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OBJECTIVE: To evaluate the impact of the first month of lockdown related to the Covid-19 epidemic on the oncologic surgical activity in the Ile de France region university hospital otorhinolaryngology departments. MATERIAL AND METHODS: A multicenter prospective observational assessment was conducted in 6 university hospital otorhinolaryngology departments (Paris Centre, Nord, Est and Sorbonne) during the 1-month periods before (Month A) and after (Month B) lockdown on March 17, 2020. The main goal was to evaluate lockdown impact on oncologic surgical activity in the departments. Secondary goals were to report population characteristics, surgery conditions, postoperative course, progression of Covid status in patients and surgeons, and adverse events. RESULTS: 224 procedures were performed. There was 10.9% reduction in overall activity, without significant difference between departments. Squamous cell carcinoma and larynx, hypopharynx, oropharynx, oral cavity and nasal cavity and sinus locations were predominant, at 79% and 75.8% of cases respectively, with no significant differences between months. T3/4 and N2/3 tumors were more frequent in Month B (P=.002 and .0004). There was no significant difference between months regarding surgical approach, type of reconstruction, postoperative course, tracheotomy and nasogastric feeding-tube time, intensive care stay or hospital stay. None of the Month A patients were Covid-19-positive, versus 3 in Month B, without adverse events. None of the otorhinolaryngologists involved in the procedures developed symptoms suggesting Covid-19 infestation. CONCLUSION: The present study underscored the limited impact of the Covid-19 epidemic and lockdown on surgical diagnosis and cancer surgery in the Ile de France university otorhinolaryngology departments, maintaining chances for optimal survival without spreading the virus.
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Infecciones por Coronavirus/epidemiología , Neoplasias de Oído, Nariz y Garganta/cirugía , Procedimientos Quirúrgicos Otorrinolaringológicos/estadística & datos numéricos , Neumonía Viral/epidemiología , Cuarentena/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , COVID-19 , Femenino , Francia/epidemiología , Hospitales Universitarios , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Estudios Prospectivos , Factores de Tiempo , Adulto JovenRESUMEN
PURPOSE: The role of postoperative irradiation to contralateral non-involved neck nodes in lateralized carcinoma of the head and neck is not clear. The contralateral neck failure rate in head and neck carcinoma treated postoperatively with ipsilateral neck irradiation only was evaluated. METHODS: Patients with carcinoma of the oral cavity, oropharynx, or hypopharynx without midline extension treated between 1990 and 2016 were analyzed. After tumor resection and neck dissection (ND), radiotherapy was given to the primary tumor site and ipsilateral neck. High-risk patients additionally received concurrent chemotherapy. Freedom from contralateral neck recurrence (FCNR), locoregional control rate (LRC), overall survival (OS), and disease-free survival (DFS) were evaluated. RESULTS: 197 patients (median age 60.7 years, 66.5% males, 52.8% oropharyngeal carcinomas) were analyzed. Complete resection (R0) was achieved in 85.8% of cases. Ipsilateral ND was performed in all patients and contralateral ND in 144 patients (73.1%). Concurrent chemotherapy was given to 59 patients (30.0%). After a median follow-up of 45.5 months, OS and DFS of all patients were 73.6% and 70.9% at 5 years, respectively. A total of 45 patients (22.8%) suffered from a locoregional recurrence, lymph node metastases of the contralateral neck developed in 12 patients (6.1%) only. There was no significant difference in contralateral nodal failure rate with or without performance of contralateral ND. CONCLUSION: Regional failure of the contralateral neck was low after surgery and ipsilateral neck irradiation in head and neck carcinomas without midline extension, supporting evidence that contralateral neck radiotherapy can safely be omitted in selected cases.
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Metástasis Linfática/radioterapia , Recurrencia Local de Neoplasia/radioterapia , Recurrencia Local de Neoplasia/cirugía , Neoplasias de Oído, Nariz y Garganta/radioterapia , Neoplasias de Oído, Nariz y Garganta/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Disección del Cuello , Recurrencia Local de Neoplasia/mortalidad , Neoplasias de Oído, Nariz y Garganta/mortalidad , Radioterapia Adyuvante , Análisis de SupervivenciaRESUMEN
BACKGROUND: Oxidized regenerated cellulose (ORC; Surgicel®; Ethicon, Neuchâtel, Switzerland) is an absorbable hemostatic agent used for hemostasis in operation, although some surgeons use it to position free flap pedicles. The increasing risk of vessel compromise is a huge concern. However, no scientific data to date demonstrate the safety and benefit of using ORC in microvascular surgery. In the present study, we compared the outcome of microvascular head and neck reconstruction with and without pedicle placement using ORC. MATERIALS AND METHODS: From January 2015 to December 2017, we reviewed patients undergoing microvascular surgery with free fibular osteocutaneous flap in our hospital. The patients were divided into the ORC group and non-ORC group and their baseline characteristics and outcomes were compared. RESULTS: In total, there were 27 patients in the ORC group and 67 in the non-ORC group. The non-ORC group had significantly higher cigarette consumption (70.4% vs. 89.6%; p = .022). The outcome of the ORC group was better regarding arterial thrombosis (0% vs. 3%), flap failure (0% vs. 4.5%), hematoma (7.4% vs. 10.4%), and wound complications (25.9% vs. 44.8%). The ORC group had a worse result than the non-ORC group for vein thrombosis (7.4% vs. 4.5%) and duration of hospitalization (24.111 days vs. 23.627 days). However, none of above results was significant. CONCLUSIONS: Though this study was underpowered to detect the differences, the results showed a trend toward better outcomes of flaps and wounds in the ORC group. It seems that using ORC in this field is safe and beneficial.
