The histologic risk model is a useful and inexpensive tool to assess risk of recurrence and death in stage I or II squamous cell carcinoma of tongue and floor of mouth.

Surgery is the mainstay of treatment for low-stage (stage I/II, ie, T1N0/T2N0) squamous cell carcinoma of oral cavity. However, a significant percentage of low-stage squamous cell carcinoma of oral cavity will develop local recurrence and disease-related mortality. In this study, we stratified 64 patients with low-stage of oral tongue and floor of mouth patients into high-, intermediate- and low-risk categories based on existing histologic risk model. The classification of these risk categories was based on presence or absence of perineural invasion and evaluation of tumor-host junction for worst pattern of invasion and lymphocytic host response. We correlated risk category and other variables with recurrence and death. In a univariate model, high-risk category tumors had a significantly higher rate of recurrence and death due to recurrence compared with low/intermediate-risk categories (P=0.000 and P=0.047, respectively). Controlling for margin status and T-stage, high-risk category had a 12.4 odds ratio of later recurrence when compared with low/intermediate-risk categories, with a P-value of 0.001. In conclusion, we found low-stage oral cavity squamous cell carcinoma patients with high-risk category have a significantly higher risk for recurrence when compared with patients in the low- or intermediate-risk category, even when controlling for margin status and T-stage. These patients may be suitable candidates for adjuvant treatment to decrease morbidity and mortality associated with a recurrence. Our results indicate that the histologic risk model is a useful and simple tool to assess risk of recurrence in stage I or II squamous cell carcinoma of oral cavity.

Florid Granuloma Annulare-Like Reaction in Regional Lymph Nodes After "Regression" of Red Pigment in Tattoos.

A healthy 50-year-old woman had a tattoo performed on the posterior aspect of her neck and another on the dorsum of her left foot. Several weeks later, she noted redness, tenderness, and intense pruritis at both tattoo sites. Treatment with cephalexin and hydrocortisone cream was instituted, without success. Within a few months, the red, but not black, pigment had disappeared from both tattoos and was replaced by pale areas of scarring. Persistently enlarged left supraclavicular and suboccipital lymph nodes were excised 7 and 10 months after receipt of the tattoos, respectively. The nodes were pigmented on gross examination, and on microscopy, a granuloma annulare-like reaction was observed. Normal lymphoid tissue was seen to be replaced by large palisading granulomas with central degenerative change, abundant stromal mucin, and scattered deposits of tattoo pigment. Histochemical stains, tissue culture, and serological studies revealed no evidence of infection. There are rare reports of granuloma annulare-like reactions in tattoos, and these are believed to represent delayed-type hypersensitivity reactions. Our case is unique in the observation of this reaction pattern in regional lymph nodes, and it expands the spectrum of complications known to be associated with tattoos.

Pivoted composite nasal septal flap for reconstruction of the nose.

Reconstruction of nasal tip support and internal lining after excision of nasal carcinoma is challenging. Since its original description by Menick in 1989, the outcomes of bipedicled septal pivot flap are rarely reported in the literature. Objective of this work is to review our results using the Septal pivoted flap in nasal reconstruction. It is a retrospective case series, Dalhousie University, Halifax, Nova Scotia. We studied six patients who underwent significant resection of the tip and dorsum of the nose for squamous or basal cell carcinoma. All involved nasal subunits were removed. Nasal reconstruction was subsequently performed using an inferiorly bipedicled pivoted composite nasal septal flap combined with a regional flap for skin coverage. The bipedicled SPF provided excellent support of the nasal tip in all six cases. All flaps in the cohort survived. Five patients had good mucosal lining from the septal flap alone and only one patient required a concurrent pericranial flap. Three patients experienced bleeding and required additional nasal packing. A bipedicled septal pivoted flap is exceptionally useful in providing a good tip support and well-vascularized nasal lining for reconstruction after major resection of the nasal tip. Bleeding is common and should be anticipated in the majority of patients.

