatment was reported in about 20% of patients, supposing it might be a valuable option for selected patients. CONCLUSIONS: Our review showed that the diagnosis and treatment of PGLs is far from being standardized and needs further, more homogeneous reports to reach consensus.

Trimming of Facial Artery Myomucosal Flap (FAMM) using Indocyanine Green Fluorescence Video-Angiography: Operative Nuances.

BACKGROUND: Facial artery myomucosal flap (FAMM) is an intraoral flap pedicled on facial artery used for reconstruction of oral/oropharyngeal defects.1 Careful assessment of perfusion is essential to avoid flap necrosis, and several options are used for this purpose. Among these, indocyanine green (ICG) fluorescence video-angiography (ICG-VA) represents an innovative tool whose adoption in flap surgery is still at its early days.2 METHODS: In this multimedia article, we described the use of ICG-VA for perfusion assessment of a FAMM flap harvested for reconstruction of oral lining after ablation of a cT2cN0 floor-of-mouth (FOM) cancer. The use of ICG-VA was aimed at defining ischemic areas on the flap according to a flap-to-normal mucosa ICG ratio. RESULTS: After transoral excision of the FOM cancer and subsequent harvesting of a FAMM flap, we used ICG-VA to intraoperatively assess its perfusion. The degree of flap perfusion was expressed point-by-point through flap-to-normal mucosa ICG ratio (percentage); a value of 25-27% was considered as threshold for ischemia.3 Perfusion was documented both with white light modality with "overlay fluorescence" and "black and white SPY fluorescence mode" designed to increase the sensitivity of ICG detection. Small, ischemic areas were detected in the distal part of the flap and were trimmed. At the end of the procedure, an adequate perfusion was evident throughout the whole flap, allowing its safe insetting for left FOM reconstruction. Postoperative course was uneventful. CONCLUSIONS: ICG-VA represents a reliable tool for intraoperative detection-and trimming-of ischemic areas on reconstructive flaps.

Local Pterional Advancement Flap: A Minimally Invasive Option to Reconstruct Spheno-Temporal Extracranial Soft Tissues Dehiscences in Fragile Patients.

BACKGROUND: Late-onset, extracranial soft tissues dehiscence in the spheno-temporal region after major neurosurgical procedures might represent a potentially life-threatening complication.Due to surgery-related galeal/pericranial and myofascial temporal atrophy, classical regional flaps are often unavailable, enforcing potential indication for free vascularized flaps.Nevertheless, in elderly multioperated patients, who are not eligible for major surgery, it becomes mandatory to consider less invasive options for reconstruction.Authors describe the application of a reconstructive option for late-onset, pterional soft tissues dehiscence in fragile patients, using a local pterional advancement flap. METHODS: Technique is stepwise described and illustrated in its clinical application. RESULTS: Local pterional advancement flap provides an excellent coverage, being extremely pliable, and flexible in contents and design. Vascular pedicle is independent from distal branches of the superficial temporal artery and provides adequate blood flow. Pedicle length enables a good arc of rotation, which facilitates its transposition. Flap preparation is very easy and minimally time consuming, due to its immediate regional availability and the easy harvesting technique. CONCLUSIONS: Local pterional advancement flap represents an effective option as regional flap for the reconstruction of late-onset, pterional soft tissues dehiscence in fragile patients.

Fine needle aspiration cytology for parotid neoplasms: risk of malignancy through inconclusive results and lower grade tumors.

PURPOSE: Fine needle aspiration cytology (FNAC) is a commonly performed procedure for parotid masses, although its accuracy in detecting malignancies widely varies through different series. We evaluated our single-center cohort of parotidectomies to highlight possible limitations of preoperative FNAC. METHODS: Seven hundred and eighteen consecutive patients submitted to parotid surgery at San Raffaele Scientific Institute (Milan) were retrospectively evaluated (2002-2018). Five hundred and fifty four FNAC were analyzed. FNAC accuracy was assessed with and without inclusion of "inconclusive" results. The peculiar role of lower grade primary parotid cancers was investigated. RESULTS: FNAC reports were "diagnostic" in 502 cases (90.4%) and "inconclusive" in 52 (9.6%). Histopathology revealed 488 benign lesions (88.1%) and 66 malignancies (11.9%). FNAC sensitivity, specificity, PPV, NPV and accuracy in detecting malignancies were 59%, 99%, 89%, 95%, and 95%, respectively. Sensitivity fell to 48%, when "inconclusive" FNAC was computed. Within 66 parotid cancers, FNAC could discriminate malignancy in 32 cases (48.5%), provide proper grading in 21 (31.8%), and precise histopathological diagnosis in 15 (22.7%). Malignancy was more likely in patients with "inconclusive" FNAC than in those with "diagnostic" cytologies (23.1% vs 10.8%, p = 0.003). Low-intermediate-grade primary parotid cancers were associated to a higher rate of FNAC failure in comparison with high-grade ones (86.4% vs 19.0%; p < 0.001). CONCLUSION: FNAC is an important tool for preoperative assessment of parotid masses, though its sensitivity in detecting malignancy remains poor. "Inconclusive" FNAC results could further jeopardize FNAC accuracy and should elicit resorting to additional tests, especially when a lower grade parotid cancer is suspected.