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Celulosa Oxidada/administración & dosificación , Colgajos Tisulares Libres/cirugía , Microcirugia/métodos , Neoplasias de Oído, Nariz y Garganta/cirugía , Procedimientos de Cirugía Plástica/métodos , Trasplante Óseo/métodos , Femenino , Colgajos Tisulares Libres/irrigación sanguínea , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias de Oído, Nariz y Garganta/patología , Complicaciones Posoperatorias/etiología , Trombosis/etiologíaRESUMEN
OBJECTIVE: Efforts have been devoted to clarify the possible factors related to postoperative complications in free-flap reconstruction. While patient-related factors have been widely discussed, studies regarding the operation/operator-related factors are rather limited in the literature. This study was designed to investigate the relationship between operation/operator-related factors and the surgical complications in free-flap reconstruction following head and neck cancer resection. METHODS: Data of 1,841 patients with a total of 1,865 free-flap reconstructions (24 double free-flap reconstructions) between March 2008 and February 2017 were retrieved from the registered microsurgery database of the hospital. The association of operation/operator-related factors (including flap length and length-width ratio, flap types, use of vein graft, opposite side microanastomosis, number of microanastomoses, operators, operator experience, and operation time) with surgical complications was assessed by 1:1 propensity score-matched study groups. RESULTS: After propensity score matching of the patient-related factors, the rate of vein grafting was significantly higher (0.6% vs. 2.2%, p = .038) and the operation time was longer (7.0 [5.8-8.5] vs. 7.4 [6.1-8.8] hr, p = .006) in the complication group. In addition, flap length and length-width ratio, flap types, opposite side microanastomosis, number of microanastomoses, operators, and operator experience were not associated with surgical complications. CONCLUSIONS: In a hospital that consisted of surgeons with high-volume or very-high-volume experience, the operators or operation experience were not significantly associated with the surgical complications. Only a longer operation time was associated with surgical complications in the patients who underwent free-flap reconstruction for head and neck cancer.
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Competencia Clínica , Colgajos Tisulares Libres/cirugía , Neoplasias de Oído, Nariz y Garganta/cirugía , Procedimientos de Cirugía Plástica/métodos , Complicaciones Posoperatorias/etiología , Puntaje de Propensión , Anastomosis Quirúrgica , Femenino , Colgajos Tisulares Libres/irrigación sanguínea , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Tempo Operativo , Neoplasias de Oído, Nariz y Garganta/patología , Factores de Riesgo , Taiwán , Resultado del Tratamiento , Venas/trasplanteAsunto(s)
Manejo de la Vía Aérea/métodos , Carcinoma de Células Escamosas/diagnóstico , Endoscopía/métodos , Neoplasias de Cabeza y Cuello/diagnóstico , Neoplasias de Oído, Nariz y Garganta/diagnóstico , Anestesia por Inhalación , Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirugía , Neoplasias de Cabeza y Cuello/radioterapia , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Hipertensión/complicaciones , Intubación Intratraqueal , Masculino , Persona de Mediana Edad , Neoplasias de Oído, Nariz y Garganta/radioterapia , Neoplasias de Oído, Nariz y Garganta/cirugía , Medicación Preanestésica , Factores de RiesgoRESUMEN
PURPOSE: The aim of this retrospective study was to evaluate the clinical outcome of a previously defined low-risk patient population with completely resected (R0) squamous cell carcinoma of the oral cavity, oropharynx, larynx (pT1-3, pN0-pN2b), hypopharynx (pT1-2, pN0-pN1), and the indication for postoperative radio(chemo)therapy. PATIENTS AND METHODS: According to predefined criteria, 99 patients with head and neck squamous cell carcinoma (SCC) who were treated at our institution from January 1, 2005 to December 31, 2014, were available for analysis. The Kaplan-Meier method was used for calculating survival and incidence rates. For univariate comparative analysis, the log-rank test was used for analyzing prognostic clinicopathologic parameters. RESULTS: Median follow-up was 67 months. Cumulative overall (OS) and disease-free survival (DFS) were 97.9%/94.7%/88.0% and 96.9%/92.6%/84.7% after 1, 2, and 5 years, respectively. Cumulative incidence of loco-regional recurrence (LRR), distant metastases (DM), and second cancer (SC) were 1.0%/1.0%/4.9%, 0.0%/3.4%/5.8%, and 2.1%/4.2%/13.1%, respectively. In univariate comparative analysis, location of the primary tumor in the oropharynx was a significant predictor for increased OS (p = 0.043) and DFS (pâ¯= 0.048). CONCLUSION: Considering the low disease relapse rates and high rates of therapy-induced late side effects, as well as the increased risk of developing SC, a prospective multicentric trial investigating de-escalation of radiotherapy in this clearly defined low-risk patient population was started and is still recruiting patients (DIREKHT-Trial, NCT02528955).