Management of positive resection margins following transoral laser microsurgery for glottic cancer.

Objectives: The current literature provides limited guidance on the management of positive margins (PMs) following transoral laser microsurgery (TLM) for glottic squamous cell carcinoma (SCC). Long-term data exploring the treatment of PMs with both initial observation and re-resection are limited. Our objective was to determine the optimal treatment for PM patients following TLM for glottic SCC. Methods: Clinical information on glottic SCC patients with PMs following treatment with TLM was prospectively collected at our institution from 2007 to 2018. We use a laryngeal template during the initial TLM where the area of resection is outlined for future reference. Data were compared with univariate analysis and survival plots were generated using the Kaplan-Meier method. Results: A total of 29 patients with PMs were treated with either re-resection (19 patients), close observation (6 patients), or adjuvant radiation alone (4 patients). Re-resection patients had SCC or severe dysplasia on initial margin pathology and 23% with early-stage disease had recurrence (T1-T2). Five (83%) patients who underwent close observation required re-resection based on clinical suspicion of recurrence (confirmed on final pathology), which was significantly different from the re-resection patients (p < .05). Close observation was therefore discontinued as a management of PMs. Four patients (21%) had no residual malignancy on re-resection specimens. Deep margins only accounted for 17% of all PMs. Disease-specific survival for all PM patients at 5 years was 82.4% (SE 9.6%, CI 53.4%-91.6%). Conclusions: Our long-term experience with treating early-stage glottic SCC with TLM supports re-resection as an appropriate management for cases of PMs. Level of Evidence: 4.

Oral Losartan After Limited Mandibulectomy for Treatment of Desmoid-Type Fibromatosis.

Desmoid-type fibromatosis (DF) is a rare soft tissue lesion with an annual incidence of 2 to 4 per million population and peak incidence occurring at approximately 4.5 years of age. While benign, the tumor has a locally aggressive infiltrative growth pattern and a high rate of recurrence. Given the functional and aesthetic implications of excision and reconstruction in the facial skeleton, novel medical treatment options are highly desirable. We describe the case of a 3-year-old boy who presented with an enlarging, asymptomatic mass involving the left mandible. Biopsy revealed an immunohistochemical profile consistent with DF. Despite the high likelihood of recurrence, conservative, mandible-sparing en bloc resection and limited mandibulectomy were performed. Pathological and immunohistochemical analysis of the resection specimen revealed DF with grossly positive margins and elevated expression of angiotensin II type 1 receptor. Postoperative medical treatment with the angiotensin receptor blocker losartan was initiated. The patient remains medically stable and disease progression-free on repeat imaging at 20 months post-resection. We describe for the first time the successful use of the angiotensin blocker losartan following conservative surgery for management of DF.

Frequency and accuracy of intraoperative bone margin sampling for T4a cancers of the head and neck at the QEII Health Sciences Centre: a retrospective chart review.

BACKGROUND: Stage T4a cancers are associated with a 5-year survival of 21.6-59.0%. Adequate resection of these tumors is a critical factor in maximizing survival. Tumors invading bone pose a unique challenge to intraoperative bone margin assessment. Due to processing limitations, there had been no formal standardized protocol for intraoperative bone sampling at the QEII Health Sciences Centre. These resections often involve extensive reconstruction, making salvage surgery difficult if positive margins are detected post-surgically. The purpose of this study was to assess the accuracy and frequency of intraoperative bone margin assessment during the study period and to determine survival and recurrence rates associated with positive final bone margins. METHODS: A retrospective chart review was conducted including patients with stage T4a head and neck cancer involving bone that underwent primary surgical resection in Nova Scotia between 2009 and 2019. Eligible patients were identified through the Cancer Care Nova Scotia registry. Exclusion criteria included patients with stage T4a tumors involving bone that did not receive primary surgical treatment with curative intent and patients with stage T4a tumors that did not invade bone. RESULTS: Of 67 patients included, 50 were amenable to intraoperative bone margin sampling while 18 had intraoperative sampling. Four patients had positive intraoperative margins and one had final positive bone margins. The incidence of final bone margin positivity was 7.5%. Median survival following surgery was 4.56 years for patients with final negative bone margins (n = 62) and 3.98 years for patients with positive final bone margins (n = 5). All patients with final positive bone margins received adjuvant radiation therapy. Of patients with negative final bone margins, 16.1% received no adjuvant therapy, 61.3% received adjuvant radiation therapy and 21.0% received adjuvant chemoradiation therapy. CONCLUSION: Intraoperative bone margin sampling occurred in 26.8% of all cases and 36.0% of amenable cases. Median survival of patients with positive final bone margins was 0.58 years lower than those with negative final bone margins, although this difference did not reach statistical significance. This will provide baseline data for comparison of the standardized intraoperative bone margin sampling protocol implemented at the QEII Health Sciences Centre.