Low skeletal muscle mass as predictor of postoperative complications and decreased overall survival in locally advanced head and neck squamous cell carcinoma: the role of ultrasound of rectus femoris muscle.

PURPOSE: Skeletal muscle mass (SMM) depletion and sarcopenia as predictors of postoperative complications and poorer overall survival (OS) have been validated in many surgical fields through cross-sectional imaging (CT, MRI), with potential limitations. We evaluated it in a stage III-IV head and neck squamous cell carcinoma (HNSCC) surgical cohort through ultrasound (US) of rectus femoris muscle (RF), a quick, cheap, repeatable alternative. METHODS: Patients submitted to surgical treatment with curative purpose were recruited and prospectively evaluated through clinical, biometric, biochemical, surgical, pathological and functional prognosticators and with preoperative US of RF with regards to 30-day complications and OS. RESULTS: Forty-seven patients completed the study. RF cross-sectional area (RF-CSA) was used to identify patients with low SMM (CSA ≤ 0.97 cm2: 18/47, 38.3%). RF-CSA was lower in complicated cases (0.95 ± 0.48 vs 1.41 ± 0.49 cm2; p = 0.003), remaining the only independent predictor of postoperative complications at multivariate analysis, with a model including ASA score and modified Frailty index (OR 9.84; p = 0.004). SMM depletion significantly impaired OS (13.6 ± 2.9 vs 26.3 ± 2.1 months; p = 0.017), being its only independent prognosticator at multivariate Cox regression analysis (OR 4.42; p = 0.033). CONCLUSION: RF-CSA, evaluated with US, seems a reliable method for identification of patients with low SMM in a stage III-IV HNSCC cohort, defining a subset at high-risk of 30-day complications and poorer OS.

Supraclavicular artery island flap (SCAIF): a rising opportunity for head and neck reconstruction.

Over the last 20 years, free flaps have represented the gold standard for moderate to large head and neck reconstruction. However, regional flaps continue to evolve and still play an important role in a reconstructive surgeon's armamentarium, especially for the more delicate patients who would certainly benefit from simpler surgical procedures. The supraclavicular artery island flap (SCAIF) is a pedicled flap that has recently gained great popularity for reconstruction of most head and neck sites, because of its unusual versatility and wide arc of rotation. SCAIF is a fasciocutaneous flap that is very reliable and both easy and quick to harvest. It is pedicled on the supraclavicular artery, which is a branch of the transverse cervical artery. Between October 2012 and July 2015, at Ospedale San Raffaele (Milan, Italy) and Policlinico San Matteo (Pavia, Italy), we used the SCAIF procedure on 14 patients with cervical and facial skin, oral cavity, oropharyngeal, and hypopharyngeal defects after oncologic surgery or as revision surgery after free-flap failure. The presence of the supraclavicular artery was demonstrated preoperatively by computed tomography angiography. Harvesting time never exceeded 50 min. Functional outcomes were excellent, and the donor site was always closed. We reported only one case of tip desquamation, which was treated conservatively, and two cases of partial flap necrosis, which required revision surgery. In our opinion, SCAIF should be considered to be a valid alternative to free-flap reconstruction, especially for facial and cervical skin, floor-of-mouth, and hypopharyngeal defects; oropharyngeal defects may be harder to reconstruct.

Obstructive sleep apnea in Prader-Willi syndrome: risks and advantages of adenotonsillectomy.

Obstructive sleep apnea is a well-known clinical manifestation of Prader-Willi syndrome. The aim of our study is to evaluate the efficacy of adenotonsillectomy for the treatment of the disorder as well as the improvement of their post-operative quality of life. Five patients with moderate to severe obstructive sleep apneas and adenotonsillar hypertrophy of grade III-IV underwent adenotonsillectomy. Pre- and postoperative apneas and Quality of Life were assessed respectively with a polysomnography with multi-sleep latency test and with the pediatric Quality of Life questionnaire, performed before and 6 months after surgery. A decrease of apnea/hypopnea index values has been detected between pre- and post-surgery (t=2.64, P=0.005), as well as oxygen desaturation index values (t=5.51, P=0.005), multi-sleep latency test (t=4.54, P=0.01), and of the values of pediatric Quality of Life questionnaire. No correlation has been detected between body mass index and apnea/hypopnea index, oxygen desaturation index and multi-sleep latency test values pre- and post-adenotonsillectomy. A correlation has been found between multi-sleep latency test and oxygen desaturation index values post-surgery (P=0.04). No post-operative complications were observed. Our data underline the efficacy of surgery in Prader-Willi patients with adenotonsillar hypertrophy in order to improve their quality of life.

