What Is the Role of Elective Neck Dissection in the Management of Patients With Buccal Squamous Cell Carcinoma and Clinically Negative Neck?

PURPOSE: Buccal squamous cell carcinoma (BSCC) is rare in the United States. Given its location, few anatomic barriers to spread exist and it has been found to have a high locoregional recurrence rate. The role of elective neck dissection (END) in patients with clinically negative neck (N0) is not clear. This study aims to answer the following research question: Among patients with N0 BSCC, does END improve locoregional control rates, distant metastasis rates, and 2- and 5-year survival rates? MATERIALS AND METHODS: A retrospective cohort study was conducted. The sample included patients who received a diagnosis of BSCC. The primary predictor variable was END status (yes or no). Five institutions participated between June 2001 and June 2011: University of Washington, University of Michigan, University of Tennessee, North Memorial Oral and Maxillofacial Surgery in Minnesota, and Head and Neck Surgical Associates (Portland, OR). The primary outcome variable was locoregional recurrence. Secondary outcome variables were distant metastasis and 2- and 5-year survival rates. Other variables collected were demographic characteristics, initial operation, adjuvant therapy, clinical and pathologic data, and staging. Kaplan-Meier and Cox proportional hazards statistics were computed. RESULTS: The sample was composed of 98 patients with clinical N0 BSCC. The mean age was 66 years (range, 30-88 years), and 54% were men. Of the patients, 74 (76%) underwent END. The locoregional recurrence-free rate was 61% for END versus 38% for no END (P = .042). The distant metastasis rate was 4% for END versus 9% for no END. The 2- and 5-year disease-free survival rates were 91% and 75% (P = .042), respectively, for END and 85% and 63% (P = .019), respectively, for no END. CONCLUSIONS: END had a therapeutic effect, as evidenced by a lower locoregional recurrence rate, lower distant metastasis rate, and improved 2- and 5-year survival rates.

Digital imaging evaluation of the scapula for prediction of endosteal implant placement in reconstruction of oromandibular defects with scapular free flaps.

OBJECTIVE: Dental implant placement in scapular free flaps is challenging. This study examines the scapula with computed tomography to identify ideal locations for predictable implant placement during preoperative planning. METHODS: Sixty-eight adult patient chest CT scans (34 men, 34 women) captured for various medical indications, were analyzed for age, height, weight, and scapula length. The lateral border of the scapula was divided into six equal segments; the midpoints of each segment (labeled proximally to distally as 1M-6M) were analyzed in cross-section as potential recipient sites for 3.5 × 8 mm implants. Also, we present a case of a 77-year-old male with ameloblastoma of the mandible who underwent patient specific planning and received a scapular free flap with dental implant placement. RESULTS: There was greater bone availability in males with a mean depth of 8.3 ± 2.8 versus 5.1 ± 3.3 mm in females (p < .01). The proximal portion (1M) of the scapula in males and females had depths of 11.3 ± 1.5 and 9.5 ± 2.3 mm, respectively. Males had depths of 8.4 ± 3.0 in M3, 9.7 ± 1.7 in M4, and 8.9 ± 1.2 mm in M6. Depth of bone available for patients with heights ≥165 cm versus <165 cm had means of 10.4 ± 1.3 and 8.0 ± 1.6 mm (p < .01), respectively; but showed no significant differences between BMI (BMI <25 vs. ≥25) and bone availability (6.8 ± 1.7 vs. 6.8 ± 1.6, p = .07), or age (<55 years vs. ≥55 years) and bone availability (9.8 ± 1.6 vs. 9.8 ± 1.6, p = .11). In our case, the patient received 6 cm length of scapular bone with four 4.1 × 14 mm endosteal implants, which upon osseointegration was able to receive a fixed dental prosthesis. Three years after the initial surgery, the patient has had no difficulty with his prosthesis. CONCLUSION: In females the most proximal portion of the scapula will predictably accommodate a dental implant, while males have multiple sites including the proximal, middle, and distal portions.

Correlation of Lymph Node Density With Negative Outcome Predictors in Oral and Maxillofacial Squamous Cell Carcinoma.