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Carcinoma de Células Escamosas/radioterapia , Quimioradioterapia Adyuvante/métodos , Neoplasias de Oído, Nariz y Garganta/radioterapia , Dosificación Radioterapéutica , Radioterapia de Intensidad Modulada/métodos , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Quimioradioterapia Adyuvante/normas , Terapia Combinada/mortalidad , Terapia Combinada/normas , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias de Oído, Nariz y Garganta/mortalidad , Neoplasias de Oído, Nariz y Garganta/patología , Neoplasias de Oído, Nariz y Garganta/cirugía , Cuidados Posoperatorios/métodos , Cuidados Posoperatorios/normas , Dosificación Radioterapéutica/normas , Radioterapia de Intensidad Modulada/normas , Estudios Retrospectivos , Nivel de Atención/normasRESUMEN
BACKGROUND: With the rising number of patients in advanced age receiving microsurgical procedures, coronary artery disease (CAD) and its challenging management is of increasing importance. Evidence based data concerning morbidity and mortality are rare. We present our experiences with this highly selected patient population and propose a preoperative assessment algorithm. PATIENTS AND METHODS: Between January 2006 and May 2016, a total of 57 patients with CAD received 58 free flaps. Median age of our patients was 64 years (interquartile range 57.5-70.0). Squamous cell carcinoma was the reason for reconstruction in all cases. Defect of the buccal, gum, tongue, lip, trigone, palatal, and hypopharyngeal regions were reconstructed. Patient characteristics and comorbidities were recorded. We especially focused on the preoperative cardiac assessment and treatment of patients who were scheduled for microsurgical free tissue transfer such as medical history, cardiac risk assessment, and further cardiac testing such as Doppler-echocardiography and myocardial perfusion assessment. Intraoperative course as well as postoperative morbidity and mortality was described. RESULTS: About 54.4% of the selected cohort received cardiac catheterization due to a clinical preoperative cardiac assessment performed individually by the cardiologist on duty. In total, 52 fasciocutaneous anterolateral thigh flaps, four osteocutaneous fibula flaps, and two radial forearm flaps were performed. The flap survival rate was 96.6%. The overall surgical complication rate was 28.1% (16 patients), mostly due to wound infections (seven cases) and partial flap necrosis (four cases). Three patients died, resulting in a mortality rate of 5.2%. CONCLUSION: CAD patients receiving head and neck microsurgical reconstructions are still at high risk for adverse consequences due to surgery. The microsurgical community is requested to share the experience of those cases in order to develop reliable and evidence based statements of the perioperative risks and prognosis for these patients. We additionally introduce a standardized perioperative cardiac assessment and treatment algorithm for head and neck surgery patients with CAD.
