Free Flap Reconstruction of the Head and Neck Region: A Series of 127 Flaps Performed by Otolaryngologists.

OBJECTIVE: To determine flap success rate and complications in patients who underwent microvascular free tissue reconstruction after major head and neck ablative surgery and to report the improvement in the results. METHODS: Medical records of 124 patients who were operated on in 2012 to 2019 were retrospectively reviewed. Indications for different free flap types, success rates and re-exploration rates, donor site morbidities, and reasons for flap loss were analyzed. Patients were divided into two groups to identify the effects of the anticoagulant and the antiaggregant treatments on postoperative results. RESULTS: There were 127 flaps in 124 patients, including two different free flaps each in three patients that were harvested and used in the same surgical session. Of the total 127 flaps, 82 (64.6%) were radial forearm flaps, 39 (30.7%) were fibula flaps, and 6 (4.7) were rectus abdominis flaps. Four patients were re-explored for flap perfusion problems, and 18 patients were re-explored for hematoma drainage (n=22/124, %17.3). The rate of hematoma and re-exploration was higher in patients who received anticoagulant and antiaggregant treatments synchronously (p=0.02). Three flaps were lost, and the overall success rate was 97.6%. Two patients died from perioperative complications. No major complications were observed at the donor site; minor complications were observed in 30 patients. CONCLUSION: The success rate for the 127 flaps in 124 patients were found comparable to those reported in the literature. These results show that successful outcomes can be achieved with experience and a head and neck team dedicated to improving the results in microsurgical reconstruction, and flap failure rarely occurs if perioperative care of the patients is given meticulously.

Endonasal endoscopic nasopharyngectomy for the treatment of nasopharyngeal papillary adenocarcinoma: Report of a rare case.

We report a case of low-grade nasopharyngeal papillary adenocarcinoma in a 9 year-old male that was diagnosed incidentally after an adenoidectomy procedure and treated with endonasal endoscopic nasopharyngectomy without any adjuvant therapy. The patient has been followed up for 3 years with no evidence of recurrence. We point out the importance of preoperative fiberoptic nasopharyngoscopy in the absence of longstanding symptoms in school-aged children and histopathologic examination of adenoidectomy specimens in the presence of atypical findings. We also suggest endonasal endoscopic resection in case of papillary adenocarcinoma.

[The use of microvascular free flaps in head and neck reconstruction performed by the otorhinolaryngologists: a series of 65 flaps]. / Bas boyun bölgesi rekonstrüksiyonunda kulak burun bogaz uzmanlarinca mikrovasküler serbest doku fleplerinin kullanimi: 65 fleplik seri.

OBJECTIVES: This study aims to assess the success rate of surgery and postoperative morbidity in patients who underwent major head and neck surgery with reconstruction by microvascular free flaps performed by otolaryngologists. PATIENTS AND METHODS: We retrospectively analyzed the medical records of 63 patients (31 males, 32 females; mean age 47.9±12.5 years; range 20-71 years) operated in our clinic between September 2012 - August 2016. The indications of reconstruction by free flap, success rates, need for revision and re-exploration, reasons of flap failure, morbidity and mortality were evaluated. RESULTS: Thirty-seven (56.9%) of the 65 microvascular free flaps were radial forearm; 23 flaps (35.4%) were fibula and five flaps (7.7%) were rectus abdominis. Three of the total 65 flaps ended up in failure; accordingly the success rate was 95.4%. Except for these three failure cases, an urgent re-exploration was performed on 13 patients in the first postoperative 48 hours (n=16, %24.6). No permanent major sequel was observed in any of the patients. CONCLUSION: From the otolaryngologists' point of view, we observed that performing microvascular surgery and the successful surgical results not only gives the flexibility in reconstruction but also provides safer resection during ablative surgery.

Paratracheal lymph node dissection, in which patients should it be performed?

OBJECTIVES: This study aims to evaluate the effect of paratracheal lymph node (PTLN) metastasis on survival in patients with advanced laryngeal and hypopharyngeal cancer. PATIENTS AND METHODS: Medical records of advanced laryngeal and hypopharyngeal cancers who underwent surgery between May 1995 and June 2008 were assessed and 78 of the patients (63 males, 15 females; mean age 55±11.3 years; range 25 to 76 years) who has PTLN metastasis were included in this study. The mean follow-up period was 23 months. Fifty-three patients had primary laryngeal cancer, and the remaining 25 patients had primary hypopharyngeal cancer. RESULTS: Paratracheal lymph node metastasis was detected in eight (15%) of 53 patients with laryngeal carcinoma, six (42%) of 14 patients with postcricoid carcinoma, and one (14%) of seven patients with posterior pharyngeal wall carcinoma. Paratracheal lymph node metastasis was not detected in patients with pyriform sinus carcinoma (n=4). Paratracheal lymph node metastasis was detected in a total of 15 patients, of whom 11 had extranodal spread (ENS). Multivariate analysis showed that the presence of ENS was the most effective prognostic factor on the overall survival (p<0.0005). CONCLUSION: The presence of PTLN metastasis with ENS is an important prognostic indicator on overall survival. We recommend PTLN dissection particularly in patients with advanced laryngeal or hypopharyngeal cancer for histopathological analysis and prognostication because ENS can only be precisely detected by pathological evaluation.

