Learning curve and technical nuances of endoscopic skull base reconstruction with nasoseptal flap to control high-flow cerebrospinal fluid leakage: reconstruction after endoscopic skull base surgery other than pituitary surgery.

PURPOSE: Although reconstruction techniques after endoscopic skull base surgery have been improved, there are difficulties in reconstructing the skull base with a nasoseptal flap (NSF), especially in the case of high-flow cerebrospinal fluid (CSF) leak. The aim of this study was to analyze risk factors for the development of postoperative CSF leaks in terms of less experienced surgeon practices. METHODS: Retrospective review of medical records was performed for 125 patients who underwent endoscopic skull base surgery for intradural pathology with intraoperative high-flow CSF leakage between Oct 2012 and Apr 2017. Basic demographic data were collected, including body mass index (BMI), tumor pathology, comorbidities, and outcomes. To assess the learning curve effect, patients were divided into early cohort (n = 30) and late cohort (n = 95) groups. RESULTS: Overall postoperative CSF leakage was 10.4% (13/125) in this series. There were no significant risk factors for postoperative CSF leakage among the demographic data including BMI, comorbidities, or radiation history. Postoperative CSF leakage was most prevalent in the transclival approach than in other approaches, but the difference was not statistically significant (20.8%, p = 0.351). When dividing the results by timetable, the patients who underwent skull base reconstruction in the early cohort experienced more postoperative CSF leakage (23.3%, 7 cases out of 30) than in the late cohort (6.3%, 6 cases out of 95, p = 0.014). The learning curve was steeper in the early cohort (30 early cases 23.3%, 31-60 10%, 61-90 6.7%, 91-125 2.9%). CONCLUSIONS: To improve the success rate of endoscopic skull base reconstruction, surgeons have to keep the basic technical details in mind to reduce the learning curve.

Tumor dimension-dependent microscopic extensions of hypopharyngeal cancer: Therapeutic implications for larynx-preserving hypopharyngectomy.

INTRODUCTION: Hypopharyngeal cancer (HPC) is well characterized by the early submucosal spread of cancer cells into adjacent subsites of the hypopharynx and deep tissues, advocating a wide extent of treatment. However, the microscopic extensions (ME) from gross tumors, according to the primary tumor dimensions, has not been reported in detail. METHODS: We included patients who underwent upfront curative surgery, and retrospectively reviewed pathology specimens from 45 HPC cases. The distance of the MEs, defined as tumor infiltration beyond the gross tumor border on the submucosal and deep sides, was measured. We analyzed potential correlations between MEs and various physical tumor factors. RESULTS: A rough linear correlation between the submucosal ME and the maximal diameter of tumors was found (p < .001, r2 = 0.225). Deep MEs did not correlate with tumor physical factors. However, the MEs differed significantly by the T status (p = .033 and .015 in submucosal and deep sides). In T1-2 tumors, the submucosal MEs were less than 0.5 cm, whereas those of T3-4 tumors were 1.5-2.0 cm. CONCLUSION: In HPC, local MEs beyond the gross tumor border correlated with primary tumor T status. Our findings support that the surgical safety margin for HPC can be adjusted according to tumor dimension.

Risk of high-grade malignancy in parotid gland tumors as classified by the Milan System for Reporting Salivary Gland Cytopathology.

BACKGROUND: The Milan System for Reporting Salivary Gland Cytopathology (Milan System) has previously shown its diagnostic utility by categorizing the seven cytology findings in salivary gland lesions. However, there has been lack of study about the risk of high-grade malignancy in the cytology diagnosis based on the Milan System. Thus, we tried to identify the diagnostic ability of the Milan System for high-grade malignancy and to suggest an improved diagnostic approach for preoperative estimation of high-grade malignancy using the Milan System. METHODS: A total of 413 patients with parotid gland tumors, who had undergone surgical resection from 2011 to 2015 were included in the present study retrospectively. Cytopathology was reclassified according to the Milan System by two independent reviewers. The outcomes were risk of malignancy and risk of high-grade malignancy. The diagnostic performance of the Milan System category [Malignant] for detecting high-grade malignancy was calculated. RESULTS: The risk of malignancy was 83.3% and 100% in the Milan System categories [Suspicious for Malignancy] and [Malignant], respectively. Meanwhile, the risk of high-grade malignancy was 16.7% and 55.9% in these two categories. Disease-free survival of patients with high-grade malignancy was significantly worse than those with low- and intermediate-grade malignancy. Union combining the Milan System category [Malignant] with the presence of nodal metastasis suggested high-grade malignancy with an acceptable diagnostic sensitivity (0.889-0.963) and negative predictive value (0.900-0.966). CONCLUSIONS: The Milan System category [Malignant] with the presence of nodal metastasis suggested parotid gland tumors as high-grade malignancy in a pretreatment setting.