The impact of national holidays on postoperative radiotherapy of squamous cell carcinoma of the head and neck.

Background: Delays in starting postoperative radiotherapy (PORT) have been established as negative predictors for clinical outcomes in head and neck squamous cell carcinomas (HNSCC). Our study aimed to examine the effect of delays during PORT, and the impact of national holidays in Canada, a publicly funded system, on oncologic outcomes such as Overall Survival (OS) and Local Recurrence (LR). Methods: The provincial cancer registry was queried to obtain demographic, pathologic, and outcomes data from cancer patients treated for all squamous cell carcinomas of the head and neck region treated between January 1, 2007 and November 30, 2019. All extracted information was cross-referenced and supplemented by chart review of patient electronic medical records. Extracted data were analyzed for OS and LR, in the context of Canadian national holidays causing delays during PORT. Results: 1433 patients treated for HNSCCs were identified, of whom 338 were treated curatively with surgery followed by PORT. 68.6% of patients experienced at least one day of interruption during treatments due to holidays. LR was 15.4% and OS was 59.6% at 5 years. Treatment interruptions by holidays were predictive of local recurrence (HR, 2.38; 95% CI 1.17-4.83; p = 0.017). Patients that developed early recurrence prior to PORT had very poor oncologic outcomes. Conclusion: Our findings were consistent with previously published studies in limiting the interval between surgery and PORT. We identified the novel finding of paired holidays as a significant predictor in determining LR, suggesting the importance of modifying RT delivery schedules and timing.

Oncological and functional outcomes following treatment of T1a glottic squamous cell carcinoma with transoral laser microsurgery.

BACKGROUND: Laryngeal cancers of glottic origin comprise a large proportion of head and neck malignancies. Transoral laser microsurgery (TLM) and radiation therapy are mainstays in the treatment of early stage glottic cancer, but debate persists as to which modality is functionally superior. Furthermore, there is a paucity of North American data related to functional and oncological outcomes in T1a glottic cancer. Here, we assessed oncological and functional outcomes of T1a glottic squamous cell carcinoma (SCC) with TLM to supplement evidence from jurisdictions outside North America. METHODS: This study is a retrospective cohort study performed from a prospectively collected tertiary center institutional TLM database. Patients who were diagnosed with T1a glottic SCC and underwent TLM as their primary treatment were included. Functional outcomes were analyzed using the Voice Handicap Index-10 (VHI-10) questionnaire. Ultimate control with TLM only was considered to be those patients with locoregional control with repeat TLM procedures, but without addition of other modalities. Student's t-test was used to test significance and Kaplan-Meier survival analysis was used to assess oncological outcomes. RESULTS: 48 patients met study criteria. The mean follow-up time was 74 months. The 5-year locoregional, ultimate control with TLM only and laryngeal preservation rates were 83.2%, 90.4% and 100%, respectively. The overall survival and disease-specific survival were 87.2% and 100%, respectively. VHI-10 scores were available for 13/48 patients and mean scores improved non-significantly from pre-op (mean: 11.23; range: 2 to 30; median: 10) and post op (mean: 7.92; range: 0 to 18; median: 8) scoring (p-value = 0.15). Sub-stratification of voice data revealed a significant improvement between pre and post-operative scores (mean difference - 10.6, 95% CI: - 0.99 to - 20.21, p-value = 0.035) for patients with abnormal pre-operative scores (VHI > 11). CONCLUSION: To our knowledge, the current work represents one of the first North American studies to report both functional and oncologic outcomes for TLM treatment of T1a glottic SCC. The oncologic and functional outcomes presented here add to existing evidence in favor of TLM as a safe and effective primary treatment option for early staged T1a glottic cancer.