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Algoritmos , Carcinoma de Células Escamosas/cirugía , Enfermedad de la Arteria Coronaria , Microcirugia/métodos , Neoplasias de Oído, Nariz y Garganta/cirugía , Atención Perioperativa , Procedimientos de Cirugía Plástica/métodos , Factores de Edad , Anciano , Cateterismo Cardíaco , Comorbilidad , Femenino , Colgajos Tisulares Libres/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Medición de Riesgo , Factores de Riesgo , Supervivencia TisularRESUMEN
OBJECTIVES: To establish a correlation between 4 measurements made on preoperative computed axial tomography and the presence of difficult airway, as well as its clinical prediction in patients undergoing otorhinolaryngological surgery. MATERIAL AND METHODS: A retrospective, observational study was carried out using the information gathered from the clinical notes of 104 patients undergoing general anaesthesia and endotracheal intubation for oncological otorhinolaryngological surgery over a period of 36 months. Based on the findings in the preoperative imaging tests, a multivariate logistic regression analysis was performed, where the dependent variable was the presence of extreme grades of visualization of the glottis visualisation (Cormack III-IV) or the presence of predictors of difficult intubation (Mallampati III-IV). This resulted in a total of 4 tomographic and clinical factors of difficult airway being introduced in this model. RESULTS: In the Cormack III-IV group, the results were not statistically significant in the multivariate model when compared to the tomography predictors, distance from epiglottis to posterior pharyngeal wall (95% CI; 0.030 - 2.31, P<.05), and the distance from the base of the tongue to the posterior pharyngeal wall (95% CI; 0.018-1.37, P<.05). In the Mallampati III-IV group, in the multivariate model only the distance from the vocal cords to the posterior pharyngeal wall showed clinically significant results (95% CI; 0.104 - 8.53, P<.05). CONCLUSIONS: In the approach to the airway, reliance on predictors is based on physical examination to anticipate situations that put oxygenation and ventilation of the patients at risk. There are still insufficient data to recommend imaging tests in this area, however it seems that in the future they may be added to the diagnostic performance of physical examination as predictors of difficult airway.
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Manejo de la Vía Aérea , Neoplasias de Cabeza y Cuello/cirugía , Neoplasias de Oído, Nariz y Garganta/cirugía , Cuidados Preoperatorios , Tomografía Computarizada por Rayos X , Anciano , Anestesia General , Epiglotis/diagnóstico por imagen , Femenino , Humanos , Intubación Intratraqueal , Masculino , Faringe/diagnóstico por imagen , Estudios Retrospectivos , Tráquea/diagnóstico por imagenRESUMEN
PURPOSE: To assess the ability of prosthetic rehabilitation versus surgical rehabilitation in improving the QOL for patients with maxillary defects. MATERIAL AND METHODS: A systematic search of PubMed, Scopus data base, Cochrane database, Ovid database, and Latin America & Caribbean database for articles published before September 2017 was performed by two independent reviewers. A manual search of articles published from January 2000 to September 2017 was also conducted. Only English studies were included which evaluate the QoL in patients with head and neck cancers. Any confusion between the two independent reviewers was resolved by means of a moderated discussion between the reviewers. RESULTS: Five studies fulfilled the inclusion criteria for this study. Many parameters were used regarding evaluation of QOL as the EORTC Head and Neck 35 assessment, UW-QOL, OHIP-14, VAS, OFS, MHI, HAD, Body Satisfaction Scale, Oral symptom check list, Swallowing, Diet consist, Pain control, Postoperative complication, and Speech. Two studies supported the surgical line of treatment for improving the QOL as compared to the prosthetic one; another two studies showed a statistically insignificant improvement in the patients' QOL with the surgical line, while only one revealed insignificant difference in QoL with both lines of treatment. CONCLUSIONS: Surgical rehabilitation provides a better line of treatment in improving the QOL for patients with maxillary defects. On the other hand, prosthetic has proved effectiveness in the immediate post-surgical times as temporary strategy, and it has represented a good alternative when the surgical obturation is compromised.
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Implantación Dental Endoósea , Prótesis Dental , Maxilar/cirugía , Neoplasias Maxilares/cirugía , Neoplasias de Oído, Nariz y Garganta/cirugía , Calidad de Vida , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Complicaciones Posoperatorias/etiología , Adulto JovenRESUMEN
BACKGROUND: To report our experience of postoperative haemorrhage in patients following transoral robotic surgery (TORS). METHODS: Data were collected on patients having TORS. Postoperative haemorrhage within 30 days was graded using the Mayo Clinic grading system. RESULTS: Transoral robotic surgery operations were performed on 122 patients. There were 23 bleeding events classified as minor to severe following 19 operations (16%). Haemorrhage requiring a return to the operating room occurred after 7 operations (6%). The odds of an emergent haemorrhage were 5.19 times greater in patients who had a staged neck dissection after TORS (P = .05). The odds of a postoperative bleeding event were 2.6 times greater in patients receiving a larger resection (P = .107). There were no haemorrhage events in the 36 patients who received a synchronous neck dissection with transcervical ligation of the external carotid artery. CONCLUSIONS: Surgical intervention for TORS haemorrhage occurred in 6% patients. No haemorrhage occurred in patients who had ligation of the external carotid artery.