Incidence of postoperative facial weakness in parotid tumor surgery: a tumor subsite analysis of 794 parotidectomies.

BACKGROUND: The reported incidence of facial weakness immediately after parotid tumor surgery ranges from 14 to 65%. The purpose of this study was to evaluate the incidence of postoperative facial weakness related to parotidectomy with use of preoperative computed tomography (CT), intraoperative facial nerve monitoring, and surgical magnification. Also, we sought to elucidate additional information about risk factors for postoperative facial weakness in parotid tumor surgery, particularly focusing on the tumor subsites. METHODS: We retrospectively reviewed 794 cases with parotidectomy for benign and malignant tumors arising from the parotid gland (2009-2016). Patients with pretreatment facial palsy were excluded from the analyses. Tumor subsites were stratified based on their anatomical relations to the facial nerve as superficial, deep, or both. Multivariable logistic regression analyses were conducted to identify risk factors for postoperative facial weakness. RESULTS: The overall incidences of temporary and permanent (more than 6 months) facial weakness were 9.2 and 5.2% in our series utilizing preoperative CT, intraoperative facial nerve monitoring, and surgical magnification. Multivariable analysis revealed that old age, malignancy, and recurrent tumors (revision surgery) were common independent risk factors for both temporary and permanent postoperative facial weakness. In addition, tumor subsite (tumors involving superficial and deep lobe) was associated with postoperative facial weakness, but not tumor size. Extent of surgery was strongly correlated with tumor pathology (malignant tumors) and tumor subsite (tumors involving deep lobe). CONCLUSION: Aside from risk factors for facial weakness in parotid tumor surgery such as old age, malignant, or recurrent tumors, the location of tumors was found to be related to postoperative facial weakness. This study result may provide background data in a future prospective study and up-to-date information for patient counseling.

Bilateral Parotid Gland Oncocytoma Mimicking Oropharyngeal Cancer Metastasis: A Case Report from a Radiation Oncologist's Perspective.

Background/Aim: Parotid oncocytomas typically present as benign, unilateral, slow-growing, painless, and solitary masses that are histologically firm and multilobulated. They are often misdiagnosed as pleomorphic adenomas, hemangiomas, or other forms of oncocytosis. However, in our case, the parotid oncocytomas initially mimicked bilateral parotid gland metastasis of advanced oropharyngeal cancer. Here, we present a case of oropharyngeal cancer with bilateral parotid oncocytomas treated with chemoradiotherapy (CCRT). Case Report: We report the case of a 74-year-old man with a sore throat, neck pain, right earache, oropharyngeal cancer, and bilateral parotid gland oncocytoma. Head and neck computed tomography and magnetic resonance imaging (MRI) showed soft-tissue swelling in the right tonsillar fossa and several enlarged level II neck lymph nodes. MRI revealed enhancing masses in both parotid glands, initially suspected to be metastatic lymph nodes. A biopsy of the right palatine tonsil confirmed squamous cell carcinoma with human papilloma virus-16 positivity. A positron emission tomography scan was performed, and biopsy-proven malignant lesions were observed in the right tonsillar region with metastatic lymph nodes in the right and left neck. Focal hypermetabolism was observed in the parotid glands, suspected to be pathological lesions such as metastatic intra-parotid lymph node or Warthin's tumor. An ultrasonography-guided biopsy of the left parotid gland confirmed an oncocytoma. Based on these results, the patient was scheduled for CCRT. After pathological confirmation of parotid oncocytoma, CCRT was administered, excluding the parotid glands within the radiotherapy field. Conclusion: This is a case of bilateral parotid gland oncocytoma mimicking oropharyngeal cancer.