Margin Sampling and Survival Outcomes in Oral Cavity and p16-Positive Oropharyngeal Squamous Cell Carcinoma.

Objective: To compare the association of margin sampling technique on survival outcomes in surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. Study Design: A prospective longitudinal cohort study. Setting: Tertiary care academic teaching hospital in Halifax, Nova Scotia. Methods: All cases of surgically treated cT1-2 oral cavity and oropharyngeal cancer undergoing specimen-oriented margin analysis between January 1, 2017, and December 31, 2018 were analyzed. The specimen-oriented cohort was compared with a cohort of patients from January 1, 2009, to December 31, 2014, where a defect-oriented margin sampling protocol was used. Kaplan-Meier survival curves were used to estimate 2-year overall survival, disease-specific survival, local control, and recurrence-free survival rates in oral cavity and p16-positive oropharyngeal squamous cell carcinoma. Cox proportional hazards models were used to assess the effect of margin sampling method on disease-specific survival and local control. Results: There was no significant association between margin sampling technique and 2-year survival outcomes for surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. In the multivariate Cox proportional hazard model, the hazard ratio (HR) of specimen-oriented sampling was not significantly different for disease-specific survival (HR, 1.32; 95% CI, 0.3032-5.727; P = .713) or local control (HR, 0.4087; 95% CI, 0.0795-2.099; P = .284). Conclusion: Intraoperative margin sampling method was not associated with a significant change in 2-year survival outcomes. Despite no effect on survival outcomes, implementation of a specimen-oriented sampling method has potential for cost avoidance by decreasing the number of re-resections for positive or close margins.

Injection laryngoplasty during transoral laser microsurgery for early glottic cancer: a randomized controlled trial.

BACKGROUND: Transoral laser microsurgery is widely used for treating T1/T2 glottic cancers. Hyaluronic acid (HA) is commonly used in vocal cord augmentation. We investigated the impact of intra-operative injection laryngoplasty on voice outcomes in early glottic cancer. METHODS: Twenty patients were randomized to the treatment group receiving HA injection to the vocal cord contralateral to the lesion; or the control group, receiving no injection. Patients had a Voice Handicap Index-10 (VHI-10) questionnaire and a Maximum Phonation Time (MPT) measurement preoperatively and at 3, 12 and 24 months post-operatively. Mean change in VHI-10 and MPT, compared to baseline and between time points, were compared. Survival estimates were calculated. RESULTS: Mean VHI-10 scores improved over time amongst all patients. There were no changes in mean VHI-10 from pre-operative values to 3, 12 or 24 months post-operatively. There were no significant differences when comparing various timepoints between groups. There were no significant changes in MPT amongst the groups, or the time-points compared. Two-year overall survival was 91.7%; disease free survival was 80.9%; no difference in recurrence free survival was seen between the groups. CONCLUSION: Subjective voice scores improved over time in both groups; there were no improvements in VHI-10 or MPT scores in the injection group, over control, at any time points. We saw no significant impact for intra-operative HA injection laryngoplasty on subjective or objective voice outcomes following surgery for early glottic cancers.

Functional and Oncologic Outcomes of Octogenarians Undergoing Transoral Laser Microsurgery for Laryngeal Cancer.