PURPOSE: Lymph node density is defined as the number of positive lymph nodes per total number of excised lymph nodes. In oral and maxillofacial cancer, there are recent data showing that increased lymph node density leads to worse outcomes for patients. However, data correlating lymph node density with other known risk parameters are lacking. This study investigated whether a direct correlation exists among cervical lymph node density, depth of invasion, perineural invasion, and extracapsular tumor spread. MATERIALS AND METHODS: A retrospective chart review was undertaken to include all patients who underwent neck dissection with resection of primary oral and maxillofacial squamous cell carcinoma from January 2009 through July 2014. After applying the exclusion criteria, 286 patients were identified. Primary tumor depth of invasion, perineural invasion, and lymph node status, including extracapsular spread, were obtained from the standard pathology report. Descriptive statistics were applied. The association between 2 continuous tumor characteristics was summarized with the Pearson correlation coefficient, and the association between a continuous and a binary tumor characteristic was summarized with 2-sample t test. Statistical significance for the study was set at a P value less than .05. RESULTS: Mean age at time of surgery was 63.9 ± 12.5 years. The final study included 169 men and 117 women (N = 286). The mean depth of invasion was 12.3 ± 11 mm (range, 1 to 69 mm). Mean lymph node density was 0.04 ± 0.1 (range, 0 to 0.81). There was a positive association between lymph node density and depth of tumor invasion (Pearson correlation coefficient, r = 0.21; P < .001). Tumors with perineural invasion had a statistically significant difference in mean lymph node density (0.074 for positive vs 0.024 for negative; P < .001). There also was a significant association in mean lymph node density with the presence of extracapsular spread (0.143 for positive and 0.010 for negative; P < .001). CONCLUSIONS: Statistically relevant positive linear relations among lymph node density, depth of invasion, perineural invasion, and extracapsular spread were identified. Lymph node density could have prognostic implications, because it is statistically correlated with other known prognostic features that lead to poor outcomes. Lymph node density could be an important feature to capture in future prospective trials. Pathology standards would be crucial in this endeavor.

Course of the mandibular incisive canal and its impact on harvesting symphysis bone grafts.

PURPOSE: To characterize the anatomic course of the mandibular incisive canal to define parameters for harvesting autogenous bone from the symphysis of the mandible. MATERIALS AND METHODS: A series of osteotomies were completed between the mental foramina in the anterior mandibles of 19 cadavers. Methylene blue dye was used to help identify the incisive canal. From the canal, distances to key adjacent landmarks were measured with a Boley gauge to 0.1 mm. Measurements included distances from the mandibular incisive canal to the buccal cortex, the lingual cortex, the inferior border of the mandible, the apices of the teeth, and the buccal cementoenamel junction (CEJ) of the teeth. RESULTS: The canal decreased in diameter from lateral to medial. It tended to be closer to the buccal cortical bone than to the lingual cortex (P < .001) and was, at times, directly abutting the buccal cortex (average distance to buccal cortex, 3.5 mm). The canal maintained a relatively constant distance from the apices of the teeth (approximately 7 to 8 mm), coursing inferiorly under the longer canines bilaterally. The canal became increasingly difficult to identify toward the midline, likely dispersing into microscopic tributaries. CONCLUSIONS: The authors suggest several modifications to the standard surgical approach to the symphysis area during the harvest of bone grafts. When the goal is to avoid the mandibular incisive canal, osteotomies should not exceed a depth of 4 mm, should be at least 5 mm anterior to the mental foramen, and 9 mm below the root apices (or 23 mm below the lowest facial CEJ) and should maintain the contour of the mandible's inferior border. Alternatively, some degree of canal compromise can be accepted and larger grafts can be obtained by increasing the depth of the harvest in the horizontal dimension or decreasing the distance from the osteotomy to the root apices (or the CEJ) in the vertical dimension.

Delayed ear reconstruction: case report of reconstruction of an avulsed ear 2 days after injury.

