Current trends in craniofacial reconstruction.

Reconstruction of the head and neck continues to pose a variety of difficult functional and aesthetic challenges to the plastic surgeon. While the surgical treatment for midfacial and skull base tumours continues to advance, the three-dimensional reconstruction predicaments continue to increase in complexity. Reconstructive strategies of the head and neck require the restoration of intricate skeletal architecture and large volumes of both internal and external soft tissue envelopes that can withstand adjuvant therapies. Vascularized bone grafts in combination with microsurgical techniques is the current trend of most reconstruction and has replaced local and pedicle flaps as the preferred modality for large defects. This article will focus on concise areas of difficulty in craniofacial reconstruction, including mandibular, midfacial, scalp and base of skull reconstruction. As our goals now move from flap survival to refinement, more complex and innovative reconstructions are executed. The problems with each modality are examined, and the frontiers of head and neck reconstruction are explored. With the potential combination of virtual surgery and tissue engineered biotechnology, we may someday be able to expand our reconstructive capabilities beyond free tissue transfer.

Gender and immunosuppression impact on Merkel cell carcinoma diagnosis and prognosis. A population based cohort study.

Background: Merkel cell carcinoma (MCC), a rare cutaneous neuroendocrine endocrine tumour is increasing in incidence, and continues to carry a poor prognosis. Objectives: The objectives of this study were to examine all Irish cases of MCC from 1 January 1994 over 2 decades, focusing on gender and organ transplantation recipients (OTRs). Cases were identified from the National Cancer Registry of Ireland. Covariates of interest included age, body site, period of diagnosis, deprivation-status and history of non-melanoma skin cancer (NMSC). Results: In total 314 MCC cases were identified. A female predominance was noted (53.8%). Comparison between age-standardised rates between the earliest period (1994-1996) with the latest period (2012-2014) showed an increase of 105% in total. The trend in age-standardised incidence rates were noted to be increasing significantly (p = 0.0004). Average age at diagnosis was 77.6 years (male 75.1 years, female 79.7 years). Overall, the majority of MCC cases presented on the head and neck (n = 170, 54.1%). Differences in anatomical location of MCCs were noted between genders. Males were found to be more likely to have a history of previous NMSCs (males n = 73 [57.9%], females n = 53 [42.1%]). Thirty-one percentage of patients died from MCC, average survival was 3.5 years in those who died of this malignancy. Ten organ transplant recipients developed MCC. OTR who developed MCC were diagnosed at a younger average age of 65.1 years. Standardized incidence ratio for MCC in OTR was 59.96. A higher proportion of OTR died from MCC (70%), with a shorter median survival of 0.14 years. In competing risks regression, gender was not significantly associated with risk of dying, females having a non-significantly higher hazard of dying. Organ transplant recipients and patients from less deprived areas were at greater risk of dying from MCC. Conclusions: This population based study provides epidemiological, clinical and outcome data for MCC over a 20-year period.

Use of the Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity ('P-POSSUM') to predict morbidity in patients undergoing surgery with reconstruction for temporal bone malignancy.

OBJECTIVE: The Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity ('P-POSSUM') is a two-part scoring system that includes a physiological assessment and a measure of operative severity. This study sought to determine whether risk estimates for this scoring system could be used in major head and neck reconstructive surgery. METHOD: A retrospective review was performed of patients undergoing resection for a temporal bone malignancy in a single head and neck centre in Dublin, Ireland, from 2002 to 2021. RESULTS: The mean ± standard deviation morbidity estimate calculated using the scoring system was 47.6 per cent ± 19.5 per cent. The actual rate of complications was 47 per cent. The optimal cut-off for the scoring system was calculated using the Youden index from the receiver operating characteristic curve, which was 40.5 per cent in this case. CONCLUSION: The study indicates that the Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity is a useful tool for predicting morbidity risk in patients undergoing head and neck resection with reconstruction for temporal bone malignancies.

Concurrent management of suppurative intracranial complications of sinusitis and acute otitis media in children.

