Underappreciated Utility of the Purse-String Suture in Head and Neck Skin Cancer Defect Reconstruction.

BACKGROUND: The purse-string suture (PSS) is a simple, reversible method for reconstructing skin cancer defects. Its utility may be underappreciated in head and neck reconstructive surgery. OBJECTIVE: To evaluate the utility of the PSS as an adjunct to the reconstructive ladder when reconstructing head and neck skin cancer defects. MATERIALS AND METHODS: This prospective nonrandomized cohort included 109 consecutive adult patients with head and neck defects resulting from skin cancer resection. The PSS was placed in every patient after resection. Patients were evaluated before and after suture placement, and final reconstructive methods were recorded. RESULTS: The PSS resulted in a mean defect area reduction of 77.1% (p < .001) and was used in the final reconstruction in 79 (72.5%) patients. The PSS reduced the number of patients requiring adjacent tissue transfer (11), regional tissue transfer (3), and free tissue transfer (1) by 69.4%, 70%, and 80%, respectively. Fifty patients underwent reconstruction in the operating room. After intraoperative placement of the PSS, it was determined that 22 (44.0%) of these defects could have been reconstructed in the clinic (p = .003). CONCLUSION: The PSS dramatically reduces defect size, simplifies reconstructive techniques, and often permits reconstruction to be performed in the clinic rather than the operating room.

Effect of Mandible and Maxilla Osteotomies on Velar, Oropharyngeal, and Hypopharyngeal Diameter.

PURPOSE: There is a lack of anatomic comparisons between maxillomandibular advancement (MMA) and other bony surgical treatments of obstructive sleep apnea (OSA). Surgical procedures were simulated in cadavers to evaluate their ability to expand the posterior airway space (PAS). MATERIALS AND METHODS: The following bony advancement surgeries were performed on each of 9 cadavers: genioglossal advancement (GGA); genioplasty with advancement of the genioglossus, geniohyoid, and anterior digastric muscles (GPA); bilateral sagittal split osteotomy; Le Fort I maxillary advancement; Le Fort I maxillary anterior impaction osteotomy (LFAI); MMA; MMA plus GPA; and MMA plus LFAI. Bony advancements were performed at increasing distances and change in PAS anteroposterior (AP) diameter was measured at the levels of the velum, oropharynx, and hypopharynx. RESULTS: Change in PAS varied in a linear fashion with advancement surgical maneuvers. GPA led to a greater increase in AP distance at the levels of the oropharynx and hypopharynx compared with GGA. LFAI showed a greater increase in AP distance at the velum compared with MMA. All maxillary movements showed greater AP expansion in the PAS at the velum compared with mandibular advancements. CONCLUSIONS: Static AP expansion of the PAS at the levels of the velum, oropharynx, and hypopharynx occurs in a roughly linear and predictable pattern with different bony surgical procedures used in OSA surgery. MMA alone and MMA plus GPA had the overall greatest effect at all airway levels. GPA had a greater effect on expansion of the oropharynx and hypopharynx compared with GGA.

Management of Frontal Sinus Fractures.

Fractures of the frontal sinus occur from extreme forces and are often associated with other injuries. Management of frontal sinus fractures is variable and dependent on involvement of the anterior table, posterior table, and frontal outflow tract. Severe complications can developed from poorly managed fractures, such as meningitis, mucocele, mucopyocele, and brain abscess. Surgeons should be aware of appropriate management and surgical techniques for addressing frontal sinus fractures. Herein, we review the presentation and management of frontal sinus fractures, including conservative, endoscopic, and open surgical techniques.

Management of Skull Fractures and Calvarial Defects.

Scalp and calvarial defects can result from a myriad of causes including but not limited to trauma, infection, congenital malformations, neoplasm, and surgical management of tumors or other pathologies. While some small, nondisplaced fractures with minimal overlying skin injury can be managed conservatively, more extensive wounds will need surgical repair and closure. There are many autologous and alloplastic materials to aid in dural and calvarial reconstruction, but no ideal reconstructive method has yet emerged. Different reconstructive materials and methods are associated with different advantages, disadvantages, and complications that reconstructive surgeons should be aware of. Herein, we discuss different methods and materials for the surgical reconstruction of calvarial defects.

Sialodochoplasty Stents: Cost Analysis and Outcomes.

