Surgical management of patients with Eagle syndrome.

OBJECTIVE: Eagle syndrome, a spectrum of disease resulting from an elongated styloid process and/or calcified stylohyoid ligament, lacks standardized recommendations regarding indications for surgical intervention and approach. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary care institution. SUBJECTS: Patients treated surgically for Eagle syndrome between January 2011 and June 2017. METHODS: Patients were diagnosed with Eagle syndrome based on thorough clinical workup and assessment. The primary outcome was improvement in pain severity following surgery, with complete resolution of pain being considered clinically meaningful. Wilcoxon rank-sum tests and Fisher's exact were used to compare numerical and categorical variables, respectively. RESULTS: Twenty-one patients were diagnosed with Eagle syndrome and underwent surgical resection of the styloid process. Patients most often complained of neck pain (81%), throat pain (62%), and ear pain (48%). Among these patients, 57% of procedures featured a transcervical approach, while the remaining 43% were transoral. The vast majority (90%) of patients experienced improvement in pain severity from a median of 6.0 before surgery to 0.0 afterwards (p < 0.01) as 62% experienced complete resolution. Using multivariable linear regression to model changes in pain severity, neck pain (ß = -1.69, p < 0.01) and jaw pain (ß = -0.93, p = 0.03) predicted greater relief, while headache (ß = 0.82, p = 0.04) predicted an inferior response. Adverse events were uncommon and typically resolved within three months, with 24% experiencing first bite syndrome and 19% reporting numbness. CONCLUSIONS: Transcervical and transoral styloidectomy are effective treatments for Eagle syndrome with minimal adverse effects. Patients with classic symptoms of neck or jaw pain benefit most from surgery.

Influence of Treatment Package Time on outcomes in High-Risk Oral Cavity Carcinoma in patients receiving Adjuvant Radiation and Concurrent Systemic Therapy: A Multi-Institutional Oral Cavity Collaborative study.

OBJECTIVES: To explore the influence of treatment package time(TPT) in high-risk oral cavity squamous cell carcinoma(OCSCC) receiving adjuvant radiotherapy with concurrent chemotherapy(CRT). MATERIALS AND METHODS: We queried our multi-institutional OCSCC collaborative database for cases diagnosed between 2005 and 2015 who underwent surgery followed by adjuvant CRT. All patients had high-risk features: extranodal extension(ENE) and/or positive surgical margin(PM). TPT was days between surgery to last radiotherapy fraction. Kaplan-Meier curves, log-rank p-values and multivariate analysis(MVA) were used to investigate the impact of TPT on overall(OS), disease-free(DFS), locoregional failure-free(LRFS) and distant metastases-free(DMFS) survival. RESULTS: We identified 187 cases: median age 58 (range, 24-87 years), males 66%, and ever smokers 69%. ENE and PM were detected in 85% and 32%, and oral tongue and floor of the mouth constituted 49% and 18%, respectively. Median radiotherapy and cisplatin doses received were 66 Gy and 200 mg/m2. Overall, median TPT was 98 (range, 63-162 days). OS was worse for TPT > 90-days (n = 134) than TPT ≤ 90 (n = 53) at two-(65% vs. 71%) and five-years (45% vs. 62%); p = 0.05, with similar results for DFS. No influence on LRFS or DMFS was noted. More lymph nodes(LN) dissected(P = 0.039), T3-4 disease(P = 0.017), and unplanned reoperations(P = 0.037) occurred with TPT > 90-days. On MVA, TPT in 10-day increments was independently detrimental for OS (Hazard Ratio: 1.14; 95 %Confidence Interval [1-1.28]; P = 0.043), perineural invasion, age and positive LN (p < 0.05 for all). CONCLUSION: In one of the largest multi-institutional cohorts, TPT > 90-days predicted worse OS for high-risk OCSCC receiving adjuvant CRT. All efforts are needed to optimize perioperative care and baseline conditions for favorable outcomes.

Risk Factors Associated with Disease Recurrence in Patients with Stage III/IV Squamous Cell Carcinoma of the Oral Cavity Treated with Surgery and Postoperative Radiotherapy.

AIM: The purpose of the present study was to identify variables associated with high risk of failure in patients with locally advanced squamous cell carcinoma of the oral cavity (SCC-OC). PATIENTS AND METHODS: This retrospective study included 191 patients with stage III-IVb SCC-OC treated with post-operative radiotherapy (RT) or chemoradiotherapy (CRT) between 1995 and 2013. Disease-free (DFS) and overall survival (OS) were analyzed; variables associated with inferior DFS were identified. RESULTS: Seventy-five patients (39%) recurred. DFS and five-year OS were 52% and 54%, respectively. Poorly differentiated tumors (p=0.03), recurrent tumors (p=0.02) and high nodal ratio (p=0.02) were associated with an increased risk of recurrence. CRT was associated with improved DFS in patients with positive margins and/or extracapsular extension (p=0.021). CONCLUSION: Tumors that are recurrent, high grade, or have high nodal ratio are at risk of recurrence. Presence of these disease features should be taken into consideration for better risk stratification.

Palatal reconstruction with the palatal island flap.