Ceftiaxone-induced neurotoxicity: case report, pharmacokinetic considerations, and literature review.

Ceftriaxone is widely used in patients for the treatment of serious gram-negative infections. Ceftriaxone can induce some potential side effects, including neurotoxicity, however, nonconvulsive status epilepticus has rarely been reported. We report a case of acute reversible neurotoxicity associated with ceftriaxone. A 65-yr-old woman with chronic kidney disease developed altered consciousness during ceftriaxone treatment for urinary tract infection. The electroencephalogram demonstrated continuous bursts of generalized, high-voltage, 1 to 2 Hz sharp wave activity. Neurologic symptoms disappeared following withdrawal of ceftriaxone. The possibility of ceftriaxone-induced neurotoxicity should be considered in patients developing neurological impairment during ceftriaxone use, and the discontinuation of the drug could lead to complete neurological improvement.

Sentinel Lymph Node Biopsy Versus Elective Neck Dissection: Long-Term Oncologic Outcomes in Clinically Node-Negative Tongue Cancer.

OBJECTIVES: The aim of this study was to compare the long-term oncologic outcomes of sentinel lymph node biopsy (SLNB) versus elective neck dissection (END) in clinically node-negative (cN0) tongue cancer. METHODS: This was a retrospective cohort study of patients with cN0 tongue cancer from a single institution, including 91 patients in the SLNB group and 120 patients in the END group. RESULTS: The overall recurrence rate showed no significant difference between the two groups. The regional control rate was also comparable between the two groups (P=0.490). The 5-year recurrence-free survival (RFS) was slightly better in the SLNB group than in the END group (P=0.427). The 5-year overall survival (OS) rate was 89.9% in the SLNB group versus 91.9% in the END group (P=0.737). In a propensity-matched subgroup analysis, the type of neck management did not affect RFS or OS. CONCLUSION: SLNB showed non-inferior oncologic outcomes compared to END in patients with cN0 tongue squamous cell carcinoma.

Effects of Sequentially Combined Arytenoid Adduction and Injection Laryngoplasty in Patients With Unilateral Vocal Fold Paralysis.

OBJECTIVES: Arytenoid adduction (AA) and injection laryngoplasty (IL) are major surgical options for the treatment of unilateral vocal fold paralysis (UVFP). AA is a laryngeal framework surgery and IL is a soft-tissue augmentation procedure. Therefore, the effect of each intervention will not be substitutive but complementary to the other. METHODS: Patients who received AA and IL were enrolled (N = 43). Mean age was 60.1 ± 12.7 years. Objective and subjective voice parameters including maximum phonation time (MPT), jitter, shimmer, noise to harmonic ratio (NHR), grade of dysphonia (G), and voice handicap index (VHI)-30 were collected preoperatively and 6 months postoperatively. AA and IL were sequentially performed with time interval; 28 (65.1%) patients received IL first followed by AA (IL+AA group) and 15 (34.9%) had AA followed by IL (AA+IL group). Time interval between first and second procedures was 9.9 ± 14.6 months. RESULTS: MPT, jitter, shimmer, NHR, G and VHI-30 significantly improved by both first and second procedures (P < 0.001). When we evaluated IL+AA group and AA+IL group separately, the final outcomes of MPT, jitter, G, and VHI-30 between the two groups were not significantly different. When the overall effects of IL and AA were compared, MPT significantly improved with AA than with IL (P < 0.001). CONCLUSION: In patients with unilateral vocal fold paralysis, sequential AA and IL (or IL and AA) provided additional improvement of subjective and objective voice parameters. Final outcomes of the two combined procedures resulted in similar degree of voice improvement regardless of the order of procedure.