PURPOSE: We reviewed a patient cohort receiving sialodochoplasty with or without salivary stent placement. We propose the Firlit-Kluge pediatric urinary catheter (Cook Medical, Bloomington, IN) as an advantageous alternative stent because of our duct patency results with stenting, considering the advantages and disadvantages of specific stents. We also provide a simple cost summary of commonly used stents. MATERIALS AND METHODS: A retrospective review of a case series of patients undergoing sialodochoplasty or salivary duct surgery from 2012 to 2015 was undertaken at a tertiary care center. The indications, duct reconstruction results, and complications were analyzed, and a comparative cost analysis was performed. RESULTS: Of 25 patients, 16 were stented with Firlit-Kluge catheters, 2 with CORFLO ULTRA feeding tubes (Corpak Medsystems, Buffalo, NY), 1 with an Introcan Safety intravenous (IV) catheter (B. Braun Medical Inc, Melsungen, Germany), and 6 were not stented. All 16 Firlit-Kluge-stented patients had successful duct reconstruction with a patent duct orifice draining saliva on the last follow-up visit, and only 1 stent dislodged early. All patients stented with feeding tubes or the IV catheter experienced discomfort or early dislodgement of the stent. Comparing the Firlit-Kluge stent to commercially available salivary stents, the cost savings in the Firlit-Kluge stent group was $2,480.16 compared with the cost of the Walvekar and Schaitkin stents (Hood Laboratories, Pembroke, MA) and $880.15 to $1,120.00 compared with Ad-Tech-Med stents (Lublin, Poland). However, the cost of the Firlit-Kluge stent exceeded the costs of the Braun IV catheter, Bard infant urinary catheter (Bard Medical Division, CR Bard, Louisville, CO), and CORFLO ULTRA stent by $60.48, $24.64, and $258.72, respectively. CONCLUSIONS: The Firlit-Kluge urinary catheter incurs considerable cost savings compared with commercial stents, and its silicone makeup and ball flange enhances comfort and prevents dislodgment by aiding in suture placement.

3D Genial Tubercle Anatomic Considerations in Genioglossus Advancement Surgery.

OBJECTIVE: To qualitatively describe variation in morphology of the genial tubercle and quantify the spatial relationship between the tubercle and genioglossus muscle. STUDY DESIGN: Case series. SETTING: Cadaver dissection. METHODS: Segmental sections of the mandible, with muscular attachments intact, were harvested from 18 fresh cadaver heads. Three-dimensional laser scans, with a resolution of 0.025 mm, were taken of each specimen with muscle attached and repeated after muscle removal. The genioglossus muscular attachment was measured relation to bony landmarks. RESULTS: The morphology of the genial tubercle varied, with anywhere from 1 large spine to 4 individual spines. However, all specimens had a distinguishable superior portion of the tubercle, where the genioglossus attached, and an inferior portion, where the geniohyoid attached. The height of the superior tubercle (ST) was 6.1 mm (95% confidence inerval [CI]: 5.7-6.5). The height of the genioglossus muscle above the peak amplitude of the ST was 4.3 mm (3.8-4.9), but only 2.5 mm (2.0-3.0) below. On average, 64.4% (58.6-70.2) of the height of the genioglossus muscle attachment was above the peak. Overall, 19.5% (14.1-25.0) of the muscle surface area extended beyond the boundaries of the tubercle. CONCLUSION: The genioglossus muscle attachment originates from the superior genial tubercle, which has a variable topography and amplitude. However, the muscle is not centered on the spines-more of the muscular fibers attach above the spine as compared to below. This new data may explain the genioglossus advancement "miss rate"-failure to advance muscle on initial osteotomy-of 39-78% reported in the literature.

A Contemporary Review of Trachea, Nose, and Ear Cartilage Bioengineering and Additive Manufacturing.

The complex structure, chemical composition, and biomechanical properties of craniofacial cartilaginous structures make them challenging to reconstruct. Autologous grafts have limited tissue availability and can cause significant donor-site morbidity, homologous grafts often require immunosuppression, and alloplastic grafts may have high rates of infection or displacement. Furthermore, all these grafting techniques require a high level of surgical skill to ensure that the reconstruction matches the original structure. Current research indicates that additive manufacturing shows promise in overcoming these limitations. Autologous stem cells have been developed into cartilage when exposed to the appropriate growth factors and culture conditions, such as mechanical stress and oxygen deprivation. Additive manufacturing allows for increased precision when engineering scaffolds for stem cell cultures. Fine control over the porosity and structure of a material ensures adequate cell adhesion and fit between the graft and the defect. Several recent tissue engineering studies have focused on the trachea, nose, and ear, as these structures are often damaged by congenital conditions, trauma, and malignancy. This article reviews the limitations of current reconstructive techniques and the new developments in additive manufacturing for tracheal, nasal, and auricular cartilages.