Surgical and radiological perspectives for the spinal accessory nerve passing through a fenestrated internal jugular vein: case series and literature review.

The preservation of the spinal accessory nerve represents a key goal in head and neck oncologic surgery during selective neck dissection. This study aims to illustrate the anatomical variants of the XI cranial nerve, delving into the relationship between the spinal nerve and the internal jugular vein, as well as the surgical implications. Two cases of patients who underwent oncologic surgery with neck dissection are described. Both cases found the spinal accessory nerve passing through the fenestration of the internal jugular vein. Alongside this case series, an independent literature review was conducted using the Medline and PubMed databases. In the majority of cases (67% - 96%), the spinal accessory nerve traces a lateral course to the internal jugular vein. Less frequently, the XI cranial nerve courses medial to the internal jugular vein. More rarely, as described in this case series, the nerve crosses through the fenestration of the vein (0.48% - 3.3%).

A Multimodal Protocol Combining 99mTc-Tilmanocept with Indocyanine Green Fluorescence Lympho-Angiography for Sentinel Lymph Node Biopsy in Early-Stage Oral Cancer: A Case Series.

Sentinel lymph node biopsy (SLNB) is currently considered as a viable alternative to elective neck dissection (END) for the management of cN0 oral cavity squamous cell carcinoma (OCSCC). However, some difficulties were detected in sentinel lymph node (SLN) identification in floor of mouth (FOM) and ventral tongue tumors because of the so-called "shine-through radioactivity" of the injection site, which may mask nodal hotspots in proximity. We assessed the feasibility and the potential strengths of combining 99mTc-Tilmanocept with indocyanine green (ICG) fluorescence lympho-angiography in a dedicated multimodal protocol for SLNB in T1/T2N0 oral cancer to evaluate the synergistic role of each of these two tracers in providing the appropriate sensitivity and ease of learning, even in such a critical anatomical subsite. A detailed, stepwise description of our multimodal protocol is provided, together with the presentation of its application in two cases of early-stage ventral tongue tumors. Radioactive guidance with 99mTc-Tilmanocept was used preoperatively to perform planar lymphoscintigraphy and single-photon emission computed tomography/computed tomography and to define the nodal hotspot(s) and the surgical "roadmap". In addition, it was used intraoperatively to pinpoint the SLN location within each nodal hotspot with high specificity but limited spatial resolution. Optical guidance with ICG injection at the tumor bed and near-infrared fluorescence imaging was then added, providing intuitive intraoperative guidance within each nodal hotspot with high spatial resolution. Our small experience with this protocol is illustrated and future perspectives are highlighted.

From Tumor Macroenvironment to Tumor Microenvironment: The Prognostic Role of the Immune System in Oral and Lung Squamous Cell Carcinoma.

BACKGROUND: The interplay between cancer cells and the immune system is crucial in cancer progression and treatment. In this regard, the tumor immune microenvironment and macroenvironment, marked by systemic inflammation markers and TILs, could be considered key prognostic factors in tumors, including oral and lung squamous cell carcinoma. METHODS: We conducted a retrospective clinical study on patients with Oral Squamous Cell Carcinoma (OSCC) and Lung Squamous Cell Carcinoma (LUSCC), examining stages, comorbidities, treatments, and outcomes. We evaluated the prognostic significance of pre-surgical systemic inflammation markers and tumor microenvironment composition. RESULTS: Associations were found between systemic inflammation markers-NLR, MLR, and PLR-and tumor microenvironment factors, such as TILs and CD8+ cell prevalence-elevated inflammation markers correlated with advanced stages. Specifically, NLR was prognostic in OSCC, whereas PLR was prognostic in LUSCC. Using a cutoff value, we divided our tumor samples into two prognostic groups. Moreover, TILs levels >15% of tumor stroma correlated with prolonged overall survival in both OSCC and LUSCC, while increased CD8+ expression was linked to extended disease-free survival in LUSCC. DISCUSSION: Systemic inflammation markers and TILs can be valuable prognostic factors of survival, highlighting the immune response's role in OSCC and LUSCC. Despite limited clinical integration of the presented cohorts due to a lack of standardization, we concluded that analyzing tumor immune profiles may offer novel prognostic insights. CONCLUSIONS: Future integration into cancer classification could improve risk stratification and treatment guidance.

Squamous Cell Carcinoma of the Nasal Vestibule: A Multi-Centric Observational Cohort Study.

