Reconstruction for Salvage Laryngectomy With Limited Pharyngectomy.

Importance: Closure technique for optimization of postoperative and functional outcomes following salvage laryngectomy remains an area of debate among head and neck surgeons. Objective: To investigate the association of salvage laryngectomy closure technique with early postoperative and functional outcomes. Design, Setting, and Participants: This retrospective cohort study included patients from 17 academic, tertiary care centers who underwent total laryngectomy with no or limited pharyngectomy after completing a course of definitive radiotherapy or chemoradiotherapy with curative intent between January 2011 and December 2016. Patients with defects not amenable to primary closure were excluded. Data were analyzed from February 14, 2021, to January 29, 2024. Exposures: Total laryngectomy with and without limited pharyngectomy, reconstructed by primary mucosal closure (PC), regional closure (RC), or free tissue transfer (FTT). Main Outcomes and Measures: Patients were stratified on the basis of the pharyngeal closure technique. Perioperative and long-term functional outcomes were evaluated with bivariate analyses. A multivariable regression model adjusted for historical risk factors for pharyngocutaneous fistula (PCF) was used to assess risk associated with closure technique. Relative risks (RRs) with 95% CIs were determined. Results: The study included 309 patients (256 [82.8%] male; mean age, 64.7 [range, 58.0-72.0] years). Defects were reconstructed as follows: FTT (161 patients [52.1%]), RC (64 [20.7%]), and PC (84 [27.2%]). A PCF was noted in 36 of 161 patients in the FTT group (22.4%), 25 of 64 in the RC group (39.1%), and 29 of 84 in the PC group (34.5%). On multivariable analysis, patients undergoing PC or RC had a higher risk of PCF compared with those undergoing FTT (PC: RR, 2.2 [95% CI, 1.1-4.4]; RC: RR, 2.5 [95% CI, 1.3-4.8]). Undergoing FTT was associated with a clinically meaningful reduction in risk of PCF (RR, 0.6; 95% CI, 0.4-0.9; number needed to treat, 7). Subgroup analysis comparing inset techniques for the RC group showed a higher risk of PCF associated with PC (RR, 1.8; 95% CI, 1.1-3.0) and predominately pectoralis myofascial flap with onlay technique (RR, 1.9; 95% CI, 1.2-3.2), but there was no association of pectoralis myocutaneous flap with cutaneous paddle interposition with PCF (RR, 1.2; 95% CI, 0.5-2.8) compared with FTT with cutaneous inset. There were no clinically significant differences in functional outcomes between the groups. Conclusion and Relevance: In this study of patients with limited pharyngeal defects, interpositional fasciocutaneous closure technique was associated with reduced risk of PCF in the salvage setting, which is most commonly achieved by FTT in academic practices. Closure technique was not associated with functional outcomes at 1 and 2 years postoperatively.

Association of Core Biopsy With Extranodal Extension in Surgically Treated Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma.