Composite Thickness and Stiffness Analysis of the Nasal Septum.

Background: The nasal septum supports the structure of the nose and is frequently manipulated during septorhinoplasty. Objective: To compare measurements of thickness and compressive Young's modulus (YM) between different regions of nasal septa from human anatomic specimens. Study Design: Case series. Methods: Cartilaginous septa from human anatomic specimens were dissected. Septum thickness was measured at 24 points with regular intervals using a digital caliper. Compressive YM was determined at 14 regions using a force gauge. Two-tailed student's t-tests were used to compare the average thickness and YM between different regions. Results: Septa from 40 human anatomic specimens were included, with age ranging from 50 to 89. Fifty percent of specimens were female. The mean (standard deviation) thickness of the septum was 1.75 (0.76) mm. The mean YM was 2.38 (1.29) MPa. The septum was thickest near the maxillary crest (3.09 [1.17] mm) and the keystone area (2.52 [0.91] mm) and thinnest near the anterior septal angle (1.29 [0.58] mm). The septum was most stiff posteriorly (2.90 [1.32] MPa) and least stiff anteriorly (1.80 [1.15] MPa). Conclusion: The nasal septum is thickest posteriorly, inferiorly, and along its bony edges. The septum is stiffest posteriorly, ventrally, and along its bony edges.

Smoking Pack Years and Eustachian Tube Dysfunction.

Objective: To determine the effect of smoking history on the risk of developing obstructive eustachian tube dysfunction (OETD). Study Design: Cross-sectional review. Setting: National database. Methods: Data from the National Health and Nutrition Examination Survey (1999 to present) was analyzed. OETD was defined as middle ear pressure less than -100 decapascals (daPa). Nonsmokers, current smokers, with tympanometry data were analyzed. Patients under the age of 18, with myringotomy tubes, or with a sinus problem/earache/cold in the past 24 hours were excluded. The relative risks (RRs) for developing OETD were calculated for nonsmokers versus smokers and those with greater versus less than 10, 20, and 30 pack years (py). Results: A total of 9472 patients met inclusion criteria (54.1% female, 75.9% non-Hispanic, mean age 43, 20.3% smokers). The RR of having OETD for smokers versus nonsmokers was 1.75 [95% confidence interval, CI: 1.45-2.11]. The RR of having OETD for patients with a 10+ py was 1.97 [95% CI 1.57-2.47], 20+ py was 2.29 [95% CI 1.76-2.95], and 30 py or greater was 2.08 [95% CI 1.49-2.90]. Conclusion: In this study, smoking roughly doubled the risk of developing OETD, as represented by a single measurement of negative middle ear pressure less than -100 daPa. The definition of OETD used in this study was limited, as it did not include symptomology, and more work is needed to examine additional covariates. However, these results may guide future research to better counsel and screen patients for OETD.

Patterns of Discordance Between Clinical and Pathologic Stage in Head and Neck Cancer.

OBJECTIVE: To enhance understanding in patterns of discordance between clinical and pathological T and N staging in multiple sites of head and neck squamous cell cancer. METHODS: A retrospective cohort of 580 newly diagnosed and surgically treated head and neck squamous cell carcinoma patients from a single institution over a 10-year period are presented. Clinical and pathologic staging are compared. RESULTS: Notably, 33% of cases had staging discordance. Overall Cohen's kappa agreement was κ = 0.55 (moderate agreement). Highly discordant site stages with κ < 0.45 included: T2 oral cavity, T2 oropharynx, T3 larynx, and N1 lymph node. T2-4 oral cavity cancers were often overstaged, and more than one-third of T3 larynx cancers were understaged. Highly concordant site stages with κ>0.65 included: T1 larynx, T4 oropharynx, N0 lymph node, and N3 lymph node. CONCLUSION: There exists a quantifiable and, in certain sites, clinically relevant pattern of discordance between clinical and pathologic staging. Tumor board multidisciplinary evaluation can highlight these discrepancies and aide in limiting effects on treatment decisions. However, discordant staging can affect the interpretation and application of prognostication, treatment, and data accuracy. Further investigation is warranted to improve clinical staging accuracy in areas of highest discordance. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Lip Wedge Resection with Orbicularis Oris Plication for Facial Paralysis: A Novel Technique.