Prediction of risk factors for pharyngo-cutaneous fistula after total laryngectomy using artificial intelligence.

OBJECTIVES: Pharyngocutaneous fistula (PCF) is one of the major complications following total laryngectomy (TL). Previous studies about PCF risk factors showed inconsistent results, and artificial intelligence (AI) has not been used. We identified the clinical risk factors for PCF using multiple AI models. MATERIALS & METHODS: Patients who received TL in the authors' institution during the last 20 years were enrolled (N = 313) in this study. They consisted of no PCF (n = 247) and PCF groups (n = 66). We compared 29 clinical variables between the two groups and performed logistic regression and AI analysis including random forest, gradient boosting, and neural network to predict PCF after TL. RESULTS: The best prediction performance for AI was achieved when age, smoking, body mass index, hypertension, chronic kidney disease, hemoglobin level, operation time, transfusion, nodal staging, surgical margin, extent of neck dissection, type of flap reconstruction, hematoma after TL, and concurrent chemoradiation were included in the analysis. Among logistic regression and AI models, the neural network showed the highest area under the curve (0.667 ± 0.332). CONCLUSION: Diverse clinical factors were identified as PCF risk factors using AI models and the neural network demonstrated highest predictive power. This first study about prediction of PCF using AI could be used to select high risk patients for PCF when performing TL.

Additional Injection Laryngoplasty for Patients With Unilateral Vocal Fold Paralysis.

OBJECTIVES: In case of insufficient voice improvement after injection laryngoplasty (IL), additional IL will be one of the next option of treatments. However, little is known about the voice outcomes regarding an additional IL. STUDY DESIGN: Retrospective comparative study in single institution. METHODS: We enrolled the patients of unilateral vocal fold paralysis (UVFP), who received IL (N = 76) twice because of insufficient voice improvement. The etiologies of UVFP were related with thoracic and esophageal surgery (51.3%), neck surgery (30.3%), skull base surgery (7.9%), or unknown (10.5%). The subjective and objective voice parameters were collected before and after (mean: 5.3 months) each IL. RESULTS: Aspiration, maximum phonation time (MPT), jitter percentage, shimmer percentage, and noise to harmonic ratio (NHR) were significantly improved after both the first and second rounds of IL (P < .05). Voice handicap index (VHI)-30 was also significantly improved after both the first and second rounds of IL (P < .001). Regarding GRBAS score, overall grade of dysphonia (G), roughness (R), and breathiness (B) were significantly improved after the first IL, but only G and R after the second IL (P < .05). In comparison between postprocedural voice parameters of the first and second ILs, MPT was significantly improved from 5.5 ± 3.5 seconds to 7.3 ± 7.5 seconds (P = .001). Grade of dysphonia (1.9 ± 0.8) and breathiness (1.7 ± 0.9) of post-first IL were significantly (P < .001) improved to those of post-second IL (1.3 ± 0.7 and 1.2 ± 0.7, respectively). VHI-30 of post-first IL (72.0 ± 20) was significantly improved (P < .001) to those of the second IL (57.2 ± 23.7). CONCLUSIONS: In selected patients, additional IL could provide further improvement of voice in patient who had unsatisfactory voice results despite of initial IL. LEVEL OF EVIDENCE: 4 Laryngoscope, 2020.

Clinical Outcome of Minor Salivary Gland Cancers in the Oral Cavity: A Comparative Analysis With Squamous Cell Carcinomas of the Oral Cavity.