Auricular reattachment and reconstruction following traumatic ear avulsion is a challenging surgical problem. Suggested reconstruction methods include direct reattachment, composite grafting, pocket methods, coverage with periauricular flaps, and microsurgical repair. A published alternative is reattachment and burial of the amputated part under a postauricular flap. If circumstances delay the surgical intervention, what is a safe window to still consider this form of treatment? In the current report, we present a case of a complete partial ear avulsion, which was reattached in the ER as a free graft. Two days later the cartilage was banked under a postauricular flap. A 22 year-old male had his ear was completely bitten off which was re-attached. Two days later the skin of the avulsed segment was dark and bloodless. The avulsed segment was removed from the ear. The overlying skin was dissected off of the attached ear leaving perichondrium on the medial aspect of the ear. The cartilage was then reattached. A postauricular pocket/flap was created and the ear tucked and secured to the postauricular fascia and skin closed overtop. Five weeks later, the patient had division and inset of the flap with a full thickness skin graft to the posterior aspect of the ear. Our results and experiences suggest that immediate reconstruction may not be crucial.

Anatomic analysis of the conchal bowl cartilage.

PURPOSE: The conchal bowl is a portion of auricular cartilage commonly used as an autologous graft for various maxillofacial procedures. Few studies have attempted to describe the anatomy of this region in detail, particularly in relation to the curvature of the conchal bowl. The present study has provided detailed information about the anatomy of the auricular cartilage in the conchal bowl region that could assist in the surgical design of graft harvesting. MATERIALS AND METHODS: A total of 35 pairs of cadaver ears without gross deformity (15 male, 20 female; aged 39 to 99 years) were dissected to completely expose the cartilage skeleton. Each cartilage was stabilized, and the conchal bowl was mapped. The starting reference point was defined as the intersection of the lateral border of the antihelix and the superiormost aspect of the inferior crux. A prefabricated grid was then used to imprint a 4 × 5 matrix of pinpoint ink spots on the surface of each cartilage, with 6-mm increments between each spot. The grid's y and x axes were then aligned with the landmarks above. Next, a MicroScribe 3-dimensional digitizer (ghost3d.com) was used to capture the 3-dimensional coordinates for each point on the ear's surface and the coordinates were transferred into an Excel spreadsheet. After digitization, a Boley gauge was used to measure the thickness of the cartilage at each premarked spot. The gathered data points and measurements were examined to describe our parameters of interest (ie, depth, thickness, and curvature). RESULTS: The average maximum conchal bowl depth was 10.5 ± 3.0 mm in the female ears and 10.7 ± 2.5 mm in the male ears. In general, the conchal bowl depth at each point did not differ significantly between the males and females. The mean cartilage thickness ranged from 0.77 to 1.79 mm (mean 1.15 ± 0.26) in the females and 0.95 to 1.45 mm (mean 1.25 ± 0.23) in the males. Both genders showed an increase in the conchal bowl depth from inferiorly to superiorly and from posteriorly to anteriorly. The cartilage thickness also increased from posteriorly to anteriorly; however, the exact shape is complex. CONCLUSIONS: A detailed understanding of the facial anatomy is important in the practice of facial surgery. The results we have presented will provide surgeons with information on the overall dimensions, thickness, and curvature of the conchal bowl that could allow more advantageous donor site selection.

Calcified chondroid mesenchymal neoplasm: report of a case involving the temporomandibular joint region and review of the literature.

The calcified chondroid mesenchymal neoplasm (CCMN) represents a recently recognized tumor type with only 50 well-documented cases in the English-language literature. Herein we report an additional case of CCMN presenting as a large mass in the temporomandibular joint region of a 41-year-old female. A review of previously reported cases and the current case of CCMN shows the following features: 1) average age 52 years (range 14-87 years) and an approximately even sex distribution; 2) most frequently involved sites: distal extremities (including foot, hand, wrist, forearm) (n=41) and temporomandibular joint/temporal/parotid region (n=9); 3) multilobular soft tissue tumor with chondroid to cartilaginous matrix, often grungy or lace-like calcifications, and variable cytologic atypia; 4) frequently detected FN1 rearrangement (n=15), including FN1 fusion with FGFR2 (n=7) or other receptor tyrosine kinases; 5) 2 reported local recurrences (after incomplete excision); 6) no reports of malignant biologic behavior.

Comparison of intraoral harvest sites for corticocancellous bone grafts.