The incidence of thyroid cartilage invasion through the anterior commissure in clinically early-staged laryngeal cancer.

In this study, the incidence of thyroid cartilage invasion in early-stage laryngeal tumors involving anterior commissure was assessed. Medical charts and pathology reports of 62 patients who underwent supracricoid partial laryngectomy as the primary treatment of early-staged laryngeal squamous cell carcinoma were retrospectively reviewed. Patients were divided into two groups according to the macroscopic examination of the surgical specimen: tumors limited to the glottis with the involvement of anterior commissure (TLG); tumors invading both supraglottis and glottis with the involvement of anterior commissure (TISG). Thirty-seven of the cases were classified as TLG group (59.7 %) and the remaining 25 of them were classified as TISG group (40.3 %). Thyroid cartilage invasion was observed totally in ten patients (16.1 %), as macroscopic invasion in two cases and microinvasion in eight patients. Only two were in the TLG group (cartilage invasion rate of 5.4 %), the remaining eight were in the TISG group (cartilage invasion rate of 32 %). Thyroid cartilage invasion rate of TISG group was significantly higher than that of TLG group (p = 0.011, p < 0.05). Tumors limited to the glottis with AC involvement may be more suitable for endoscopic resection; on the contrary, tumors with vertical extension invading both AC and supraglottis should be evaluated more suspiciously due to high rate of thyroid cartilage invasion, which may still necessitate external laryngectomy techniques.

The Effect of Arytenoidectomy on Functional and Oncologic Results of Supracricoid Partial Laryngectomy.

OBJECTIVE: The effect of arytenoid resection was investigated in patients who had undergone supracricoid partial laryngectomy (SCPL) by comparing functional and oncologic results between patients with both arytenoids preserved with those with one arytenoid resected. METHODS: Patients were divided into 2 groups: (1) both arytenoids preserved SCPL (BASCL) cases and (2) one arytenoid preserved SCPL (OASCL). The functional outcomes of the 2 groups were compared in terms of nasogastric tube removal time, decannulation time, incidence of aspiration pneumonia, and Performance Status Scale Scores for Head and Neck Cancer Patients for the late postoperative period. Additionally, the oncologic outcomes of both groups were compared using the 5-year local control rate, overall survival, disease-specific survival, and larynx preservation rate. RESULTS: Of the 68 patients who were enrolled in the study, 20 of them were in the OASCL group and 48 in BASCL group. There was no statistically significant difference in the early and late functional outcomes, and the oncologic outcomes were also similar. CONCLUSION: In addition to the proven oncologic safety, arytenoid resection does not increase the functional morbidity of the SCPL.

Unilateral endoscopic optic nerve decompression for idiopathic intracranial hypertension: a series of 10 patients.

OBJECTIVE: Several surgical treatment modalities, including lumboperitoneal or ventriculoperitoneal shunt surgery, subtemporal decompression, endovascular venous sinus stenting, optic nerve decompression (OND), were used in the management of idiopathic intracranial hypertension (IIH). Each surgical technique has different advantages and disadvantages. Endoscopic OND is rarely used in the management of IIH. There are only four reported cases. The aim of this study is to describe the surgical results of patients treated with this less invasive surgical technique. METHODS: A series of 10 consecutive cases of unilateral OND was reviewed. Between December 2008 and December 2012 these patients underwent the endoscopic approach without nerve sheath opening. Presenting symptoms, neurological examination findings, magnetic resonance venography imaging results, fundoscopic and visual acuity examination findings, and automated perimetry test results were recorded. Perioperative results, including complications and length of hospital stay, were evaluated. Findings at follow-up evaluations were also recorded. RESULTS: This report is the first series of unilateral OND performed using the endoscopic approach. The mean patient age was 34.1 years (range, 9-49 years); there were nine female and one male patients. Visual impairment was the main symptom in this patient group, whereas headache was a secondary complaint. The patients were first managed with medical treatment for at least 3 months. Unilateral endoscopic OND was performed on the side with the most visual failure. Mean follow-up was 28.4 months (range, 8-55 months). The visual field defects and visual acuity improved in eight of nine patients, whereas papilloedema improved in seven of nine patients. Also headaches resolved in four of seven patients. There were no complications in this relatively small series. CONCLUSIONS: The surgical treatment of IIH by using the unilateral endoscopic OND technique is a safe and effective method in the hands of experienced surgeons with advanced endoscopic skills. A collaboration with the ophthalmology team is needed for the follow-up. Further studies with larger patient numbers is needed to compare unilateral endoscopic OND technique with the current techniques used in the surgical management of IIH.

