Elective Irradiation of Retropharyngeal Lymph Nodes as an Indication for Adjuvant Radiation Therapy After Transoral Surgery for Tonsil Cancer.

Treatment of squamous cell carcinoma of the tonsil involves primary radiation therapy (RT) or surgical resection. Historically, if RT was the primary or adjuvant treatment modality, most of the bilateral retropharyngeal lymph nodes (RPLNs) were treated electively with a therapeutic dose for subclinical disease, regardless of whether radiographically pathologic lymph nodes were seen on initial diagnostic imaging. De-escalation strategies include the incorporation of transoral surgery with the goal to either eliminate or reduce the dose of adjuvant RT or chemotherapy. Transoral surgery does not include elective removal of the RPLNs, and no guideline or outcome paper recommends adjuvant RT specifically to electively treat RPLNs. In this Topic Discussion, we discuss pertinent literature and suggest management decisions. The management decisions discussed in this Topic Discussion pertain to only tonsillar primaries and not those of the soft palate or base of the tongue.

Association of Virtual Surgical Planning With External Incisions in Complex Maxillectomy Reconstruction.

Importance: Maxillectomy can commonly be performed through a transoral approach, but maxillectomy defect reconstruction can be difficult to precisely design, contour, and inset through this approach. Objective: To evaluate whether the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling is associated with a decrease in the requirement of lateral rhinotomy (LR) for patients undergoing total and partial maxillectomy reconstruction. Design, Setting, and Participants: This retrospective cohort study was conducted among patients undergoing subtotal or total maxillectomy with microvascular free flap reconstruction with or without VSP and 3-D modeling at a single tertiary care academic medical center between January 1, 2008, and October 3, 2019. Interventions: Maxillectomy and free flap reconstruction with or without VSP. Main Outcomes and Measures: Necessity of LR or other external incision for contouring, placement, and fixation of reconstruction as well as surgical complications. Results: Fifteen patients (12 men [80%]; mean age, 64 years) underwent maxillectomy with free flap reconstruction without VSP. Eight patients (53%) in this group underwent total maxillectomy, and 4 patients in this group (27%) underwent partial maxillectomy. Twenty-three patients (18 men [78%]; mean age, 58 years) underwent maxillectomy with free flap reconstruction and VSP and 3-D modeling. Twelve of these patients (52%) underwent total maxillectomy, and 11 (48%) underwent partial maxillectomy. Lateral rhinotomy was necessary for 1 patient (4%) in the VSP group vs 12 patients (80%; 95% CI, 54%-98%) in the pre-VSP group. There were no LR complications in the VSP group vs 6 in the pre-VSP group. Among both groups, 14 patients underwent fibula free flap, 22 patients underwent subscapular system free flap, and 2 patients underwent cutaneous or osteocutaneous radial forearm free flap. There were no flap failures in the LR group and 1 flap failure in the group without LR. Conclusions and Relevance: This cohort study suggests that the use of VSP and 3-D modeling for maxillectomy reconstruction is associated the a decrease in the need for external incisions without compromising reconstructive flap utility.

One-year outcomes for da Vinci single port robot for transoral robotic surgery.

BACKGROUND: The da Vinci single-port (SP) robot is a new instrument for transoral robotic surgery (TORS) in oropharyngeal cancers (OPSCCs). We describe one-year SP surgical outcomes and compare them to da Vinci Si outcomes. METHODS: Retrospective cohort study at a high-volume TORS center. Consecutive patients undergoing TORS SP procedures from 10/2018 to 09/2019 were included. SP OPSCC outcomes were compared to a historical cohort of Si OPSCC patients. t tests were used to compare continuous variables; χ2 or Wilcoxon rank-sum tests were used to compare nonparametric categorical variables. RESULTS: Seventy-eight patients underwent SP TORS. The bleed rate was 5.1%, mortality rate was 2.6%, and conversion rate was 0%. Compared to the Si cohort, OPSCC patients undergoing TORS SP procedures saw no significant differences in operative time or post-TORS bleeds (P > .05). CONCLUSIONS: The SP is a comparably safe surgical instrument. Overall learning curve for the SP was rapid among experienced TORS surgeons.

Preliminary results of tissue-engineered injection laryngoplasty material in a rabbit model.

OBJECTIVES/HYPOTHESIS: Design and test a novel biomaterial for injection laryngoplasty aimed to increase the duration of effectiveness of micronized acellular dermis. STUDY DESIGN: Animal model. METHODS: Injection laryngoplasty was performed in three groups (n = 5) of New Zealand White rabbits. Acellular dermis was either used alone as a control (group 1), was combined with undifferentiated stem cells (group 2), or with predifferentiated chondrocytic cells (group 3). Groups 2 and 3 were supplemented with growth factors. Animals were sacrificed 4 and 12 weeks after laryngoplasty and histologic analysis was completed. The major outcome measure was volume of tissue remaining. RESULTS: After 4 weeks, the mean volume of tissue remaining was 341 ± 89 mm3 , 295 ± 102 mm3 , and 133 ± 15 mm3 , for groups 1 to 3, respectively. At the 12-week time point, volumes were 62 ± 62 mm3 , 235 ± 35 mm3 , and 107 ± 99 mm3 . After 12 weeks, there was a significantly higher volume in group 2 compared to group 1 or 3 (P = .01, P = .04). Volumes between week 4 and week 12 were significantly lower in group 1 (P = .02), but not significantly different for groups 2 and 3 (P = .38, P = .74). Histologic evaluation revealed a robust lymphocytic infiltration in all cases as well as morphologic and immunophenotypic features suggestive of chondrogenic differentiation in a single animal. CONCLUSIONS: Micronized acellular dermis combined with stem cells and growth factors showed significantly less resorption 12 weeks after injection laryngoplasty compared to micronized acellular dermis alone. Groups using novel tissue-engineered biomaterial showed a lower resorption rate over time compared with acellular dermis alone. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:160-167, 2018.