OBJECTIVES: Squamous cell carcinoma of the nasal vestibule (NV-SCC) is a rare but challenging entity, due to the complex anatomy of the region. Consensus on the best treatment strategy is still lacking, as well as a dedicated staging system. Our aim was to analyze oncological outcomes of surgically treated patients and to investigate possible prognostic factors. METHODS: We performed a retrospective multi-centric observational study including six Academic Hospitals over a 10-year period, including only patients who underwent upfront surgery for primary NV-SCC. Patients were staged according to all currently available staging systems. The Kaplan-Meier method was used to compute overall, disease-free, and disease-specific survival. Logistic regression models were used to correlate between survival outcomes and clinical and pathological variables. RESULTS: Seventy-one patients with a median follow-up of 38 months were included in the study. Partial and total rhinectomy were the most commonly performed procedures, respectively, in 49.3% and 25.4% of cases. Neck dissection was performed on 31% of patients, and 45.1% of them underwent adjuvant radiotherapy. Three years overall, disease-specific and disease-free survival were, respectively, 86.5%, 90.3%, and 74.2%. None of the currently available staging systems were able to effectively stratify survival outcomes. Factors predicting lower overall survival on multivariate analysis were age (p = 0.021) and perineural invasion (p = 0.059), whereas disease-free survival was negatively affected by age (p = 0.033) and lymphovascular invasion (p = 0.019). CONCLUSION: Currently available staging systems cannot stratify prognosis for patients who underwent surgery for NV-SCC. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2634-2645, 2024.

Challenging management of an enlarged tracheoesophageal fistula in an irradiated patient.

Speech restoration after total laryngectomy may be achieved in different ways, the gold standard being tracheoesophageal puncture (TPE) with the positioning of a speech prosthesis. TPE is not immune to complications, the most common of which being leakage through or around the prosthesis. When dealing with an enlarged tracheoesophageal fistula, the management can be either conservative or surgical. In the following case report, we present a particularly challenging case, in which every conservative strategies failed and a major surgery was required to close the fistula.

The carotid sheath route: An option to approach retrocarotid prespinal tumors with paravertebral extension.

Background: The elective route to approach paravertebral lesions growing into the anterolateral lodge of the neck is widely recognized as the prespinal route with its two major variants. Recently, attention has been focused on the possibility of opening the inter-carotid-jugular window in case of reparative surgery for traumatic brachial plexus injury. Aims: For the first time, the authors validate the clinical application of the carotid sheath route in the surgical treatment of paravertebral lesions expanding into the anterolateral lodge of the neck. Methods: A microanatomic study was conducted to collect anthropometric measurements. The technique was illustrated in a clinical setting. Results: The opening of the inter-carotid-jugular surgical window allows additional access to the prevertebral and periforaminal space. It optimizes the operability on the prevertebral compartment, compared to the retro-sternocleidomastoid (SCM) approach, and on the periforaminal compartment, compared to the standard pre-SCM approach. The surgical control of the vertebral artery is comparable to that obtained with the retro-SCM approach, while the control of the esophagotracheal complex and the retroesophageal space is comparable to the pre-SCM approach. The risk profile on the inferior thyroid vessels, recurrent nerve, and sympathetic chain is superimposable to the pre-SCM approach. Conclusions: The carotid sheath route is a safe and effective option to approach prespinal lesions with retrocarotid monolateral paravertebral extension.

Anterior selective scalenectomy for periforaminal exposure in the ventral supraclavicular approach.

Aims and Objectives: Route of choice to access cervical paravertebral lesions with foraminal involvement is the anterolateral corridor with its variants. Main limitation of these techniques is represented by the limited surgical access to periforaminal area due to the bulk generated by the anterior scalene muscle (ASM). Over the years, alternative techniques for ASM surgical management have been developed, which are still today a matter of debate. Most popular include ASM scalene complete section (SCS) and ASM medial detachment (SMD). Authors describe an innovative, minimally invasive muscle section technique, the anterior selective scalenectomy (ASS), which reduces the risk of iatrogenic morbidity and optimizes exposure of periforaminal area in anterolateral cervical routes. Materials and Methods: A laboratory investigation was conducted. Technique was applied in a surgical setting, and an illustrative case was reported. Results: ASS is a quick and easy technique to perform. It allows optimization of surgical visibility and control on the periforaminal area in the cervical anterolateral corridor. It respects muscle anatomy and vascularization, favoring functional recovery and management of peri-operative pain; it reduces the risk of morbidity on phrenic nerve and pleura. Considering the minimally invasive nature of the technique, it allows for a slightly more limited exposure compared to traditional techniques while ensuring optimal surgical maneuverability on the target area. Conclusions: ASS represents an effective and safe alternative to traditional ASM section techniques for the exposure of periforaminal area in anterolateral cervical routes. It is indicated in case of lesions with paravertebral development and minimal intraforaminal component in the C3-C6 segment.