Importance: Extranodal extension (ENE) is an adverse feature in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) and is an indication for adjuvant treatment escalation. Preoperative core needle biopsy (CNB) may cause lymph node capsule disruption related to ENE development; however, evidence regarding this association in OPSCC is lacking. Objective: To assess whether preoperative nodal CNB is associated with presence of ENE in final pathology findings among patients with HPV-associated OPSCC targeted for primary surgical resection. Design, Setting, and Participants: This retrospective cohort study was conducted at a single academic tertiary care center from 2012 to 2022. All patients with OPSCC treated with transoral robotic surgery were assessed for eligibility, and primary surgical patients with HPV-associated OPSCC and node-positive disease confirmed on neck dissection were included in analyses. Data were analyzed from November 28, 2022, to May 21, 2023. Exposure: Preoperative nodal CNB. Main Outcomes and Measures: The primary outcome was presence of ENE in final pathology findings. Secondary outcomes included adjuvant chemotherapy and recurrence rates. Outcomes of interest were investigated against patient demographic, clinical, and pathologic features. Results: Of 106 patients (mean [SD] age, 60.2 [10.9] years; 99 [93.4%] men) included in analyses, 23 patients (21.7%) underwent CNB. Mean (range) preoperative node size was 3.0 (0.9-6.0) cm. Pathologic node class was pN1 in 97 patients (91.5%) and pN2 in 9 patients (8.5%). A total of 49 patients (46.2%) had ENE identified in final pathology analysis. Of 94 patients who received adjuvant therapy, 58 (61.7%) underwent radiation therapy and 36 (38.3%) underwent chemoradiation therapy. There were 9 recurrences (8.5%). In univariate analysis, CNB was associated with ENE (odds ratio [OR], 2.70; 95% CI, 1.03-7.08), but there was no association in a multivariable model including pN class and preoperative node size (OR, 2.56; 95% CI, 0.97-7.27). Compared with pN1 class, pN2 class was associated with ENE (OR, 10.93; 95% CI, 1.32-90.80). There were no associations of ENE with preoperative node size, presence of cystic or necrotic nodes, fine needle aspiration, tobacco or alcohol exposure, pathologic T class, prior radiation, or age. Furthermore, use of CNB was not associated with macroscopic ENE, adjuvant chemotherapy, or recurrence. Conclusions and Relevance: This cohort study of patients with HPV-associated OPSCC found that preoperative nodal CNB was strongly associated with ENE in final pathology, supporting the possibility of an artifactual ENE component in this population.

Margins in Stage I and II Oral Cavity Squamous Cell Carcinoma: A Review From the American Head and Neck Society.

Importance: The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality. Observations: This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design. Conclusions and Relevance: Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.

Presentation and Outcomes of Otolaryngologic Surgeries in Patients With Mental Illness History.

BACKGROUND: Describe the epidemiology and characteristics of patients with a history of mental illness undergoing otolaryngologic procedures. METHODS: A retrospective cross-sectional analysis utilizing the Nationwide Readmissions Database, 2010 to 2015. The study sample included adult (≥18 years) patients undergoing otolaryngologic procedures. RESULTS: A total of 146 182 patients were included, 18.3% with mental illness history. The prevalence of patients who required otolaryngologic surgeries with history of mental illness increased significantly from 14.9% in 2010 to 25.0% in 2015 (P < .001). Mental illness diagnoses included: depression (6.9%), anxiety (5.8%), alcohol dependence (4.2%), substance dependence (2.9%), bipolar disorder (1.4%), memory disorders (1.2%), delusional disorders (0.6%), self-harm (0.1%). Patients with a history of mental illness were more likely to be <65 years, female, and have multiple comorbidities (P < .05 each). Patients with history of mental illness had a higher risk of complications [OR:1.59, 95% CI:1.50,1.69, P < .001]. CONCLUSIONS: Patients with a history of mental illness are increasingly encountered in otolaryngology service. This study provides an epidemiological perspective that warrants increasing clinical investigation of this subpopulation.

Presentation and outcomes of patients with clinically T1-2, N0 oropharynx squamous cell carcinoma: The interplay of primary treatment modality and human papillomavirus status.

BACKGROUND: To examine the pattern of utilization and outcomes of definitive radiotherapy (RT) versus primary robotic-assisted surgery in patients with early-stage oropharyngeal squamous cell carcinoma (OPSCC). METHODS: A retrospective cohort analysis of patients with clinically T1-2, N0 OPSCC was performed using the National Cancer Database, 2010-2016. RESULTS: A total of 1451 patients were included. Prevalence of human papillomavirus (HPV)-positive tumors was 58.30%. Primary surgery was performed in 30.25% of the sample. Tongue base and clinically T1 tumors were each associated with a higher likelihood of undergoing surgery (p < 0.05). Histopathology of patients who underwent surgery demonstrated a prevalence of 15.95% with lymphovascular invasion, 16.67% with extranodal extension, 19.36% were T updated, and 30.00% were N upstaged. Improved survival was observed in the surgery + adjuvant RT group compared to RT alone for HPV-positive tumors (HR: 0.27; 95%CI: 0.12, 0.62; p = 0.002). CONCLUSION: This study provides epidemiological perspective regarding management pattern and outcomes of patients with early-stage OPSCC.