Purpose: Salivary gland cancer (SGC) in the oral cavity is not common and has been less studied in comparison with oral squamous cell carcinoma (SCC). This study aimed to identify the clinical characteristics and outcomes of SGC in the oral cavity compared with oral SCC. Methods: The medical charts of the patients with SGC (N = 68) arising from minor salivary glands and SCC (N = 750) in the oral cavity between 1995 and 2017 were reviewed retrospectively. The clinical and pathological factors and treatment outcomes were compared to identify clinical differences between oral SGC and SCC in total cases and in tumor size and subsite (propensity score)-matched pairs (N = 68 in each group). In addition, pattern of local invasion was pathologically assessed in a subset of SGC and SCC tumors. Results: Patients with SGC in the oral cavity showed >90% survival at 5 years. Most common pathologies of SGC were mucoepidermoid carcinoma (39.7%) and adenoid cystic carcinoma (35.3%), where high-grade tumors (including adenoid cystic carcinomas having solid components, grade 2 or 3) represented only 36.8%. Compared with oral SCC, surgery for SGC had narrow surgical safety margin. However, local control was very successful in SGC even with <5 mm or positive resection margin through surgery plus adjuvant radiation treatments or surgery alone for small low-grade tumors. Pathologic analysis revealed that the frequency of oral SGC with infiltrative tumor border was significantly lower than that of oral SCC (46.4 vs. 87.2%, P < 0.001). Conclusions: SGC in the oral cavity represents relatively good prognosis and has a locally less aggressive pathology compared with oral SCC. Adjuvant radiation can be very effective to control minimal residual disease in oral SGC. Our study proposed that a different treatment strategy for oral SGC would be reasonable in comparison with oral SCC.

Safe surgical tracheostomy during the COVID-19 pandemic: A protocol based on experiences with Middle East Respiratory Syndrome and COVID-19 outbreaks in South Korea.

BACKGROUND: A subset of patients with COVID-19 require intensive respiratory care and tracheostomy. Several guidelines on tracheostomy procedures and care of tracheostomized patients have been introduced. In addition to these guidelines, further details of the procedure and perioperative care would be helpful. The purpose of this study is to describe our experience and tracheostomy protocol for patients with MERS or COVID-19. MATERIALS AND METHODS: Thirteen patients with MERS were admitted to the ICU, 9 (69.2%) of whom underwent surgical tracheostomy. During the COVID-19 outbreak, surgical tracheostomy was performed in one of seven patients with COVID-19. We reviewed related documents and collected information through interviews with healthcare workers who had participated in designing a tracheostomy protocol. RESULTS: Compared with previous guidelines, our protocol consisted of enhanced PPE, simplified procedures (no limitation in the use of electrocautery and wound suction, no stay suture, and delayed cannula change) and a validated screening strategy for healthcare workers. Our protocol allowed for all associated healthcare workers to continue their routine clinical work and daily life. It guaranteed safe return to general patient care without any related complications or nosocomial transmission during the MERS and COVID-19 outbreaks. CONCLUSION: Our protocol and experience with tracheostomies for MERS and COVID-19 may be helpful to other healthcare workers in building an institutional protocol optimized for their own COVID-19 situation.

Clinical outcomes and management of facial nerve in patients with parotid gland cancer and pretreatment facial weakness.

OBJECTIVES: In parotid gland cancer (PGC), it is not clear whether facial weakness always reflects tumor invasion of the facial nerve (FN) requiring nerve resection. The aims of this study were to evaluate oncological and functional outcomes in patients with PGC and pre-treatment facial weakness, and to analyze local tumor invasion of the FN. MATERIALS AND METHODS: The clinical outcomes of patients (n = 45) with PGC and pretreatment facial weakness were retrospectively analyzed. Patients had undergone 1 of 4 types of treatments: complete tumor resection, FN sacrifice with or without FN reconstruction, tumor resection with FN preservation and primary non-surgical treatments. Pathologic specimens in patients with nerve resection patients (n = 26) were reviewed to identify FN invasion by the tumor. RESULTS: Patients with PGC and facial weakness had poor clinical outcomes (44.0%, 3Y progression-free survival), and 86.7% of tumors were high-grade. In these subjects, regional or distant metastasis was an independent prognostic factor for survival. Recovery from facial weakness was suboptimal in patients with FN graft. In cases with nerve resection, 26.9% had intra-neural tumor invasion, 42.3% had perineural invasion, and 30.8% had no neural invasion in the FN. CONCLUSION: Facial weakness did not always indicate tumor invasion of the FN in PGC. Thus, the decision regarding FN resection can reasonably be further based on intraoperative findings. In cases with incomplete facial weakness and safe separation of the FN from the tumor, FN preservation offers the best functional outcomes, without compromising oncological outcomes.