OBJECTIVE: To evaluate the oncologic and functional outcomes of transoral laser microsurgery (TLM) for glottic cancers in patients ≥80 years. STUDY DESIGN: Prospectively collected case series. SETTING: QEII Health Sciences Centre, Halifax, Canada. METHODS: This case series used a prospectively collected glottic cancer database to examine consecutive elderly patients (≥80 years old) undergoing TLM. Kaplan-Meier analysis was used to evaluate rates of disease-free, disease-specific, and overall survival as the primary end points of oncologic control. Secondary functional outcomes included voice function, length of hospital stay, and time to readmission. RESULTS: From 2005 to 2017, 17 octogenarian patients underwent TLM for glottic cancer. Median follow-up was 4.19 years (interquartile range, 0.71-6.95). Kaplan-Meier estimates of 5-year survival were 78.4% (disease free), 92.9% (disease specific), and 81.9% (overall). The median length of hospital stay was 1 day (range, 0-8). There was only 1 readmission within 30 days of surgery. No patients in this study developed significant surgical or postoperative complications requiring unplanned readmissions. Patient-perceived voice function improved to normal after treatment in 62.5% of patients. CONCLUSION: The results of this study suggest that TLM is a safe and effective treatment modality for glottic cancer in patients aged ≥80 years, providing good oncologic control and satisfactory functional outcomes.

Treatment Choices in Managing Bethesda III and IV Thyroid Nodules: A Canadian Multi-institutional Study.

OBJECTIVE: Patient-centered decision making is increasingly identified as a desirable component of medical care. To manage indeterminate thyroid nodules, patients are offered the options of surveillance, diagnostic hemithyroidectomy, or molecular testing. Our objective was to identify factors associated with decision making in this population. STUDY DESIGN: This is a retrospective cross-sectional study of patients with Bethesda III and IV thyroid nodules. SETTING: Multi-institutional. METHODS: Factors of interest included age, sex, socioeconomic status (SES), nodule size, institution, attending surgeon, surgeon payment model, and hospital type. Our outcome of interest was the initial management decision made by patients. RESULTS: A total of 956 patients were included. The majority of patients had Bethesda III nodules (n = 738, 77%). A total of 538 (56%) patients chose surgery, 413 (43%) chose surveillance, and 5 (1%) chose molecular testing. There was a significant variation in management decision based on attending surgeon (proportion of patients choosing surgery: 15%-83%; P≤.0001). Fee-for-service surgeon payment models (odds ratio [OR], 1.657; 95% CI, 1.263-2.175; P < .001) and community hospital settings (OR, 1.529; 95% CI, 1.145-2.042; P < .001) were associated with the decision for surgery. Larger nodule size, younger patients, and Bethesda IV nodules were also associated with surgery. CONCLUSION: While it seems appropriate that larger nodules, younger age, and higher Bethesda class were associated with decision for surgery, we also identified attending surgeon, surgeon payment model, and hospital type as important factors. Given this, standardizing management discussions may improve patient-centered shared decision making.

Management of Peritonsillar Abscesses in Adults: Survey of Otolaryngologists in Canada and the United States.

OBJECTIVE: The management of peritonsillar abscess (PTA) has evolved over time. We sought to define contemporary practice patterns for the diagnosis and treatment of PTA. STUDY DESIGN: Cross-sectional survey. SETTING: The 15-question survey was distributed to members of the Canadian Society of Otolaryngology-Head and Neck Surgery (CSO) and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). METHODS: An iterative, consensus-based process was used for survey development. Primary outcomes were to determine methods of diagnosis and first-line treatments for PTA. Exploratory, secondary outcomes were analyzed using multivariable logistic regression models. RESULTS: The survey response rate was 12.6% (n = 1176). Most participants were attending staff (86%) in a community hospital setting (60%) and had been in practice for more than 20 years (38%). Most respondents (78%) indicated that at least half of the time, cross-sectional imaging had already been performed before they were consulted. Half of respondents (49%) indicated that they perform incision and drainage of the abscess as first-line treatment, while few (16%) provide medical management alone. In exploratory analysis, participants from the AAO-HNS had higher odds of imaging already being performed before consultation (odds ratio [OR], 11.7; 95% CI, 4.6-29.4) and increased odds of using medical management alone as a first-line treatment (OR, 2.4; 95% CI, 1.3-4.2) compared to respondents from the CSO. CONCLUSION: There is wide practice variation in the diagnosis and management of acute, uncomplicated PTA among otolaryngologists in Canada and the United States. The use of cross-sectional imaging and medical management alone may differ between countries of practice.