Introduction: Oral incompetence (OI) following facial nerve injury or sacrifice remains a frustrating problem for patients and clinicians alike. Dynamic procedures for facial paralysis often do not fully address OI and static surgeries are frequently needed. Current static options frequently involved multiple facial incisions. Methods: We describe a novel technique to address OI due to lower division facial nerve paralysis and report outcomes in an initial series of patients. Results: OI symptoms improved in 94% of patients following a single-stage surgery. Revision was required in one patient with subsequent resolution of symptoms. Major complications (19%) included persistent OI, wound dehiscence, and bothersome lip "bulk". Conclusion: Lip wedge resection with orbicular oris plication resolves OI in facial paralysis patients with the added benefit of only a single incision on the face.

Introduction : L'incompétence orale après une blessure ou un sacrifice des nerfs faciaux demeure un problème frustrant, tant pour les patients que pour les cliniciens. En cas de paralysie faciale, il n'est pas rare que les interventions dynamiques ne corrigent pas toute l'incompétence orale, et des interventions statiques sont souvent nécessaires. Les options statiques actuelles exigent souvent de multiples incisions faciales. Méthodologie : Les chercheurs décrivent une nouvelle technique pour corriger une incompétence orale en raison d'une paralysie de la partie inférieure des nerfs faciaux et rendent compte des résultats auprès d'une série initiale de patients. Résultats : Les symptômes d'incompétence orale ont diminué chez 94 % des patients après une chirurgie en un temps. Un patient a dû subir une révision, puis les symptômes se sont résorbés. Les complications majeures (19 %) incluaient une incompétence orale persistante, la déhiscence de la plaie et un « volume ¼ dérangeant de la lèvre. Conclusion : La résection en coin par plicature de l'orbiculaire des lèvres résout l'incompétence orale en cas de paralysie faciale et a l'avantage supplémentaire de nécessiter une seule incision sur le visage.

Patient Satisfaction with Nonopioid Postoperative Analgesia in Head and Neck Surgery: A Prospective Randomized Trial.

OBJECTIVE: To evaluate patients' satisfaction with opioid versus opioid-sparing postoperative analgesia in patients undergoing outpatient head and neck surgery. STUDY DESIGN: Prospective randomized trial. SETTING: Tertiary care academic hospital. METHODS: Adult patients undergoing outpatient head and neck surgery were randomly assigned to 1 of 3 analgesic regimens. First- and second-line medications were the following by group (1) Hydrocodone-acetaminophen with ibuprofen, (2) ibuprofen with hydrocodone-acetaminophen, and (3) ibuprofen with acetaminophen. Preoperative counseling was provided to patients regarding expected pain and proper medication use. Postoperative questionnaires were administered to assess satisfaction. RESULTS: One hundred three patients were enrolled in the study (mean age, 56.5 years; women, 75 [73%]). The mean satisfaction score with the pain regimen assigned was similar between the 3 groups (scale 0-10, [7.7, 8.3, 8.5, P = .46]). A similar percentage of patients in each group reported that surgery was more painful than anticipated (25%, 32%, 26%, P = .978), and a similar percentage of patients reported willingness to utilize the same analgesic regimen following future surgeries (75%, 83%, 76%, P = .682). Additional questions evaluating the side effect profile, maximum and minimum pain scores, and difficulty of recovery were not statistically different between the 3 groups. CONCLUSION: In the postoperative population for outpatient head and neck surgeries, there was no significant difference in patient satisfaction and pain control between the opioid and nonopioid arms. Providers should discuss opioid-sparing regimens preoperatively with patients and describe them as effective in providing adequate pain control without a significant impact on patient's perception of care.

The Creation of an Average 3D Model of the Human Cartilaginous Nasal Septum and Its Biomimetic Applications.