PURPOSE: The aim of this study is to quantify and compare the amount of bone that can be harvested from the mandibular symphysis, ascending ramus/body, coronoid process, and the zygomatic-maxillary buttress using a within-subject study design. MATERIALS AND METHODS: Three continuous outcomes (area, thickness, and volume) were measured at 4 sites (zygomatic-maxillary buttress symphysis, ramus, coronoid) from each of the 59 cadavers used in this study. The explanatory variables were age, gender, and site. To account for the within-subject research design, a linear mixed-effects model was performed separately for each of the 3 outcomes to compare the sites controlling for age and gender. Level of significance was set at 0.05. RESULTS: For all 3 outcomes, there was a statistically significant difference among the average values of the 4 sites (P < 0.0001). The ramus had the highest average cortical bone area and volume harvested, while the symphysis had the highest average thickness. CONCLUSIONS: The characteristics among different potential intraoral donor sites vary greatly regarding thickness, volume, and cortical surface area. Using the estimates of the various yields derived from these grafts, a surgeon will be more adequately equipped to confront the reconstructive challenges of the maxillofacial region.

Correlating the depth of invasion at specific anatomic locations with the risk for regional metastatic disease to lymph nodes in the neck for oral squamous cell carcinoma.

BACKGROUND: The purpose of this study was to investigate the critical primary tumor depth of invasion in oral squamous cell carcinoma that would lead to a 20% or greater risk of nodal metastasis. METHODS: An institutional review board approved retrospective review of our head and neck database was performed from 2009 to 2014 and the data were statistically analyzed. RESULTS: Two hundred eighty-six patients with a diagnosis of oral squamous cell carcinoma who met our inclusion criteria underwent primary excision and neck dissection. For a depth of invasion of 1 mm or less, there were no patients with a positive node. From 1.1 mm to 2 mm of depth of invasion, there was 1 of 11 patients (9%) who had at least 1 positive node. At 2.1 mm to 3 mm, 5 of 25 patients (20%) had at least 1 positive node. CONCLUSION: Depth of invasion and the location of the tumor are 2 important variables to consider when making treatment recommendations to patients with clinical N0 disease. © 2017 Wiley Periodicals, Inc. Head Neck 39: 974-979, 2017.

Vessel injuries of the head and neck presenting in mandibular fractures.

OBJECTIVE: Extracranial vascular injuries of the head and neck are relatively underdiagnosed in patients with acute trauma and can carry devastating sequelae. We wished to identify the correlation between mandibular fractures and injuries to major vessels of the head and neck. STUDY DESIGN: A retrospective review of our trauma registry was performed for the 1993-2007 period. The data on all mandibular fractures were collected. RESULTS: A total of 2288 patients presented to Parkland Memorial Hospital with mandibular fractures, of whom 47 (2%) had an injury to a major vessel of the neck. Nearly half, 23 (48.9%), were the result of high-velocity penetrating injuries, namely gunshot wounds, whereas 17 (36.2%) were the result of high-velocity blunt motor vehicle or motorcycle collisions. CONCLUSIONS: Patients who sustain a mandibular fracture in the setting of a high-velocity mechanism should be approached with the possibility of vascular injury of the great vessels of the neck kept in mind.

Comparison of intraoral harvest sites in the edentulous versus dentate specimen.

OBJECTIVE: The aim of this study was to compare the edentulous vs dentate specimen intraoral bone harvest sites. We wished to identify if there were any sites that yielded similar quantities of bone regardless of the status of the dentition. STUDY DESIGN: There were 59 cadavers in the study. Three continuous outcomes (area, thickness, and volume) were measured for each cadaver at 4 sites (zygoma, symphysis, ramus, and coronoid). RESULTS: Status of the dentition was not a factor in the quantity of harvested bone in regard to surface area and volume. The only difference noted between the dentate and edentulous groups was the thickness in the symphysis and zygomaticomaxillary buttress, with the dentate group, on average, having greater thickness. CONCLUSIONS: There appeared to be similar amounts of bone available in dentate and edentulous specimens in our study. This information should encourage clinicians to consider intraoral bone harvest for augmentation of an edentulous ridge regardless of the status of the dentition.