Carbon footprint reduction associated with a surgical outreach clinic.

BACKGROUND: Healthcare systems generate substantial carbon footprints that may be targeted to decrease greenhouse gas emissions. Outreach clinics may represent tools to assist in this reduction by optimizing patient related travel. Therefore, we sought to estimate the carbon footprint savings associated with a head and neck surgery outreach clinic. METHODS: This study was a cross-sectional survey of patient travel patterns to a surgical outreach clinic compared to a regional cancer treatment centre from December 2019 to February 2020. Participants completed a self-administered survey of 12 items eliciting travel distance, vehicle details, and ability to combine medical appointments. Canadian datasets of manufacturer provided vehicular efficiency were used to estimate carbon emissions for each participant. Geographic information systems were used for analyses. RESULTS: One hundred thirteen patients were included for analysis. The majority of patients (85.8%) used their own personal vehicle to travel to the outreach clinic. The median distance to the clinic and regional centre were 29.0 km (IQR 6.0-51.9) and 327.0 km (IQR 309.0-337.0) respectively. The mean carbon emission reduction per person was therefore 117,495.4 g (SD: 29,040.0) to 143,570.9 g (SD: 40,236.0). This represents up to 2.5% of an average individual's yearly carbon footprint. Fewer than 10% of patients indicated they were able to carpool or group their appointments. CONCLUSION: Surgical outreach clinics decrease carbon footprints associated with patient travel compared to continued care at a regional centre. Further research is needed to determine possible interventions to further reduce carbon emissions associated with the surgical care of patients.

Psychosocial Distress in Adult Patients Awaiting Cancer Surgery during the COVID-19 Pandemic.

Cancer causes substantial emotional and psychosocial distress, which may be exacerbated by delays in treatment. The COVID-19 pandemic has resulted in increased wait times for many patients with cancer. In this study, the psychosocial distress associated with waiting for cancer surgery during the pandemic was investigated. This cross-sectional, convergent mixed-methods study included patients with lower priority disease during the first wave of COVID-19 at an academic, tertiary care hospital in eastern Canada. Participants underwent semi-structured interviews and completed two questionnaires: Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS). Qualitative analysis was completed through a thematic analysis approach, with integration achieved through triangulation. Fourteen participants were recruited, with cancer sites including thyroid, kidney, breast, prostate, and a gynecological disorder. Increased anxiety symptoms were found in 36% of patients and depressive symptoms in 14%. Similarly, 64% of patients experienced moderate or high stress. Six key themes were identified, including uncertainty, life changes, coping strategies, communication, experience, and health services. Participants discussed substantial distress associated with lifestyle changes and uncertain treatment timelines. Participants identified quality communication with their healthcare team and individualized coping strategies as being partially protective against such symptoms. Delays in surgery for patients with cancer during the COVID-19 pandemic resulted in extensive psychosocial distress. Patients may be able to mitigate these symptoms partially through various coping mechanisms and improved communication with their healthcare teams.

Composite submental flaps in facial reconstructive surgery involving the zygoma and orbit.