OBJECTIVE: Intracranial complications of sinusitis and acute otitis media (AOM) are rare but life-threatening events. In children with suppurative intracranial complications, concurrent neurosurgical and otolaryngological (ORL) intervention has been recommended to optimize outcomes. The aim of this study was to investigate outcomes following concurrent neurosurgical and ORL intervention. METHODS: A retrospective cohort study of children undergoing neurosurgical intervention for intracranial complications of sinusitis or AOM in two neurosurgical centres in Ireland was conducted. RESULTS: 65 children were identified. Mean age was 11.9 years. The most prevalent symptoms were headache, pyrexia, altered level of consciousness, facial swelling, and vomiting. Subdural empyema (n = 24, 36.9%) and extradural abscess (n = 17, 26.2%) were the most common complications. 54 underwent same admission ORL intervention; 47 (87%) were performed concurrently or earlier. For rhinogenic infections, 35 (64.8%) underwent endoscopic sinus surgery (ESS), 13 (24.1%) underwent frontal sinus trephine, and 5 (9.3%) underwent maxillary sinus washout alone. For otogenic infections, 10 (90.9%) underwent mastoidectomy and 7 (63.6%) underwent tympanostomy tube placement. 19 (29.2%) had post-operative neurological deficits, of which 2 (3.1%) were permanent. Streptococcus intermedius was the most common pathogen (n = 30, 46.2%). Concurrent intervention reduced the prevalence of residual collection (p = 0.018) and the need for revision neurosurgical intervention (p = 0.039) for sinogenic complications. The same trends did not achieve statistical significance for the otogenic group. Mortality was 0%. CONCLUSION: Intracranial complications of sinusitis and AOM are best managed in a specialist centre with multidisciplinary input. Concurrent ORL and neurosurgical intervention reduces abscess recurrence and requirement for revision neurosurgery in sinogenic complications and should represent the standard of care. ESS is the ORL modality of choice in experienced hands.

Declining incidence of keratinocyte carcinoma in organ transplant recipients.

BACKGROUND: All organ transplant populations are predisposed to increased rates of keratinocyte carcinoma (KC). Since this increased risk was first appreciated, immunosuppressive regimens have changed and organ transplant recipients (OTRs) have been aggressively screened for KC. There is a perception that these measures have impacted on KC incidence but there is a paucity of population-based studies on post-transplant rates of basal cell carcinoma (BCC). OBJECTIVES: To identify trends in incidence rates for KC following solid organ transplantation over the past two decades. METHODS: This nationwide, population-based study included all solid OTRs transplanted between 1994 and 2014. Patient data were matched to national cancer registry data to determine the standardized incidence ratio (SIR) of KC in solid OTRs compared with the general population. RESULTS: In total 3580 solid OTRs were included. The total follow-up time was 28 407 person-years (median follow-up 7·11 years). The overall SIRs for squamous cell carcinoma (SCC) and BCC were 19·7 and 7·0, respectively. Our study documents a progressive fall in the SIRs for SCC and BCC from peak SIRs (95% confidence intervals) in 1994-1996 of 26·4 (21·5-32·4) and 9·1 (7·4-11·3) to 6·3 (2·3-16·7) and 3·2 (1·4-7·1) in 2012-2014, respectively. The ratio of SCC to BCC has remained at 3 to 1 over the last two decades. CONCLUSIONS: Our study is the first to demonstrate a significant reduction over the past two decades in the incidences of both SCC and BCC following solid organ transplantation. The SCC-to-BCC ratio was maintained, demonstrating that both are reducing equally. This trend coincided with temporal changes in immunosuppressive protocols and the introduction of skin cancer prevention programmes. What's already known about this topic? Prior studies have shown that the risk of cutaneous squamous cell carcinoma (SCC) has declined over recent decades following solid organ transplantation. It is not known whether the risk of basal cell carcinoma (BCC) has reduced in line with this. What does this study add? Our study documents a progressive fall in the risk of SCC and BCC following solid organ transplantation over the last two decades. The SCC-to-BCC ratio was maintained, demonstrating that both are reducing equally. The trends observed in our study coincided with temporal changes in immunosuppressive protocols and the introduction of cancer prevention programmes, suggesting that these factors have positively impacted on the risk of keratinocyte carcinoma in this cohort.

Prognostic markers in well differentiated papillary and follicular thyroid cancer (WDTC).