Prognostic Role of Neutrophil-to-Lymphocyte Ratio in Patients with Human Papillomavirus-Positive Oropharyngeal Cancer.

Objective To investigate the prognostic impact of the neutrophil-to-lymphocyte ratio (NLR) for human papillomavirus-positive oropharyngeal cancer (HPV+ OPC). Study Design Retrospective institutional database analysis. Setting Tertiary referral medical center. Material and Methods In total, 104 patients with HPV+ OPC were enrolled. From the blood laboratory data checked within 4 weeks before initiation of primary treatment, NLR was calculated. The association between clinicopathological characteristics and NLR was analyzed, and the prognostic role was evaluated based on overall survival (OS) and disease-free survival (DFS). Results According to the cutoff value (2.42) for NLR, the patients were classified into the low NLR group (n = 61) or the high NLR group (n = 43). High NLR was associated with a higher rate of advanced T classification ( P = .007) and diabetes mellitus ( P = .01). The proportion of surgery-based treatment was lower in the high NLR group (20.9% vs 42.6%, P = .02). The high NLR group showed a lower 5-year OS rate (85.3% vs 96.3%, P = .09) and a lower 5-year DFS rate (68.1% vs 94.7%, P = .01) than those in the low NLR group. Multivariate analysis showed that advanced N classification was a significant predictor for worse 5-year OS (hazard ratio [HR], 17.40; 95% confidence interval [CI], 2.36-128.29) and that both advanced N classification (HR, 7.78; 95% CI, 2.33-25.93) and high NLR (HR, 4.16; 95% CI, 1.24-13.95) were important prognosticators for worse 5-year DFS. Conclusion Elevated pretreatment NLR was associated with poor DFS in patients with HPV+ OPC.

Using the nasoseptal flap for reconstruction after endoscopic debridement of radionecrosis in nasopharyngeal carcinoma.

BACKGROUND: Radionecrosis is a complication of nasopharyngeal carcinoma (NPC) that is difficult to treat. Endoscopic debridement is the first-line treatment for radionecrosis. After debridement, however, either bone or the internal carotid artery is exposed and requires mucosal coverage. OBJECTIVES: This study sought to demonstrate the effectiveness of a nasoseptal flap (NSF) after endoscopic debridement of radionecrosis in the reconstruction of nasopharyngeal or skull base defects. METHODS: Nine patients with NPC who underwent navigation-guided endoscopic debridement, followed by NSF reconstruction between April 2013 and July 2016, were included. The patients' clinical features and outcomes were evaluated. RESULTS: All nine patients had headaches, and eight had a foul odor associated with their radionecrosis. One patient underwent three radiotherapy treatments, four had two treatments, and the remaining four had just one treatment. The foul odor disappeared after treatment in all the patients who had been affected. The headache was significantly reduced after treatment in all patients. The NSF detached in two patients. In one patient, NSF failed, and the patient experienced postoperative rupture of the internal carotid artery. In the seven other patients, the NSF successfully covered the resultant defects, despite one intraoperative internal carotid artery rupture. Only two patients required further debridement, whereas the others experienced complete healing after just one surgical procedure. The nasopharyngeal surface was healthy-appearing in eight patients (median follow-up, median 11 months). CONCLUSION: Reconstruction by using NSF after endoscopic debridement for radionecrosis of NPC allowed for faster healing and reduced the need for further debridement.

Comparison of Endoscopic Tympanoplasty to Microscopic Tympanoplasty.