Xanthogranulomatous sialadenitis clinically mimicking a malignancy: case report and review of the literature.

BACKGROUND: Xanthogranulomatous tissue reaction is a well-documented process that is most common in kidney. There are other uncommon sites being documented as case reports in the literature. We would like to describe the clinicopathologic findings in a case of xanthogranulomatous sialadenitis that involved the parotid gland, which was clinically thought to be a tumoral mass, and compare it with the 4 previously reported cases. CASE REPORT: A 52-year-old man presented with a left parotid mass. Fine needle aspiration biopsy was consistent with Warthin's tumor. The mass lesion was excised. DISCUSSION: The lesion measured 2.5 × 1.5 × 1.5 cm. Microscopic examination revealed sheets of foamy macrophages centrally admixed with neutrophils, eosinophils, lymphocytes, plasma cells and scattered giant cells indicating a xanthogranulomatous reaction. As a conclusion xanthogranulomatous tissue reaction can mimic neoplasms.

Induction chemotherapy with docetaxel and cisplatin is highly effective for locally advanced nasopharyngeal carcinoma.

Radiotherapy (RT) with concomitant chemotherapy (CT) has improved the therapeutic outcome of patients with locally advanced nasopharyngeal carcinoma (LANC). However, the importance of induction CT before definitive therapy is still undefined. Patients (n=59) who had LANC were included in this retrospective study. They received induction CT consisting of cisplatin and docetaxel followed by definitive RT with cisplatin. The median age was 49 years (18-68). All patients were of stages II (15%), III (63%) and IV (22%). Fifty eight patients could receive 3 cycles of CT. Except one patient, there was no grade 3 or 4 toxicity during induction CT. Chemoradiotherapy could be given to 49 patients (83%). Twelve percent of patients had complete response after induction CT and this number had increased to 95% after the completion of the therapy. Objective responses (complete and partial) were 100% after the completion of the therapy. Median follow up time was 29 months. Nine patients had relapse (2 had local only, 4 distant, 3 local and distant). Three patients who had both local and distant relapse died during follow-up. Three year overall and progression free survival rates were 94.9% and 84.7%, respectively. Induction CT with docetaxel and cisplatin is a feasible and tolerable treatment for patients with LANC.

Vitamin D levels in children with recurrent tonsillitis.

AIM: Although recurrent tonsillitis can be the consequence of defects in immune system, the exact etiology of recurrent tonsillitis is not clear. In this study, our aim was to determine the serum vitamin D levels and vitamin D receptor polymorphism among children undergone tonsillectomy due to the recurrent tonsillitis. METHODS: A 106 children undergone tonsillectomy due to recurrent tonsillitis and a 127 healthy children aging between 2 and 12 years were enrolled in this study, to determine serum 25-hydroxyvitamin D level and vitamin D receptor gene polymorphisms (Apa1, Taq 1, fok1). Serum vitamin D level was measured with ELISA (nmol/L) and receptor gene polymorphism was determined by PCR. Vitamin D serum level below 80nmol/L was accepted as insufficient. RESULTS: The average serum vitamin D level was 176±79nmol/L in recurrent tonsillitis group and 193±56nmol/L in control group. There was no significant difference between the groups (p=0.13). In recurrent tonsillitis group, 18% (n=15) of children had their serum vitamin D levels below 80nmol/L. The vitamin D receptor gene polymorphism (APA1, TAQ 1, FOK 1) in each group was compared (AA, Aa, aa, TT, Tt, tt, FF, Ff, ff). There was no significant difference between the two groups. The vitamin D serum levels and receptor sub-genotypes are also compared, and there was no significant difference between the groups. CONCLUSION: There is no difference between the serum vitamin D level and receptor gene polymorphism among children with recurrent tonsillitis and healthy children. But vitamin D insufficiency is more prevalent in children with recurrent tonsillitis group (18%).

A rare complication after transcanalicular dacryocystorhinostomy: tissue necrosis and nasal-cutaneous fistula.

Transcanalicular dacryocystorhinostomy (TCDCR) with diode laser is a minimally invasive technique with good cosmetic results. The reported complication rate is low. In this brief report, the authors describe a patient with tissue necrosis and nasal-cutaneous fistula after TCDCR. A 65-year-old woman attended the authors' clinic 1 month after TCDCR. Examination revealed a large tissue defect and nasal-cutaneous fistula in the medial canthal region. Aspergillus growth was noted in culture specimens taken from the nasal cavity. The patient was treated with intravenous amphotericin B. The treatment resulted in granulation and closure of the defect.