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Carcinoma de Células Escamosas/cirugía , Neoplasias de la Boca/cirugía , Disección del Cuello/efectos adversos , Neoplasias de Oído, Nariz y Garganta/cirugía , Hemorragia Posoperatoria/epidemiología , Procedimientos Quirúrgicos Robotizados/efectos adversos , Anciano , Carcinoma de Células Escamosas/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/patología , Estadificación de Neoplasias , Neoplasias de Oído, Nariz y Garganta/patología , Estudios RetrospectivosRESUMEN
OBJECTIVES: Treatment failure and poor 5-year survival in mucosal head and neck squamous cell carcinoma (HNSCC) has remained unchanged for decades mainly due to advanced stage of presentation and high rates of recurrence. Incomplete surgical removal of the tumour, attributed to lack of reliable methods to delineate the surgical margins, is a major cause of disease recurrence. The predictability of recurrence using immunohistochemistry (IHC) to delineate surgical margins (PRISM) in mucosal HNSCC study aims to redefine margin status by identifying the true extent of the tumour at the molecular level by performing IHC with molecular markers, eukaryotic initiation factor, eIF4Eand tumour suppressor gene, p53, on the surgical margins and test the use of Lugol's iodine and fluorescence visualisation prior to the wide local excision. This article describes the study protocol at its pre - results stage. METHODS AND ANALYSIS: PRISM-HNSCC is a bilateral observational research being conducted in Darwin, Australia and Vellore, India. Individuals diagnosed with HNSCC will undergo the routine wide local excision of the tumour followed by histopathological assessment. Tumours with clear surgical margins that satisfy the exclusion criteria will be selected for further staining of the margins with eIF4E and p53 antibodies. Results of IHC staining will be correlated with recurrences in an attempt to predict the risk of disease recurrence. Patients in Darwin will undergo intraoperative staining of the lesion with Lugol's iodine and fluorescence visualisation to delineate the excision margins while patients in Vellore will not undertake these tests. The outcomes will be analysed. ETHICS AND DISSEMINATION: The PRISM-HNSCC study was approved by the institutional ethics committees in Darwin (Human Research Ethics Committee 13-2036) and Vellore (Institutional Review Board Min. no. 8967). Outcomes will be disseminated through publications in academic journals and presentations at educational meetings and conferences. It will be presented as dissertation at the Charles Darwin University. We will communicate the study results to both participating sites. Participating sites will communicate results with patients who have indicated an interest in knowing the results. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12616000715471).
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Carcinoma de Células Escamosas/metabolismo , Factor 4E Eucariótico de Iniciación/metabolismo , Neoplasias de la Boca/metabolismo , Recurrencia Local de Neoplasia/metabolismo , Neoplasias de Oído, Nariz y Garganta/metabolismo , Proyectos de Investigación , Proteína p53 Supresora de Tumor/metabolismo , Australia/epidemiología , Biomarcadores de Tumor/metabolismo , Carcinoma de Células Escamosas/epidemiología , Carcinoma de Células Escamosas/cirugía , Humanos , Inmunohistoquímica , India/epidemiología , Periodo Intraoperatorio , Márgenes de Escisión , Neoplasias de la Boca/epidemiología , Neoplasias de la Boca/cirugía , Estudios Multicéntricos como Asunto , Recurrencia Local de Neoplasia/epidemiología , Neoplasia Residual , Estudios Observacionales como Asunto , Neoplasias de Oído, Nariz y Garganta/epidemiología , Neoplasias de Oído, Nariz y Garganta/cirugía , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
PURPOSE: Surgical treatment of head and neck malignancies frequently includes microvascular free tissue transfer. Preoperative radiotherapy increases postoperative fibrosis-related complications up to transplant loss. Fibrogenesis is associated with re-expression of embryonic preserved tissue developmental mediators: osteopontin (OPN), regulated by sex-determining region Ybox 9 (Sox9), and homeobox A9 (HoxA9) play important roles in pathologic tissue remodeling and are upregulated in atherosclerotic vascular lesions; dickkopf-1 (DKK1) inhibits pro-fibrotic and atherogenic Wnt signaling. We evaluated the influence of irradiation on expression of these mediators in arteries of the head and neck region. MATERIALS AND METHODS: DKK1, HoxA9, OPN, and Sox9 expression was examined immunohistochemically in 24 irradiated and 24 nonirradiated arteries of the lower head and neck region. The ratio of positive cells to total cell number (labeling index) in the investigated vessel walls was assessed semiquantitatively. RESULTS: DKK1 expression was significantly decreased, whereas HoxA9, OPN, and Sox9 expression were significantly increased in irradiated compared to nonirradiated arterial vessels. CONCLUSION: Preoperative radiotherapy induces re-expression of embryonic preserved mediators in arterial vessels and may thus contribute to enhanced activation of pro-fibrotic downstream signaling leading to media hypertrophy and intima degeneration comparable to fibrotic development steps in atherosclerosis. These histopathological changes may be promoted by HoxA9-, OPN-, and Sox9-related inflammation and vascular remodeling, supported by downregulation of anti-fibrotic DKK1. Future pharmaceutical strategies targeting these vessel alterations, e. g., bisphosphonates, might reduce postoperative complications in free tissue transfer.