OBJECTIVES: WDTC (papillary and follicular thyroid cancer) make up around 90% of all thyroid tumours. Overall, the prognosis in patients with WDTC is excellent. However, there are small cohorts of patients who experience a more aggressive form of disease which is often associated with certain poor prognostic factors. Identifying these patients at an early stage is imperative for guiding treatment decisions. With recent developments in this area we plan to discuss the current evidence surrounding prognostic markers. METHODS: The literature regarding prognostic factors in WDTC was reviewed using an electronic database Medline - Pubmed. Using the MeSH search engine specific prognostic factors including age, size, grade, lymph node involvement, distant metastasis, extension/invasion, ethnic background, radioactive iodine avidity, and thyroglobulin level and their association with WDTC were evaluated. A broader search of prognostic markers in thyroid cancer was also carried out to avoid missing other pertinent markers. RESULTS: Multiple clinical and pathologic variables have been shown to be poor prognostic factors in WDTC with statistical significance. Extensive extrathyroidal extension and age may be the most important factors when predicting clinical outcomes in WDTC, although the age threshold may be increased from 45 to 55 years in due course. CONCLUSIONS: Management of WDTC has changed considerably over the last two years as reflected in evolving British and American Thyroid Guidelines. In all cases a combined multi-disciplinary approach, with consideration of the available guidelines and stratification systems should be utilised when planning an individualised treatment program to offer the best contemporary care to WDTC patients.

High-risk cutaneous malignancies and immunosuppression: Challenges for the reconstructive surgeon in the renal transplant population.

Renal transplantation is the most frequently performed transplant procedure. Immunosuppressive therapies have dramatically increased survival rates in transplant recipients but are associated with an increased risk of skin cancers. Recent changes in immunosuppressive strategies have been adopted with the aim of reducing this challenging adverse effect. Despite these new strategies, cutaneous malignancies tend to be numerous, aggressive and associated with a higher risk of local and distant dissemination than in the non-transplant population. This represents a significant workload for transplant physicians, dermatologists, and head and neck and plastic surgeons. This review highlights key concepts in the pathogenesis of skin cancer in transplant patients, the impact current and evolving immunosuppressive strategies and regimens will have on the epidemiology, and the management of cutaneous malignancies in renal transplant patients, with particular focus on the implications for the plastic surgery community.

Aggressive medullary thyroid cancer, an analysis of the Irish National Cancer Registry.

BACKGROUND AND OBJECTIVES: Medullary thyroid cancer consists of a spectrum of disease that ranges from extremely indolent tumors to aggressive types associated with a high mortality rate. The objective of our study is to evaluate the prognostic factors and outcomes of patients diagnosed with MTC in a homogenous population, and to examine patients diagnosed with MTC for mutations in the RET proto-oncogene from the same period. METHODS: A retrospective analysis of the National Cancer Registry in Ireland was undertaken, between 1998 and 2007. The Kaplan-Meier method was used to determine overall survival and factors predictive of outcome were determined by univariate and multivariate analysis by cox regression using Stata 13 software. MAIN FINDINGS: Forty-three patients were diagnosed with medullary thyroid cancer, 55.8 % were female and 44.2 % were male. A median age of 52 was found. The overall median survival was 6.32 years and the 1- and 5-year overall survival was 88.37 and 62.79 %, respectively, with 10-year survival calculated at 48.63 %. On univariate analysis age, stage and surgical intervention were statistically significant indicators of prognosis. T stage and age remained statistically significant indicators of prognosis on multivariate analysis. Two patients with no history of MEN syndromes or family history of medullary thyroid cancer had RET proto-onocogene mutations. CONCLUSIONS: Our patient cohort was substantially older and presented at an advanced T status than what is commonly seen in the literature. This may account for poor survival outcomes and the very low pick-up of RET mutations in sporadic medullary thyroid cancer.

Total rhinectomy, a clinical review of nine cases.

INTRODUCTION: A large proportion of malignancies involving the external nose can be managed with limited resection and local autologous reconstruction or, in some cases, radiotherapy as primary or adjuvant treatment. We highlight a small cohort of patients undergoing total rhinectomy for advanced nasal malignancies. METHODS: A retrospective review of all patients undergoing total rhinectomy in our institution from 2006 to 2014 was undertaken. We reviewed patient demographics, surgical management, adjuvant treatment, histology, reconstruction and outcomes. RESULTS: Nine patients underwent total rhinectomy over an 8-year period, three of whom were being treated for recurrent disease. Eight patients had squamous cell carcinoma (SCC) and a single patient had an angiosarcoma. Two patients completed adjuvant radiotherapy. Seven patients underwent nasal prosthetic rehabilitation. All nine patients are alive and disease free at latest follow-up. CONCLUSION: Total rhinectomy is an uncommon procedure usually undertaken for extensive nasal malignancy. Nasal prosthetic rehabilitation is a viable method of reconstruction.