Safety of fibula free flap in patients following total knee replacement.

BACKGROUND: Fibula free flap (FFF) is the preferred osteocutaneous flap for reconstruction of large head and neck composite defects. There is a paucity of data whether FFF can be performed safely in patients with knee replacement (total knee arthroplasty [TKA]). METHODS: Multi-institutional review of outcomes following FFF in patients who had prior TKA. RESULTS: Ten surgeons reported successful FFF in 53 patients with prior TKA. The most common preoperative imaging was a CT angiogram of the bilateral lower extremities. There was no evidence of intraoperative vascular abnormality. Physical therapy began between postoperative day 1 to postoperative day 3. At 1 month postoperatively, 40% of patients were using a cane or walker to ambulate, but by 3 months all had returned to baseline ambulatory status. At >1 year, there were no gait complications. CONCLUSION: FFF appears safe in patients with prior knee replacement without an increased risk of complications compared to baseline.

Human Papillomavirus (HPV)-Related Carcinoma of the Oropharynx with Squamous Cell and Adenoid Cystic Carcinoma-Like Features: Report of a Case.

We describe the heretofore unreported case of an HPV-related carcinoma of the palatine tonsil with distinct areas of squamous cell- and adenoid cystic carcinoma-like differentiation in a 54-year old patient. The morphological, immunophenotypic and molecular findings of the tumor are illustrated. We discuss the parallels between the tumor and HPV-related multiphenotypic sinonasal carcinoma (HMSC) which is well-known to exhibit adenoid cystic carcinoma-like features. A review of the literature of high-risk HPV-associated non-squamous carcinomas of the oropharynx is presented.

A novel surgeon credentialing and quality assurance process using transoral surgery for oropharyngeal cancer in ECOG-ACRIN Cancer Research Group Trial E3311.

PURPOSE: Understanding the role of transoral surgery in oropharyngeal cancer (OPC) requires prospective, randomized multi-institutional data. Meticulous evaluation of surgeon expertise and surgical quality assurance (QA) will be critical to the validity of such trials. We describe a novel surgeon credentialing and QA process developed to support the ECOG-ACRIN Cancer Research Group E3311 (E3311) and report outcomes related to QA. PATIENTS AND METHODS: E3311 was a phase II randomized clinical trial of transoral surgery followed by low- or standard-dose, risk-adjusted post-operative therapy with stage III-IVa (AJCC 7th edition) HPV-associated OPC. In order to be credentialed to accrue to this trial, surgeons were required to demonstrate active hospital credentials and technique-specific surgical expertise with ≥20 cases of transoral resection for OPC. In addition, 10 paired operative and surgical pathology reports from the preceding 24 months were reviewed by an expert panel. Ongoing QA required <10% rate of positive margins, low oropharyngeal bleeding rates, and accrual of at least one patient per 12 months. Otherwise surgeons were placed on hold and not permitted to accrue until re-credentialed using a new series of transoral resections. RESULTS: 120 surgeons trained in transoral minimally invasive surgery applied for credentialing for E3311 and after peer-review, 87 (73%) were approved from 59 centers. During QA on E3311, positive final pathologic margins were reported in 19 (3.8%) patients. Grade III/IV and grade V oropharyngeal bleeding was reported in 29 (5.9%) and 1 (0.2%) of patients. CONCLUSIONS: We provide proof of concept that a comprehensive credentialing process can support multicenter transoral head and neck surgical oncology trials, with low incidence of positive margins and *grade III/V oropharyngeal bleeding.

Presentation and Outcomes of Elderly Patients Undergoing Head and Neck Surgeries: A National Perspective.

