Milan system for reporting salivary gland cytology in diagnosis and surgery of parotid gland lesions.

INTRODUCTION: A cytology report is always a challenge for both head and neck surgeons and cytopathologists to diagnose and manage parotid gland (PG) diseases, because of the various similar features between the lesions. OBJECTIVES: The present study was conducted to assess our practice using the Milan System for Reporting Salivary Cytopathology (MSRSGC) and to evaluate the risk of malignancy (ROM) in different categories. PATIENTS AND METHODS: The patients with parotid gland lesions were diagnosed by clinical examination, ultrasound, and FNAC under ultrasound guidance at our hospital from 1 May 2019 to 30 April 2021. The FNAC results were divided into six categories according to the Milan system. We calculated the ROM for each category of the Milan system based on histopathological follow-up. RESULTS: This study included 204 patients. There were 115 men (56 %) aged 46-60 years. Pathology results were 33 cases for malignant and 182 cases for benign. The rate of malignancy for each category according to the MSRSGC were 23.1 % (non-neoplastic), 20 % (atypical), 50 % (neoplastic), 1 % (benign), 10.3 % (salivary neoplasm of uncertain neoplastic potential), 84.6 % (suspicious for malignancy), and 100 % (malignant) categories. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of FNAC with application of Milan system were respectively 90.9 %, 98.2 %, 90.9 %, 98.9 % and 97 %. CONCLUSION: When the Milan system was applied, FNAC had a high efficacy, suggesting that MSRSGC can improve the communication between the cytopathologist and the surgeon. This system can allow the surgeon to decide the extent of the surgery.

Transoral endoscopic thyroidectomy with or without central neck dissection.

PURPOSES: Minimally invasive thyroid surgeries are universally accepted. We report on one, transoral endoscopic thyroidectomy with or without central neck dissection. METHODS: A case series of 103 patients were operated on between December 2018 and December 2021. We performed transoral endoscopic thyroidectomy vestibular approach (TOETVA) for 76 patients with a benign nodule, and 27 with papillary thyroid carcinoma (PTC). The patients with malignant nodules also underwent ipsilateral central neck dissection. The extent of surgery, operative time and operative complications were analyzed. RESULT: No cases were converted to open surgery. Average tumor size was 3.8 ± 1.62 cm, mean operative time was 116.5 ± 41.7 min, median blood loss 40.1 ± 49 mL. There were 95 patients with lobectomy and 8 patients with total thyroidectomy. Temporary hoarseness occurred in 9 patients (8.7 %). No patients developed permanent hoarseness. Twelve patients had middle chin numbness. CONCLUSION: The transoral endoscopic thyroidectomy vestibular approach, with or without central neck dissection, is a safe, effective and highly aesthetic treatment.

Twelve Years of Establishing the Strategies for Tongue Reconstruction.

BACKGROUND: Reconstruction after resection of malignant tongue tumors remains one of the most difficult problems in head and neck oncology. Recent trends in tongue reconstruction have focused on optimizing speech and swallowing functions and maximizing quality of life. In the recent literature, several reconstructive strategies including regional flaps and free flaps have been described. PATIENTS AND METHODS: A case series of 328 patients underwent oral tongue reconstruction between March 2011 and March 2022. Functional evaluation was performed in all patients 3 months after reconstruction (where the patients required no adjuvant radiotherapy) or after radiotherapy. RESULTS: Total flap necrosis was seen in 5 patients with free flap reconstruction (2 radial forearm flaps, 1 lateral arm flap, and 2 anterolateral thigh flaps), 5 patients with infrahyoid myocutaneous flap, and 1 patient reconstructed with a supraclavicular flap. Our success rate is 96.6%; partial flap necrosis was observed in 11 patients with infrahyoid myocutaneous flap and 2 patients with a supraclavicular flap. Most patients with subtotal glossectomy or smaller defects (type II-IVA defects) could communicate on the phone and had the near-normal capacity for an oral diet. The remaining patients (type IVB-V defects) had significantly lower speech scores. The majority of patients could eat liquid and semiliquid foods. CONCLUSION: Tongue cancer surgery and subsequent reconstruction posed exciting challenges for the surgeon to optimize tongue function and quality of life for patients. Attention to the principles of tongue reconstruction and choosing appropriate flap for each defect achieve better functional results.

Double free flaps for complex oromandibular defects with two teams of head and neck reconstructive surgical oncologists.