Conceiving a national head and neck cancer screening programme.

BACKGROUND: This study was undertaken to determine the optimum approach to screening for head and neck cancer based on international experiences. OBJECTIVE: To determine whether or not head and neck cancer is suitable for screening, and, if so, what the ideal approach should be. METHODS: An electronic search of online databases up to and including May 2014 was conducted. Key search terms included 'head and neck', 'cancer', 'screening', 'larynx', 'oropharynx' and 'oral'. RESULTS: Subset analysis of high-risk cohorts showed statistically significant improvements in early detection of head and neck cancer via screening. CONCLUSION: Current levels of public awareness regarding head and neck cancers are suboptimal, despite increased incidence and mortality. Scheduled and opportunistic screening, coupled with efforts to enhance education and health behaviour modification, are highly recommended for pre-defined, high-risk, targeted populations. This can enable early detection and therefore improve morbidity and mortality.

Ongoing challenges in the treatment of adenoid cystic carcinoma of the head and neck.

BACKGROUND: Adenoid cystic carcinoma is a malignant tumour of major and minor salivary glands. Distant metastasis and poor survival are persistent in the literature, with recent publications aimed at understanding molecular pathogenesis and development of pharmaceutical therapeutic options. AIM: Provide an update of recent studies in the management of adenoid cystic carcinoma of the head and neck. METHODS: Literature search using Medline, Scopus, Google Scholar, the Cochrane Database of Systematic Reviews and the Cochrane central register of controlled trials for articles on adenoid cystic carcinoma from January 2005 to January 2015. CONCLUSION: Adenoid cystic carcinoma is characterized by a slow growing mass, with distant metastasis independent of local or regional control. Primary tumour resection remains the preferred option with radiotherapy having an adjuvant role. Recent advances have been made with novel targeted therapies however, limited to clinical trials and advanced disease.

Effect of metronidazole versus standard care on length of stay of patients admitted with severe infectious mononucleosis: a randomized controlled trial.

Metronidazole may be of use in the treatment of infectious mononucleosis (IM). Our aim is to show that metronidazole shortens hospital stay for patients with severe IM. A single-centre randomized controlled trial was undertaken in patients admitted with severe IM, who were with a similar group treated by the standard care. Patients were blinded to which treatment arm they were in. Forty-two of these patients were enrolled in the trial. The primary endpoint was the difference in length of stay. This was significantly less in the metronidazole group (3.67 days v 4.67) (p 0.032). This study demonstrates that metronidazole has a role to play in severe infectious mononucleosis.

Papillary type thyroid carcinoma in an ovarian struma.

BACKGROUND: Struma Ovarii are mature teratomas. In rare circumstances thyroid tissue is found as part of the histopathological makeup. Malignant transformation may occur in 1-2% of these rare cases. AIM: To report a rare case of malignant thyroid carcinoma within a struma ovarii. RESULT: A 22-year-old lady presented with a right pelvic mass. A right-sided laparoscopic salpingo-oophrectomy was performed which revealed a malignant struma ovarii neoplasm. A total thyroidectomy was performed with adjuvant I(131) therapy. CONCLUSION: This is a rare tumour which necessitates surgical extirpation and removal of a normal thyroid gland to facilitate thyroglobulin monitoring.

Major otology day case surgery: viable, cost efficient and safe.

BACKGROUND: There has been no study or institution in Ireland promoting major ear surgery performed as a day case procedure in adults. At present, there is a strong political and financial drive for increased elective day case surgery and also a public responsibility to reduce surgical waiting times. METHODS: A prospective study of 43-day case otology patients who underwent major otological surgeries over an 18-month period in a tertiary referral center. We recorded morbidity, readmission rates and assessed the relationships between procedures performed and complications observed. RESULTS: We report a same day discharge rate of 88.4% with a next day readmission rate of 2.3%. We report no major morbidities and found no association between the otological procedure performed and complications observed. Furthermore, there was no statistical association between age and complications observed. We have reduced our waiting list from 9 months to 4 weeks over the 18-month period. CONCLUSION: Major day case otology surgery is an acceptable alternative to an inpatient procedure with favorable discharge rates in comparison to the UK results. Day surgery in this context is safe, cost efficient and expands the surgical possibilities within our department and specialty.