BACKGROUND: The submental island flap (SIF) is a reliable option for reconstructing defects in the facial region and offers several advantages when compared to free-flap alternatives. While the reconstructive applications of the SIF have been demonstrated in the lower face, there are limited reports on its utility as a composite flap for reconstructing defects of the upper facial skeleton. To our knowledge, we report the first cases of composite (osteocutaneous) SIFs used for reconstruction of complex facial defects involving the zygoma and lateral orbit respectively. CASE PRESENTATIONS: Three consecutive cases are presented. All were performed following resection of skin cancers with invasion of the upper facial skeleton. The first case was a 68-year-old male with a longstanding history of non-melanoma skin cancers who presented with a 7 cm recurrent basal cell carcinoma (BCC) with bicortical invasion of the left zygoma. The second case was an 88-year-old female with several squamous cell carcinomas (SCC), including a dominant 7.1 cm SCC on the right temple with orbital invasion. A third case was a 75-year-old immunosuppressed male with a 6.5 cm SCC of the right cheek with invasion of the orbit and zygoma following prior resection as well as high dose radiotherapy. The operative management of all cases involved harvesting the SIF on its vascular pedicle alongside the inferior portion of the mandible with rigid fixation to address the bony defects. The first case was robust throughout adjuvant radiotherapy with no flap complications after 2 year follow up. The second patient received adjuvant radiation therapy to an area that was previously radiated. Although the flap remained viable for a year, the patient experienced delayed soft tissue loss over the bony segment and eventual devitalization of the distal flap. The third case achieved a satisfactory result with no complications. CONCLUSIONS: Our case series outlines a unique application of the composite (osteocutaneous) submental island flap (SIF) for reconstruction of complex facial defects involving the upper facial skeleton. The osteocutaneous SIF should be used with caution in patients receiving adjuvant radiotherapy who have a history of previous radiation to the same or overlapping field.

Tubed Anterolateral Thigh Free Flap for Pharyngoesophageal Reconstruction.

Caustic ingestions can severely injure the upper and lower aerodigestive tract, resulting in detrimental mucosal changes both acutely and chronically. Injuries are most severe following alkaline ingestion. Esophagectomy is often recommended in patients with high-grade esophageal injuries to mitigate the risk of perforation. Esophageal reconstruction after these injuries is often delayed, and staged, allowing adequate tissue stabilization before further manipulation. Here, we report on a 25 year-old woman who presented with a high-grade caustic esophageal injury following the ingestion of an alkaline drain cleaner. She underwent an emergent thoracic esophagectomy, gastrectomy and a cervical salivary esophagostomy. Post-operatively, she developed supraglottic and hypopharyngeal strictures, but maintained a functional larynx. She subsequently underwent a staged, extrathoracic total esophageal reconstruction using an anterolateral thigh (ALT) myocutaneous free flap with laryngeal preservation. Although serial esophageal dilatations and trans-oral laser procedures for pharyngeal strictures were required, she was able to maintain the ability to swallow.

Prospective outcomes following drainless superficial parotidectomy with sternocleidomastoid flap reconstruction.

BACKGROUND: Patients undergoing superficial parotidectomy for benign parotid lesions are at risk of postoperative complications, most notably cosmetic complications such as facial paralysis and contour defects, and functional complications including Frey's syndrome. Traditionally, surgical drains have been placed at the end of surgery to prevent hematoma and sialocele formation. However, this can increase the risk of postoperative complications and contribute to a prolonged course in hospital. To try and prevent these risks and complications, we introduced a novel technique of a drainless parotidectomy by reconstructing the resulting parotid bed defect with a superiorly based sternocleidomastoid (SCM) rotational flap and by placement of gelfoam into the wound bed and a facelift dressing postoperatively to provide additional hemostasis and avoid drain placement. METHODS: All patients with benign parotid disease undergoing a drainless superficial parotidectomy and reconstruction with a superiorly based SCM rotational flap at our center were identified within a prospective cohort database between July 2010-2018. Primary outcomes included postoperative cosmetic and functional outcomes, complications and length of hospital stay. A secondary cost analysis was done to compare this novel technique to traditional superficial parotidectomy with surgical drain placement. RESULTS: Fifty patients were identified within the database and were included in the final analysis. The average length of hospital stay was 1.02 days. All patients were satisfied with their aesthetic outcome at 1 year. During long term follow-up, 63% of patients reported normal appearance of the operated side. Seven patient's (14%) developed temporary facial paresis following surgery. All patients had resultant normal facial function at follow-up in 1 year. No patients developed subjective Frey's Syndrome. Two patients (4%) developed a postoperative sialocele requiring drainage and one patient (2%) developed a hematoma on extubation requiring evacuation and drain placement. Cost analysis demonstrated a cost savings of approximately $975 per person following surgery. CONCLUSION: In the current study, we introduced a novel approach of a drainless superficial parotidectomy using a superiorly based SCM flap, gelfoam and placement of a post-operative facelift dressing. This drainless approach was associated with good long-term cosmetic and functional outcomes with few postoperative complications. This new technique may also offer the potential for long-term savings to the health care system.

Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-analysis.

OBJECTIVE: Peritonsillar abscesses (PTAs) are common emergency consultations for otolaryngologists. Medical management alone may offer satisfactory treatment without the risk associated with surgical drainage. Therefore, we performed a systematic review of medical treatment alone compared to surgical drainage for the treatment of PTA. DATA SOURCES: MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov. REVIEW METHODS: Studies comparing the outcomes of medically treated to surgically treated patients were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. All screening and data extraction were completed by 2 independent reviewers. Meta-analysis was performed using a random-effects model. Subgroup and sensitivity analyses were performed. RESULTS: Ten cohort studies and 2 randomized studies were included (ntotal = 33,468). Study quality was low, with only 1 study providing multivariable analysis. The combined rate of treatment failure in patients initially treated with medical management alone was 5.7% compared to 5.5% in the surgical group. There was no statistically significant difference in the odds of treatment failure between interventions through random-effects meta-analysis (odds ratio [OR], 1.10; 95% CI, 0.53-2.26; I 2 = 41%; P = .13). Subgroup analysis excluding pediatric-specific studies revealed similar odds of treatment failure when initially managed with medical intervention (OR, 0.92; 95% CI, 0.56-1.50; P = .39; I 2 = 0%). CONCLUSION: Meta-analysis of available studies demonstrated no difference in odds of treatment failure for patients with PTA managed through medical intervention alone compared to surgical intervention. These findings should be interpreted with caution due to high probability of bias and overall low quality of studies.

Open resection and reconstruction of a Nasoseptal Chondrosarcoma: case report and literature review.

BACKGROUND: Primary chondrosarcomas of the nasal septum are rare, with a variety of clinical features that evade detection and treatment. While endoscopic surgery has become increasingly accessible, open approaches may be needed to provide adequate visualization for tumour ablation and reconstruction. We report the resection and reconstructive considerations of a septal chondrosarcoma. CASE PRESENTATION: A 75-year-old woman presented with a 3-year history of a slow growing, firm mass in the nasal tip causing protrusion and septal fullness. Computed Tomography scan of the paranasal sinuses revealed a well-circumscribed, 2.2 cm mass at the anterior nasal septum extending into the right vestibule. Biopsy of the cartilaginous lesion confirmed the diagnosis of a low-grade chondrosarcoma by histopathology. The tumour was removed using a transcolumellar open rhinoplasty approach with a large septal resection. Primary reconstruction of the surgical defect was performed using an L-shaped strut from the nasal keystone area to the columella. Follow-up examinations demonstrated no evidence of recurrent disease with satisfactory functional and cosmetic outcomes at 1-year. CONCLUSION: This report describes a case of nasal septal chondrosarcoma successfully treated with surgical excision using an open rhinoplasty approach. Only 5-10% of chondrosarcomas are located in the head and neck region and arise rarely in the nasal septum in approximately 2-4%. With this mass, an open rhinoplasty approach was required to allow optimal exposure of the margins and to facilitate reconstruction without disruption of normal sinonasal anatomy and function. Although rare, chondrosarcoma of the nasal septum should be considered in the differential diagnosis of nasal masses.