The cartilaginous nasal septum is integral to the overall structure of the nose. Developing our an-atomic understanding of the septum will improve the planning and techniques of septal surgeries. While the basic dimensions of the septum have previously been described, the average shape in the sagittal plane has yet to be established. Furthermore, determining the average shape allows for the creation of a mean three-dimensional (3D) septum model. To better understand the average septal shape, we dissected septums from 40 fresh human cadavers. Thickness was measured across pre-defined points on each specimen. Image processing in Photoshop was used to superimpose lateral photographs of the septums to determine the average shape. The average shape was then combined with thickness data to develop a 3D model. This model may be utilized in finite elemental analyses, creating theoretical results about septal properties that are more translatable to real-world clinical practice. Our 3D septum also has numerous applications for 3D printing. Realistic models can be created for educational or surgical planning purposes. In the future, our model could also serve as the basis for 3D-printed scaffolds to aid in tissue regeneration to reconstruct septal defects. The model can be viewed at the NIH 3D model repository (3DPX ID: 020598, Title: 3D Nasal Septum).

Prevalence of Occult Central Lymph Node Metastasis by Tumor Size in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis.

BACKGROUND: While papillary thyroid carcinoma (PTC) is associated with high occult central neck metastasis (CNM) rates, prophylactic central neck dissection (pCND) is controversial. This meta-analysis aims to look at the occult CNM rate according to tumor size. METHODS: A literature search was conducted in PubMed from inception to April 2023. Inclusion criteria were primary studies that determined occult CNM rates in cN0 PTC by tumor size. Heterogeneity, influential case diagnostics, and proportion data were evaluated with Cochran's Q-test, Baujat plots and Forest plots, respectively. RESULTS: Fifty-two studies were included in this meta-analysis. The findings demonstrated an occult CNM rate of 30.3% for tumors ≤ 5 mm, 32.7% for tumors ≤ 1 cm, 46.0% for tumors between 1 and 2 cm, 43.1% for tumors between 2 and 4 cm, and 61.2% for tumors > 4 cm. The heterogeneity of each study group was high, though no publication bias was noted. While there was a trend towards increased occult CNM rates with larger tumors, comparisons between different size cutoffs varied in significance. CONCLUSION: This comprehensive review affirms that occult CNM is high and that an ipsilateral pCND can be justified in all PTC patients for accurate differentiation between Stage I and Stage II disease and its clinical implications.

Dysphagia Severity and Outcomes Following Iatrogenic High Vagal Nerve Injury.

OBJECTIVE: To examine severity of dysphagia and outcomes following iatrogenic high vagal nerve injury. METHODS: Retrospective chart review of all patients with iatrogenic high vagal nerve injury that were seen at a tertiary referral center from 2012 to 2020. RESULTS: Of 1304 patients who met criteria for initial screening, 18 met all inclusion criteria. All 18 required intervention to address postoperative dysphagia. Eleven required enteral feeding tubes with 7 eventually able to advance to exclusively per oral diets. Fourteen underwent vocal fold injection and 6 underwent laryngeal framework surgery. Sixteen pursued swallowing therapy with speech language pathology. Patients lost a mean of 8.6 kg of weight in the 6 months following the injury. Swallowing function on the Functional Outcome Swallowing Scale (FOSS) and Functional Oral Intake Scale (FOIS) was 4.4 and 2.4 respectively immediately following the injury and improved to 1.9 and 5.3 at the last follow-up. No patients had complete return of normal swallowing function at last follow up. CONCLUSION: Iatrogenic high vagal injury causes significant lasting dysphagia which improves with intervention but does not completely resolve. Interventions such as vocal fold injection, medialization laryngoplasty, cricopharyngeal myotomy, or swallowing therapy may be required to reestablish safe swallowing in these patients.

Neurotrophin Pathway Receptors NGFR and TrkA Control Perineural Invasion, Metastasis, and Pain in Oral Cancer.

Oral squamous cell carcinoma (OSCC) patients suffer from poor survival due to metastasis or locoregional recurrence, processes that are both facilitated by perineural invasion (PNI). OSCC has higher rates of PNI than other cancer subtypes, with PNI present in 80% of tumors. Despite the impact of PNI on oral cancer prognosis and pain, little is known about the genes that drive PNI, which in turn drive pain, invasion, and metastasis. In this study, clinical data, preclinical, and in vitro models are leveraged to elucidate the role of neurotrophins in OSCC metastasis, PNI, and pain. The expression data in OSCC patients with metastasis, PNI, or pain demonstrate dysregulation of neurotrophin genes. TrkA and nerve growth factor receptor (NGFR) are focused, two receptors that are activated by NGF, a neurotrophin expressed at high levels in OSCC. It is demonstrated that targeted knockdown of these two receptors inhibits proliferation and invasion in an in vitro and preclinical model of OSCC, and metastasis, PNI, and pain. It is further determined that TrkA knockdown alone inhibits thermal hyperalgesia, whereas NGFR knockdown alone inhibits mechanical allodynia. Collectively the results highlight the ability of OSCC to co-opt different components of the neurotrophin pathway in metastasis, PNI, and pain.