Challenging the use of the lymphocyte to white cell count ratio in the diagnosis of infectious mononucleosis by analysis of a large cohort of Monospot test results.

OBJECTIVE: We investigated the hypothesis that a lymphocyte/white cell count ratio should be used as a diagnostic indicator of infectious mononucleosis. DESIGN: Retrospective study to compare lymphocyte counts and white blood cell counts, against the criterion standard, the mononucleosis spot test. SETTING: Department of Otolaryngology, Mater Misericordiae University Hospital, Dublin, Ireland. PARTICIPANTS: We reviewed 1000 patients who had Monospot assays, 500 positive and 500 negative. MAIN OUTCOME MEASURES: The lymphocyte counts and white blood cell ratio was calculated and compared with the monospot result to calculate the sensitivity and specificity at various ratios. RESULTS: The lymphocyte counts and white blood cell ratio was significantly different in the positive and negative monospot groups (P < 0.05). The mean lymphocyte counts and white blood cell ratio in the positive group was 0.49 and the mean lymphocyte to white cell count ratio in the monospot negative group was 0.29.A ratio of 0.35 had a specificity of 72% and a sensitivity of 84% for the detection of glandular fever. A higher ratio will give a greater specificity, but a lower sensitivity, and vice versa. CONCLUSIONS: The mean lymphocyte to white cell count ratio is not sufficient to diagnose or exclude infectious mononucleosis. Thus, this study does not confirm the conclusions of earlier studies.

Prospective, blinded trial of whole-body magnetic resonance imaging versus computed tomography positron emission tomography in staging primary and recurrent cancer of the head and neck.

OBJECTIVES: To compare the use of computed tomography - positron emission tomography and whole-body magnetic resonance imaging for the staging of head and neck cancer. PATIENTS AND METHODS: From January to July 2009, 15 consecutive head and neck cancer patients (11 men and four women; mean age 59 years; age range 19 to 81 years) underwent computed tomography - positron emission tomography and whole-body magnetic resonance imaging for pre-therapeutic evaluation. All scans were staged, as per the American Joint Committee on Cancer tumour-node-metastasis classification, by two blinded consultant radiologists, in two sittings. Diagnoses were confirmed by histopathological examination of endoscopic biopsies, and in some cases whole surgical specimens. RESULTS: Tumour staging showed a 74 per cent concordance, node staging an 80 per cent concordance and metastasis staging a 100 per cent concordance, comparing the two imaging modalities. CONCLUSION: This study found radiological staging discordance between the two imaging modalities. Whole-body magnetic resonance imaging is an emerging staging modality with superior visualisation of metastatic disease, which does not require exposure to ionising radiation.

Oncogenic impact of human papilloma virus in head and neck cancer.

There is considerable debate within the literature about the significance of human papilloma virus in head and neck squamous cell carcinoma, and its potential influence on the prevention, diagnosis, grading, treatment and prognosis of these cancers. Cigarette smoking and alcohol consumption have traditionally been cited as the main risk factors for head and neck cancers. However, human papilloma virus, normally associated with cervical and other genital carcinomas, has emerged as a possible key aetiological factor in head and neck squamous cell carcinoma, especially oropharyngeal cancers. These cancers pose a significant financial burden on health resources and are increasing in incidence. The recent introduction of vaccines targeted against human papilloma virus types 16 and 18, to prevent cervical cancer, has highlighted the need for ongoing research into the importance of human papilloma virus in head and neck squamous cell carcinoma.

Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects.

BACKGROUND: With the advent of microsurgery the pedicled flap is considered by many to be an outdated surgical option. AIMS: To explore the relationship between flap survival and pre-morbid risk factors, conduct a comparative analysis of flap and systemic morbidities and complete a cosmesis and functionality assessment for oral and oropharyngeal reconstruction patients. METHODS: 114 patients, over a 13-year period, who had a one-stage reconstructive procedure employing the pectoralis major myocutaneous flap (PMMF) or radial forearm-free flap (RFFF). RESULTS: Variables, including age, smoking and radiation exposure were not statistically significant predictors of flap survival probability. Atelectasis was a significant post-op finding of RFFF patients. Flap dehiscence of >50% was a significant morbidity of PMMF. No statistical difference in cosmetic deformity, diet and socialisation was noted. CONCLUSIONS: Pectoralis major myocutaneous flap remains an enduring and safe flap; however, the RFFF has markedly improved speech performance over the PMMF.