OBJECTIVES: To examine clinical profile and outcomes of elderly patients (65-90 years) undergoing head and neck surgeries in the United States. STUDY DESIGN: A retrospective cross-sectional analysis. SETTING: The Nationwide Readmissions Database, 2010 to 2015. SUBJECTS AND METHODS: Adult (≥18 years) patients who underwent head and neck surgeries. Analysis included χ2 test and logistic analysis. RESULTS: A total of 113,602 and 32,580 patients <65 and ≥65 years old, respectively, were included. Patients ≥65 years old were more likely to have multiple comorbidities (62.8% vs 32.6%, P < .001) and to present with head and neck cancer (19.8% vs 11.4%, P < .001). The most common comorbidity was diabetes (21.0%). The most common cancer types by site were mouth (29.12%), thyroid (28.08%), and nonmelanoma skin cancer (13.22%). The percentage of geriatric patients who underwent head and neck surgeries increased from 21.8% in 2010 to 25.0% in 2015 (P < .001). A total of 5450 (16.85%) patients developed postoperative complications, and the most common complications were pulmonary related (10.55%), bleeding (6.96%), acute renal failure (6.01%), and infection (3.97%). Blood transfusion was required in 3.53% of the patients. Readmission prevalence was 0.32%, and mortality risk was twice as likely (odds ratio, 2.05; 95% confidence interval, 1.77-2.38; P < .001). Independent risk factors of mortality were older age, multiple comorbidities, type of surgery, blood transfusion, and tracheostomy (P < .05, each). CONCLUSION: Elderly patients currently represent 25% of patients admitted for head and neck surgery. This population should be provided with a different level of care due to a higher risk of complications and mortality.

Submental Flap for Soft Tissue Reconstruction following Radical Parotidectomy.

This study analyzed our institution's experience with a buried submental flap for soft tissue reconstruction following radical parotidectomy. A retrospective chart review was conducted of patients who had parotid malignancies requiring radical parotidectomy, who also underwent a buried submental flap reconstruction. Analysis included patient demographics and clinical, surgical, and outcome data. Three patients met criteria for this study who underwent a buried submental flap at a tertiary medical center between 2012 and 2016. All patients had oncologic surgery and reconstruction using a deepithelialized submental island flap, which was used to fill the radical parotidectomy surgical defect with no complications and good aesthetic results. Each patient received appropriate adjuvant therapy. This case series shows that the buried submental island flap is a versatile flap that is adequate bulk after radical parotidectomy. It also has no impact on hospital length of stay and provides excellent cosmetic outcomes with minimal donor site morbidity.

Adult type rhabdomyoma presenting as a parathyroid adenoma.

BACKGROUND: Adult-type rhabdomyoma (ATR) is a rare mesenchymal tumor of skeletal muscle differentiation. Extracardiac ATR occurs most commonly in the head and neck, but do so in a heterogeneous fashion, arising at numerous different locations within this region. METHODS: At our institution, we encountered a patient who was diagnosed clinically with parathyroid adenoma based on signs and symptoms of hyperparathyroidism and suggestive radiologic findings. A parathyroidectomy with intraoperative consultation was performed. RESULTS: The frozen section diagnosis was ambiguous and a diagnosis of ATR was only made on permanent section. CONCLUSION: Awareness of this tumor can prevent incorrect diagnosis and overtreatment intraoperatively. Herein, we describe the clinical history, pathologic findings, and review histologic features of rhabdomyomas.

Utility of 3-Month Surveillance F-18 FDG PET/CT in Surgically Resected Oral Squamous Cell Carcinoma.