From December 2019 to July 2021, double free flaps were used by two teams of head-and-neck reconstructive surgical oncologists in 10 patients with large composite mandibulofacial defects following malignant tumor (n = 8) and osteoradionecrosis (n = 2) ablation. Our report included 10 patients. All of our patients were reconstructed by two free flaps, a combination of an anterolateral thigh flap (n = 8) or a radial forearm flap (n = 2) with an osteocutaneous fibula flap. The survival rate of these flaps was 100%. The mean operative time was 597 ± 41.7 min (range 545-660 min). There were no patients with major complications. Most of our patients had accepted functional and cosmetic results of both recipient site and donor site after a median follow-up of 22.5 months. Two teams of reconstructive surgical oncologists may shorten the operative time and reduce the rate of major complications. Main Points: Huge complex oromandibular defects may require the use of double free flap reconstruction.Double free flaps were used by two teams of head-and-neck reconstructive surgical oncologists.This approach may shorten the operative time and reduce the rate of major complications.

Use of the double-paddle anterolateral thigh flap for locally advanced tongue carcinoma requiring second site reconstruction.

BACKGROUND: Advanced oral tongue carcinoma can present with extension beyond the oral cavity. Operative defects after resection may involve multiple anatomical sites and significantly impact speech and swallowing. Dependence on long-term enteral feeding is not uncommon for these patients. The anterolateral thigh (ALT) flap is one of the most reliable and flexible flaps used in the reconstruction of total and subtotal tongue defects. The double-paddle flap modification may be a more suitable option for complex oral tongue defects after advanced tumor ablation. METHODS: Case series of 31 patients with oral tongue squamous cell carcinoma that were classified as stage IV. The age of patients ranged from 32 to 63 years. We designed the double-paddle ALT flaps to reconstruct the two-site surgical defects (tongue defect and pharynx or neck skin defect). Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after the completion of adjuvant chemoradiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) using a Speech Intelligibility Score and the Functional Oral Intake Scale. RESULTS: A total of 31 patients with surgical defects after total or subtotal tongue resection for cancer underwent double-paddle ALT flaps for reconstruction from March 2018 to December 2019. The dimension of flaps from 8 × 12 cm to 10 × 18 cm were divided into double-paddle from 8 × 5 cm to 10 × 10 cm. There was one case of pedicle thrombosis, one case of postoperative bleeding, three cases of neck infection, and six cases of salivary fistula. Our patients were seen in follow up from 6 to 36 months, with median follow-up of 23.5 months. The survival rate of ALT flap was 100%. All of our patients achieved an oral diet by 9 months after surgery. The mean score speech intelligibility was 2.74 ± 0.68 (4-point ordinal scale). The 2-year disease-free survival rate was 61.3%. CONCLUSIONS: The double-paddle ALT flap is a reliable flap suitable for oral defects involving multiple subsites after ablative procedures. The majority of patients demonstrated acceptable functional rehabilitation. CLINICAL QUESTION/ LEVEL OF EVIDENCE: Therapeutic, IV.

Cocowood Fibrovascular Tissue System-Another Wonder of Plant Evolution.

The coconut palm (Cocos nucifera L.) stem tissue (referred to as cocowood in this study) is a complex fibrovascular system that is made up of fibrovascular bundles embedded into a parenchymatous ground tissue. The complex configuration of fibrovascular bundles along with the non-uniform distribution of the material properties likely allow senile coconut stems to optimize their biomechanical performance per unit mass (i.e., mechanical efficiency) and grow into tall, slender, and very flexible plants with minimum resources of biomass and water. For the first time, to the best of the authors' knowledge, this paper examines, from the integral (i.e., stem structure) and macroscopic (i.e., tissue structure) levels of hierarchy, the characteristic triple helix formation depicted by the fibrovascular bundles within the monocotyledon cocowood. The natural course of the tangential orientation of the axial fibrovascular bundles is mapped for the whole cocowood structure by quantifying 264 cocowood discs, corresponding to 41 senile coconut palms estimated to be >70 years old. The observed variations were modeled in this paper by simple equations that partially enabled characterization of the cocowood fibrovascular tissue system. Furthermore, 11 finite element analyses (FEA) were performed over a three dimensional (3D) finite element (FE) model resembling a characteristic coconut palm stem of 25 m in height to analyze the biomaterial reactions produced by the progressive deviation of the tangential fibrovascular bundles on the cocowood mechanical response (i.e., on the material compressive strength and the bending stiffness). The analyses in this study were carried out for the critical wind speed of 23 m/s (i.e., Gale tornado according to the Fujita tornado scale). For each analysis, the characteristic average maxima degree of orientation of the cocowood fibrovascular bundles was varied from 0° to 51°. The acquired results provided a deep understanding of the cocowood optimum fibrovascular tissue system that denotes the natural evolution of the material through millions of years. The knowledge advanced from this study may also serve as concept generators for innovative biomimetic applications to improve current engineered wood products.