Esophageal stenosis in head and neck cancer patients: Imaging's accuracy to predict dilation response.

OBJECTIVES: The primary goal of this study was to examine how well findings of cervical esophageal stenosis on modified barium swallow (MBS) and esophagram correlate with clinical improvement following dilation in patients with a history of head and neck (H&N) cancer. METHODS: A retrospective review was performed at an academic hospital. The study population included H&N cancer patients with a history of neck dissection surgery who underwent esophageal dilation from 2010 to2018. Pre and postdilation swallowing function was assessed. The Functional Outcomes Swallowing Scale (FOSS) and Functional Oral Intake Scale (FOIS) were used as outcome measures. RESULTS: The 95 patients were included. All patients had imaging prior to dilation. Post-dilation FOSS and FOIS scores were significantly improved (P < .001). In identifying the patients that would have improvement from dilation, esophagram and MBS had average sensitivities of 81% and 82%, respectively. The negative predictive value (ie, the ability of a normal esophagram or normal MBS to exclude patients that would not improve with dilation) was only 46% and 38%, respectively. When the specific finding of aspiration on MBS was considered, the positive predictive value (PPV) (ie, the ability of an MBS positive for aspiration to predict that a patient would benefit from dilation) was 87% (P = .03). When only the specific finding of stenosis on esophagram was considered, the PPV of improvement post-dilation was 58% (P = .97). The delay in time from imaging to dilation was significantly longer in those who had an unidentified stenosis (false negative) on imaging when compared to those who did not (46.8 ± 35.2 days vs 312.6 ± 244.1 days, P < .001). CONCLUSION: In high risk patients for cervical esophageal stenosis, such as those with a history of H&N cancer and open neck surgery with or without radiation, MBS and esophagram appear to have mixed reliability as predictors of response to esophageal dilation. In these patients, a "negative" result on MBS and esophagram may not be diagnostically accurate enough to exclude patients from consideration of dilation. LEVEL OF EVIDENCE: IIb.

Transoral Excision of Parapharyngeal Tumors.

OBJECTIVES: The transoral approach for parapharyngeal space tumors has been criticized due to its restrictive exposure and increased rate of vascular and nerve injuries. However, for certain tumors-namely those that are prestyloid, benign, and well-encapsulated-the transoral approach reduces overall morbidity while providing direct access. Transoral surgeons can rely on this approach for select tumors seen clearly on intraoral examination in the bulging lateral pharynx. In this article and with a supplemental operative technique video, we demonstrate our transoral approach in these select patients. METHODS: We reviewed our 26 cases using this approach and chose a representative case of a 50-year-old man who presented with a large, prestyloid, encapsulated parapharyngeal mass affecting his voice and swallowing. A transoral approach to the parapharyngeal tumor is illustrated. RESULTS: A vertical curvilinear incision is completed from the hamulus to below the inferior extent of the tumor. Blunt dissection of the tumor capsule proceeds inferiorly. Controlled violation of the tumor capsule can aid in visualization. After tumor delivery, the wound is irrigated and closed. CONCLUSIONS: In our experience, the transoral approach is an effective method to access well-encapsulated, prestyloid parapharyngeal space tumors. Patient selection is important when considering a transoral approach.

Colon mass: a rare site of metastasis for squamous cell cancer of the head and neck.

A 61-year-old man with a past medical history significant for heavy alcohol consumption and an extensive smoking history presented with a left neck mass which was diagnosed as a pT3N2bM0 squamous cell carcinoma (SCC) of the submandibular gland. The patient was later found to have recurrence with mediastinal metastasis despite adjuvant chemoradiation. He subsequently developed abdominal distention with computed tomography revealing an ascending colon mass and findings concerning for perforation. The patient underwent an exploratory laparotomy with right hemicolectomy. Surgical pathology was consistent with metastatic SCC.