OBJECTIVES/HYPOTHESIS: The management of palatal defects resulting from the extirpation of benign and malignant lesions uses a variety of methods, with the optimal techniques allowing maximal postoperative function with minimal morbidity. The palatal island flap is an effective, reliable technique for reconstructing postablative oral cavity defects. METHODS: All patients who underwent palatal resections for benign or malignant lesions at a tertiary care, referral-based head and neck cancer center since 1995 were eligible. Ten patients were identified whose surgical defects were reconstructed with palatal island flaps. The cases were reviewed for the symptomatology, tumor features, defect size, perioperative and postoperative management, complications, and impact on palatal function. RESULTS: Ten patients ranging in age from 18 to 81 years underwent palatal island mucoperiosteal flaps after resection of a variety of benign and malignant tumors, most arising from minor salivary glands. The defects ranged in size from 5 to 15 cm2, with extension into the floor of the nose in four cases and to the skull base in two. Nine patients were discharged on a regimen of oral diet, and no patient manifested permanent velopharyngeal insufficiency, speech impairment, or airway compromise. Follow-up ranged from 3 months to 6 years, with an average follow-up of 18.5 months. Delayed donor site re-epithelialization required debridement in one case, and two patients required obturation of small oronasal fistulae. CONCLUSION: The palatal island mucoperiosteal flap provides an effective means of reconstructing hard and soft palate defects with few complications and low morbidity.

Functional outcomes after free flap reconstruction of the upper aerodigestive tract.

PURPOSE OF REVIEW: When the complex structures of the upper aerodigestive tract are disrupted after resection of head and neck tumors, an appropriate reconstructive option should be chosen in an attempt to regain maximum function. Reconstructions using microvascular free tissue transfer offer unparalleled flexibility, both in tissue composition and in placement. This article will examine functional outcomes after free flap reconstruction of the upper aerodigestive tract. RECENT FINDINGS: With the maturation of free tissue transfer techniques, functional outcomes are being analyzed with increasing frequency. Recent reports show promising results for free flap reconstruction of oral cavity, oropharyngeal, and hypopharyngeal soft tissue defects, as well as for bony mandibular and maxillary defects. SUMMARY: For both soft tissue and bony defects of the upper aerodigestive tract, microvascular free flaps provide good functional outcomes. In the future, randomized studies are needed to compare the functional outcomes of microvascular free flaps with those of other reconstructive options.

Current concepts in lip reconstruction.

PURPOSE OF REVIEW: Approximately 25% of all oral cavity carcinomas involve the lips, and the primary management of these lesions is complete surgical resection. The management of the resulting lip defect remains a significant reconstructive challenge, requiring meticulous preoperative planning and surgical technique to optimize the functional and cosmetic outcome. Reviewed here are the accepted techniques of lip reconstruction, as well newer techniques that have been reported. RECENT FINDINGS: There have been no major advances in lip reconstruction; rather, continued improvement on accepted techniques. The main goals of reconstruction remain the restoration of oral competence, maintenance of oral opening, and the restoration of normal anatomic relations such that both the active (smile) and passive (form) cosmetic outcome is acceptable. The reconstruction should be tailored to the individual needs of the patient and should take into account the patient's condition, local tissue characteristics, previous treatment(s), and functional needs (eg, denture use), in addition to the size and location of the defect. SUMMARY: The lips play a key role in facial expression, speech, and eating. This requires meticulous attention to preoperative planning and surgical technique to maximize the functional and cosmetic outcome. It is important to assess local tissue characteristics (skin laxity) and previous treatment (surgery and/or irradiation) before the surgical plan is made final. Local tissue should be used whenever possible to provide the least donor site morbidity and the best overall tissue color and texture match. Whenever possible, dynamic reconstruction should be attempted. Careful preoperative assessment and planning will allow the surgeon to reach an acceptable balance between form and function with the reconstruction.

Transoral excision of the submandibular gland: techniques and results of nine cases.

OBJECTIVES/HYPOTHESIS: We will discuss the transoral surgical approach to excising the submandibular gland, the relevant anatomy, the indications, and the risks and benefits of the procedure. We will present our case series of nine patients. STUDY DESIGN: A retrospective review of a series of nine patients in which transoral submandibular gland excision was attempted over the past 10 years was performed. METHODS: The series of nine patients who underwent transoral submandibular gland excision was examined for age, indication for operation, complications, length of stay, and postoperative pathology. Relevant indications, risks, and benefits are also discussed in conjunction with relevant surgical anatomy and approach utilized. RESULTS: Of nine patients who underwent attempted transoral submandibular gland excision, eight operations were completed transorally. Only one operation was converted to a standard external approach due to severe scarring. Six of nine patients presented with chronic sialadenitis, three of nine having obstructing sialoliths. Three patients presented with other benign cystic lesions consistent with a ranula, an infected mucocele, and a cystic teratoma. There was only one patient with a complication of incision breakdown and delayed healing in an irradiated field. There were no long-term complications involving the lingual or hypoglossal nerves, and there were no hemostatic complications. CONCLUSIONS: Transoral excision of the submandibular gland is a viable and safe approach to be utilized. There are no external scars caused, there is minimal risk to the marginal mandibular branch of the facial nerve, and skin incisions through irradiated fields are avoided. Although the surgical anatomy is somewhat novel, the transoral approach has been used effectively and without complication in removing benign submandibular gland pathology in our series.