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Arteriolas/efectos de la radiación , Proteínas de Homeodominio/metabolismo , Péptidos y Proteínas de Señalización Intercelular/metabolismo , Terapia Neoadyuvante , Osteopontina/metabolismo , Neoplasias de Oído, Nariz y Garganta/radioterapia , Colgajo Perforante/irrigación sanguínea , Colgajo Perforante/patología , Complicaciones Posoperatorias/patología , Traumatismos por Radiación/patología , Factor de Transcripción SOX9/metabolismo , Arteriolas/metabolismo , Arteriolas/patología , Fibrosis , Humanos , Neoplasias de Oído, Nariz y Garganta/patología , Neoplasias de Oído, Nariz y Garganta/cirugía , Transducción de Señal/efectos de la radiaciónRESUMEN
Background Schwannomas are rare benign tumors originating from the perineural cells forming the myelin layer in the peripheral nervous system (PNS). While well established therapeutic concepts exist for intracranial schwannomas, there is a lack of consistent clinical standards for extracranial schwannomas. Method This retrospective study describes the clinical pathway of 20 patients with histologically proven extracranial schwannomas of the head and neck. The diagnostic and therapeutic strategies for schwannomas are discussed with special emphasis on localization and functional outcome. Results Extracranial schwannomas of the head and neck region mostly originated from the facial nerve (n = 4), vagal nerve (n = 4) or sympathetic chain (n = 3). Most common symptoms were swelling (n = 12) and pain (n = 3). Preoperative imaging included MRI (n = 13), ultrasound (n = 12) and CT (n = 3). Surgical intervention was performed in 18 cases (n = 14 complete extirpation, n = 3 partial extirpation, n = 1 unknown). Regarding completely extirpated schwannomas of motor nerves (n = 10) severing the nerve of origin was more often required in patients with a preexisting functional deficit (3 out of 4 = 75â %) than in patients without preexisting deficits (2 out of 6 = 33â %). Conclusion Representing rare tumors of the head and neck region mostly originating from the facial nerve, sympathetic chain or caudal cranial nerves extracranial schwannomas require a systematic diagnostic and therapeutic approach. Postoperative functional deficits after complete extirpation must especially be anticipated in patients with a preexisting functional deficit.
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Neurilemoma/cirugía , Neoplasias de Oído, Nariz y Garganta/cirugía , Adulto , Anciano , Nervios Craneales/patología , Nervios Craneales/cirugía , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Neurilemoma/diagnóstico , Neurilemoma/patología , Examen Neurológico , Neoplasias de Oído, Nariz y Garganta/diagnóstico , Neoplasias de Oído, Nariz y Garganta/patología , Complicaciones Posoperatorias/etiología , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
BACKGROUND: Acellular dermal matrices are increasingly used in laryngotracheal and pharyngeal reconstruction, but specific indications and the type of acellular dermal matrix used vary. The authors systematically reviewed outcomes relating to acellular dermal matrix use in head and neck reconstruction. METHODS: Electronic databases were searched through 1 May 2016 for literature on acellular dermal matrix use in laryngotracheal and pharyngeal reconstruction. Studies were appraised for surgical indications, outcomes and study design. RESULTS: Eleven publications with 170 cases were included. Eight articles reported on acellular dermal matrix use in oncological reconstruction. Most studies were case series; no high-level evidence studies were identified. Graft extrusion was more common in non-oncological applications. In general, post-oncological reconstruction with an acellular dermal matrix demonstrated complication rates similar to those reported without an acellular dermal matrix. CONCLUSION: Evidence in support of acellular dermal matrix use in head and neck reconstruction is generally poor. Prospective comparative studies are required to define the indications, safety and effectiveness of acellular dermal matrices in laryngotracheal and pharyngeal reconstruction.
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Dermis Acelular , Carcinoma de Células Escamosas/cirugía , Cervicoplastia/métodos , Neoplasias de Oído, Nariz y Garganta/cirugía , Carcinoma de Células Escamosas/patología , Estudios de Seguimiento , Neoplasias Laríngeas/cirugía , Estadificación de Neoplasias , Neoplasias de Oído, Nariz y Garganta/patología , Neoplasias Faríngeas/cirugía , Colgajos Quirúrgicos/cirugía , Neoplasias de la Tráquea/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this study was to present our systematic review and meta-analysis of the data on venous thromboembolism (VTE; deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in otolaryngology-head and neck surgery (OHNS). METHODS: PubMed and Scopus databases were searched for studies reporting VTE in OHNS. Incidence of VTE and bleeding is reported and meta-analyzed overall and for chemoprophylaxis and squamous cell carcinoma (SCC)/free flap subgroups. RESULTS: A total of 23 studies were included with a total of 618,264 patients. Incidence of VTE was 0.4%. The incidence of bleeding complications was 0.9%. The addition of chemoprophylaxis did not result in a decreased VTE incidence (odds ratio [OR], 0.86), but produced an increased risk of bleeding (OR, 3.78). The overall OR for VTE in SCC/free flap cases was 6.28. CONCLUSION: Chemoprophylaxis may not be necessary in the OHNS non-SCC or free flap patient population and must be balanced against an increased risk of bleeding. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1249-1258, 2017.