OBJECTIVES: To evaluate the performance of surveillance F-18 fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) 1 year after imaging in oral squamous cell carcinoma (OSCC) patients treated with definitive surgery and adjuvant (chemo)radiotherapy (RT). METHODS AND MATERIALS: Surveillance PET/CT accuracy was retrospectively evaluated in OSCC patients receiving surgical resection and (chemo)RT. Pathologic risk factors were assessed for influence on accuracy of the post-RT PET/CT. RESULTS: Fifty-four patients with median follow-up of 3.8 years met inclusion criteria. A PET/CT obtained a median of 3.4 months after RT revealed 11 (20.4%) instances of true disease recurrence: 4 locoregional alone, 6 distant alone, and 1 patient with locoregional and distant disease. Locoregional detection sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 55.6%, 75.0%, 33.3%, and 88.2%, respectively. For distant recurrence, the respective values were 100%, 95.2%, 77.8%, and 100%. Absence of bone invasion, absence of pT4 disease, and disease within the tongue were independently associated with higher sensitivity ( P = .048). Perineural invasion was associated with increased specificity ( P = .027), and tumor location in the tongue was associated with a higher PPV ( P = .007) on surveillance PET/CT. CONCLUSIONS: Post-RT PET/CT accuracy information for surgically managed OSCC patients demonstrates significant associations with pathologic factors.

A Hairy Situation: Laser Hair Removal after Oral Reconstruction.

OBJECTIVES: To present a case series of 4 patients who underwent postoperative hair removal using the long-pulsed Alexandrite or Nd:YAG laser following intraoral cutaneous flap reconstruction. METHODS: Patients underwent epilation in dermatology clinic with long-pulsed Alexandrite or Nd:YAG lasers, spaced 8 weeks apart, until hair removal was achieved. RESULTS: All patients achieved improvement in hair removal regardless of initial flap donor site with significant improvement in quality of life and minimal side effects. CONCLUSIONS: The long-pulsed Alexandrite and Nd:YAG represent safe and effective treatment options to improve patient quality of life following intraoral flap repair following excision of malignancy.

Venous Complications in One Versus Two Vein Anastomoses in Head and Neck Free Flaps.

OBJECTIVE: The purpose of this study was to compare rates of reexploration and flap failure in patients with 1- and 2-vein anastomoses in free flap reconstructions. METHODS: Retrospective chart review of 300 patients undergoing free flap reconstruction to head and neck defects from 2010 to 2014. RESULTS: One venous anastomosis was performed in 229 patients, and 2 venous anastomoses were performed in 71 patients. The 1-vein group had significantly more reexplorations in the operating room (36/229, 15.7%) compared with the 2-vein group (4/71, 5.6%; P = .028), even when controlling for flap type ( P = .022). This finding remained true among radial forearm flaps (17/81, 21% vs 3/53, 5.7%; P = .024). The number of venous anastomoses was not significantly associated with flap failure, though patients with flap failure did have a significantly greater proportion of venous issues ( P < .001). CONCLUSIONS: Two-vein anastomoses do not appear to reduce rates of flap failure or postoperative venous thrombosis but are associated with a lower number of reexplorations in the operating room even after accounting for differences in flap types and surgeons.

Ketorolac after free tissue transfer: a comparative effectiveness study.

OBJECTIVE: We sought to compare postoperative pain and complications in patients undergoing free tissue transfer for reconstruction of head and neck defects with and without ketorolac. METHODS: In this retrospective cohort study, we identified patients who underwent head and neck free tissue transfer procedures at the University of Iowa between July 2010 and December 2012. A subset of patients received ketorolac as an anti-platelet agent. Main outcome measures include postoperative analgesic use, pain scores, and bleeding complications. RESULTS: We identified 138 free tissue transfers, with 42 procedures in the ketorolac cohort. In the first 7 postoperative days, patients in the ketorolac and non-ketorolac cohorts received equivalent narcotic doses (morphine equivalents, 48.9 mg/day vs 46.6 mg/day, P = .72). The ketorolac group reported higher mean pain scores (3.1 vs 2.4, P = .004). Ketorolac use was not associated with need for transfusion (P = .86) or number of days with neck drains (P = .79). CONCLUSION: Ketorolac did not demonstrate a significant analgesic effect in this group of patients in terms of pain scores and opioid requirements. However, there also was no evidence to suggest a higher likelihood of bleeding complications. Ketorolac may be safely used as an anti-platelet agent, with narcotic requirements unchanged.