OBJECTIVES: This study aimed to compare the outcome of endoscopic and microscopic tympanoplasty. METHODS: This was a retrospective comparative study of 73 patients (35 males and 38 females) who underwent type I tympanoplasty at Samsung Medical Center from April to December 2014. The subjects were classified into two groups; endoscopic tympanoplasty (ET, n=25), microscopic tympanoplasty (MT, n=48). Demographic data, perforation size of tympanic membrane at preoperative state, pure tone audiometric results preoperatively and 3 months postoperatively, operation time, sequential postoperative pain scale (NRS-11), and graft success rate were evaluated. RESULTS: The perforation size of the tympanic membrane in ET and MT group was 25.3%±11.7% and 20.1%±11.9%, respectively (P=0.074). Mean operation time of MT (88.9±28.5 minutes) was longer than that of the ET (68.2±22.1 minutes) with a statistical significance (P=0.002). External auditory canal (EAC) width was shorter in the ET group than in the MT group (P=0.011). However, EAC widening was not necessary in the ET group and was performed in 33.3% of patients in the MT group. Graft success rate in the ET and MT group were 100% and 95.8%, respectively; the values were not significantly different (P=0.304). Pre- and postoperative audiometric results including bone and air conduction thresholds and air-bone gap were not significantly different between the groups. In all groups, the postoperative air-bone gap was significantly improved compared to the preoperative air-bone gap. Immediate postoperative pain was similar between the groups. However, pain of 1 day after surgery was significantly less in the ET group. CONCLUSION: With endoscopic system, minimal invasive tympanoplasty can be possible with similar graft success rate and less pain.

Free flap outcome of salvage surgery compared to primary surgery for head and neck defects: A propensity score analysis.

OBJECTIVES: To compare free flap outcomes for head and neck defects between primary surgery and salvage surgery and identify factors affecting the outcomes in the two settings. METHODS: A total of 225 patients (primary group, n=56; salvage group, n=169) were retrospectively identified. The salvage group was previously treated with radiotherapy, chemoradiation, surgery, or any combination of these treatments. Clinical data were retrieved and analyzed between the two groups to compare the incidence and contributing factors of flap-related complications and flap failure. A propensity score analysis with matching T stage, defect, and flap types was also performed for unbiased comparisons. RESULTS: Flap-related complication rate was 22.2% in all patients. The salvage group showed higher rates of wound dehiscence than the primary group (3.6% in primary vs. 13.0% in salvage; p=0.04). Flap failures occurred in 10 patients (4.4%), including 3 (5.4%) in the primary group and 7 (4.1%) in the salvage group (p=0.71). Multivariate analysis showed no critical factor that influenced the occurrence of flap-related complications or flap failure, including surgery type (primary or salvage). In propensity score analysis, incidences and types of flap-related complications and flap failure were not statistically different between the two groups (primary and salvage). CONCLUSIONS: Free flap reconstruction is a safe and reliable method to restore the ablative defects in previously irradiated or operated head and neck defects.

Nasoseptal Flap Elevation in Patients with History of Septal Surgery: Does It Increase Flap Failure or Cerebrospinal Fluid Leakage?

OBJECTIVE: The nasoseptal flap (NSF) has been shown to be a mainstay in the reconstruction of skull base defects. We evaluated the efficacy and complications of NSF in patients with a history of septal surgery who had the potential risk of tearing and poor vascularity. METHODS: We performed a retrospective chart and video review of patients who underwent NSF for skull base reconstruction between February 2012 and May 2015. Comparison was made between 18 patients (revision group) who had a history of septoplasty and/or transseptal transsphenoidal approach and 88 patients (primary group) without a history of septal surgery. Laceration when raising the flap, vascularity on postoperative magnetic resonance imaging, viability on postoperative endoscopy, and cerebrospinal fluid (CSF) leakage were compared between the revision and primary groups. RESULTS: Laceration of the flap occurred during NSF elevation in 2 patients (11.1%) in the revision group and 4 patients (4.5%) in the primary group (P = 0.269). Poor flap vascularity on magnetic resonance imaging was observed in 2 patients (11.1%) in the revision group and 8 patients (9.1%) in the primary group (P = 0.674). The rate of flap necrosis on endoscopy was 5.6% in the revision group and 1.1% in the primary group (P = 0.312). There was no significant difference in CSF leakage rate between the 2 groups (revision 5.6% and primary 10.2%). CONCLUSIONS: There was no difference in rate of CSF leakage or flap integrity between the 2 groups. Therefore, NSF for skull base reconstruction is feasible in patients with a history of septal surgery.