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Neoplasias de Oído, Nariz y Garganta/cirugía , Procedimientos Quirúrgicos Otorrinolaringológicos/efectos adversos , Embolia Pulmonar/epidemiología , Tromboembolia Venosa/epidemiología , Supervivencia sin Enfermedad , Femenino , Neoplasias de Cabeza y Cuello/mortalidad , Neoplasias de Cabeza y Cuello/patología , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Incidencia , Masculino , Enfermedades Otorrinolaringológicas/patología , Enfermedades Otorrinolaringológicas/cirugía , Neoplasias de Oído, Nariz y Garganta/diagnóstico , Procedimientos Quirúrgicos Otorrinolaringológicos/métodos , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Pronóstico , Embolia Pulmonar/etiología , Embolia Pulmonar/fisiopatología , Medición de Riesgo , Análisis de Supervivencia , Tromboembolia Venosa/etiología , Tromboembolia Venosa/fisiopatologíaRESUMEN
PURPOSE: The purpose of this article is to describe the characteristics and experiences of individuals who use technology to support telephone or face-to-face communication after total laryngectomy. METHOD: An online questionnaire was used to identify potential participants. Seventeen individuals met inclusion criteria and participated in an in-depth survey. They were compared with a reference group matched for age, gender, and time postsurgery who did not use these technologies. Open-ended responses were summarized. RESULTS: Compared with the matched reference group, individuals who used technology to support verbal communication had undergone more aggressive cancer treatment and used more communication methods. They were less likely to use an alaryngeal speech method, had greater difficulty over the telephone, and used more repair strategies in face-to-face communication. The 2 groups did not differ significantly in the frequency or success of their communication, however. Open-ended responses revealed great variety with regard to their reasons, purposes, and timing of technology use. CONCLUSIONS: There is a subset of individuals using technology to support verbal communication very successfully after laryngectomy. Usage was not limited to those who were unable to communicate verbally and often continued long after the initial postoperative period in many settings, for various purposes, and in combination with other methods of communication.
Asunto(s)
Equipos de Comunicación para Personas con Discapacidad , Comunicación , Relaciones Interpersonales , Neoplasias Laríngeas/cirugía , Laringectomía/rehabilitación , Neoplasias de Oído, Nariz y Garganta/cirugía , Satisfacción del Paciente , Teléfono , Adulto , Anciano , Terapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Motivación , Valores de Referencia , Voz Alaríngea , Encuestas y CuestionariosRESUMEN
OBJECTIVES/HYPOTHESIS: Unplanned readmissions within 30 days of surgery represent a significant marker for healthcare quality. Small institutional studies have described rates of readmission for patients undergoing head and neck free flap reconstruction. However, large, multi-institutional analyses have not previously been described. STUDY DESIGN: Retrospective study of cases from the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: Patients who underwent free flap reconstruction of the head and neck from 2011 to 2013 were identified. Univariate and multivariate analyses of unplanned readmission based on patient, laboratory, and hospital course characteristics were conducted. RESULTS: In total, 1,238 patients who underwent head and neck microvascular free flap reconstruction were included within the database, of which 1,204 patients had information pertaining to readmission. Overall 30-day readmission rate was 9.6%. A multivariate analysis of preoperative variables demonstrated that leukocytosis, diabetes mellitus, and hyponatremia were all associated with increased rates of readmission (odds ratio 2.224, 1.843, and 1.7423, respectively). A similar analysis of postoperative variables demonstrated that wound-related complications (surgical site infections and wound disruption), perioperative blood transfusion, and sepsis were associated with an increased rate of readmission. CONCLUSION: In patients with microvascular free flap reconstruction of the head and neck, the 30-day readmission rate was 9.6%. Preoperative diabetes mellitus, hyponatremia, and leukocytosis were associated with an increased rate of 30-day readmissions. Postoperative complications, particularly wound infections, perioperative blood transfusions, and sepsis, were found to be significant contributors to readmission. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:325-330, 2017.
Asunto(s)
Colgajos Tisulares Libres/irrigación sanguínea , Colgajos Tisulares Libres/cirugía , Microcirugia/métodos , Neoplasias de Oído, Nariz y Garganta/cirugía , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/cirugía , Garantía de la Calidad de Atención de Salud , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVES: The timing of neck dissection (ND) in relation to transoral robotic surgery (TORS) is controversial. This study identifies local practice patterns and economic and social access disparities during adoption of TORS. STUDY DESIGN: We analyzed utilization patterns of TORS and ND using the New York Statewide Planning and Research Cooperative System all-payer administrative database. Statewide head and neck cancer incidence from the Centers for Disease Control and Prevention (Bethesda, MD) was used to control for overall cancer incidence. METHODS: Patient demographic, insurer, and institutional information of patients aged ≥ 18 (n = 225) years from 2008 to 2012 were evaluated. Temporal trends were analyzed with Poisson regression models for counts. RESULTS: Transoral robotic surgery was used in 386 procedures, and 58.3% involved ND (n = 225). Concurrent ND was most frequent (n = 173), followed by staged TORS then ND (n = 44) and staged ND preceding TORS (n = 8). Caucasians were more likely than Blacks/Hispanics to undergo TORS (P = 0.03). Medicare (26.2%) and Medicaid (2.7%) payers comprised a minority of patients compared to those commercially insured (70.2%). Only 20% of patients received care outside a major urban center, and these patients were more likely to undergo staged procedures, P = 0.02. Staged procedures resulted in higher mean hospital charges (P = 0.02). CONCLUSION: Concurrent TORS + ND, the most common practice in New York, is more cost-effective. Patients without commercial insurance, patients in racial minorities, or patients residing outside major urban centers may be targeted to improve care access disparities with respect to minimally invasive TORS technology. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:1571-1576, 2017.
Asunto(s)
Endoscopía/estadística & datos numéricos , Endoscopía/tendencias , Disección del Cuello/estadística & datos numéricos , Disección del Cuello/tendencias , Neoplasias de Oído, Nariz y Garganta/cirugía , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Procedimientos Quirúrgicos Robotizados/tendencias , Adulto , Anciano , Estudios Transversales , Femenino , Predicción , Humanos , Masculino , Persona de Mediana Edad , Método de Montecarlo , New York , Neoplasias de Oído, Nariz y Garganta/epidemiología , Revisión de Utilización de RecursosRESUMEN
OBJECTIVES/HYPOTHESIS: The diagnostic gain of narrow band imaging in the definition of surgical margins in the treatment of head and neck cancer was evaluated. STUDY DESIGN: A prospective study, blinded to the pathologist, with historical comparison. METHODS: The study group included 45 patients subjected to the intraoperative definition of margins by narrow band imaging. The control group included 55 patients who had undergone standard definition of margins. All patients underwent resection of the tumor and frozen section analysis of superficial margins. The rate of initial R0 resection and the ratio of histologically negative margins for both groups were statistically compared. RESULTS: The rate of initial R0 resection in the study group and in the control group was 88.9% and 70.9% (P = .047), and the ratio of histologically negative margins was 95.9% and 88.4% (P = .017), respectively. CONCLUSIONS: Narrow band imaging reveals a microscopic extension of the tumor that could be effectively used to better define superficial margins and to achieve a higher rate of initial R0 resections. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:1577-1582, 2017.
Asunto(s)
Márgenes de Escisión , Membrana Mucosa/patología , Imagen de Banda Estrecha , Neoplasias de Oído, Nariz y Garganta/patología , Neoplasias de Oído, Nariz y Garganta/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Secciones por Congelación , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Patients undergoing ablative and reconstructive head and neck surgery with a microvascular flap have multiple factors that potentially decrease postoperative mean arterial pressure, which may endanger flap survival. The safety of vasopressor use has long been a topic of discussion. The authors analyzed the effect of vasopressors on microvascular flap perfusion after head and neck cancer reconstruction. METHODS: A total of 27 patients were enrolled in a randomized, controlled, clinical trial. A microvascular radial forearm flap was used for reconstruction. Patients were allocated into one of three groups: dopamine, norepinephrine, and control. The intervention groups received the vasoactive drug, aiming to maintain the mean arterial pressure between 80 and 90 mmHg. Normovolemia was maintained according to central venous pressure. Flap perfusion was monitored with continuous tissue partial pressure of oxygen and microdialysate metabolite (lactate-to-pyruvate ratio) measurements. RESULTS: No adverse effects were observed, and postoperative recovery was free of complications in all groups. Neither the lactate-to-pyruvate ratio nor continuous tissue partial pressure of oxygen values differed significantly between groups during the first 24 hours of the vasoactive drug infusion period or during the 72-hour follow-up. CONCLUSIONS: Norepinephrine and dopamine are safe and effective vasopressors for use during the postoperative period following head and neck cancer surgery with microvascular reconstruction. Dopamine should be used with caution, however, because of the risk of side effects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.