The use of the latissimus dorsi myocutaneous flap in the reconstruction of complex head and neck defects.

OBJECTIVES: To compare and contrast the use of the latissimus dorsi myocutaneous flap in complex head and neck defects requiring major reconstructive surgery with respect to the other reconstruction techniques, and to emphasize the importance of this flap as an life and surgeon-saving reconstruction modality. PATIENTS AND METHODS: In this study, 20 cases (17 males, 3 females; mean age 58.5 years; range 48 to 72 years) of major head and neck operations reconstructed with a latissimus dorsi myocutaneous flap in Istanbul University, Istanbul Medical Faculty, Ear, Nose and Throat Clinic between October 2004 and November 2006 were retrospectively examined. The latissimus dorsi myocutaneous flap was preferred as a primary reconstructive modality in eight of the cases and a secondary reconstructive modality in the remaining 12 cases. The reasons for choosing the latissimus dorsi myocutaneous flap as the reconstructive modality were examined in this study and compared with other reconstruction techniques. RESULTS: Partial flap necrosis was observed in four of the 20 cases. In two of these unsuccessful cases, minor intervention was sufficient to achieve functionally satisfactory results. However, one case with partial flap necrosis was lost due to the uncontrollable primary disease. In the one remaining case who had undergone cranioplasty, partial necrosis of the flap developed after the completion of radiotherapy in the 4th postoperative month. No total flap necrosis was encountered in any of the cases. CONCLUSION: The latissimus dorsi myocutaneous flap is a reconstructive modality with a high success rate and should be considered among reconstruction alternatives.

Significance of the counteracting oxidative and antioxidative systems in the pathogenesis of laryngeal carcinoma.

OBJECTIVE: To evaluate the parameters of oxidative and antioxidative systems in laryngeal carcinoma for their effects on pathogenesis. METHODS: Blood and plasma samples from 30 patients with laryngeal carcinoma were compared with 15 smokers who were otherwise healthy. The tumour tissue samples of the 30 patients were compared with the adjacent non-tumour-bearing mucosal tissue in which carcinoma was ruled out histologically. Although malondialdehyde was used as the main indicator of oxidative stress, superoxide dismutase, glutathione, and catalase activities were accepted as indicators of the antioxidative defense mechanism. RESULTS: Malondialdehyde was significantly higher in the plasma and blood of patients when compared with those of the control group. Glutathione, superoxide dismutase, and catalase activity levels were measured in blood, and these parameters were significantly higher in the control group (p < .001). All results were found to be statistically significant (p < .001). The malondialdehyde level was also found to be significantly higher (p < .01) in the tumour tissue sample. Among the parameters of the tissue antioxidative defense mechanism, superoxide dismutase levels were determined to be significantly higher (p < .001) in the tumour when compared with the levels in adjacent healthy tissue. However, there was no statistically significant difference between the glutathione and catalase activities of the tumour and non-tumour-bearing tissues (p > .05). CONCLUSION: Although the parameters of the oxidative system appear to increase, the antioxidative variants seem to be reduced in laryngeal carcinoma, with one exception: superoxide dismutase has been found in higher amounts in tumour tissue. These results may reflect the effect of oxidative stress in the pathogenesis of laryngeal carcinoma.

Allergic vs nonallergic rhinitis: which is more predisposing to chronic rhinosinusitis?

BACKGROUND: The impact of allergy on chronic rhinosinusitis (CRS) is controversial. OBJECTIVE: To evaluate whether a history of CRS is more prevalent in patients with allergic rhinitis than in those with nonallergic persistent rhinitis. METHODS: A total of 115 patients (78 females; mean age, 31.9 years; age range, 14-64 years) with persistent rhinitis were included in the study. A 7-point analog scale was used to report the severity of individual and global CRS symptoms and to determine the impact of rhinosinusitis symptoms on quality of life. The allergic status of the patients was evaluated using skin prick tests for common inhalant allergens, and asthma was evaluated by means of history, physical examination, and respiratory function tests. Rhinoscopy and paranasal sinus computed tomography were used to determine CRS. RESULTS: Asthma and CRS were not significantly different in allergic and nonallergic patients. Nasal polyps were found equally in both groups (8 patients). However, mean Lund-Mackay staging scores, postnasal drainage, dental pain, and global CRS scores were significantly higher in patients with nonallergic rhinitis (P = .045, P = .001, P = .02, and P = .01, respectively). No significant correlations, except for dental pain (correlation coefficient, 0.250; P = .008), were found between Lund-Mackay scores and CRS symptoms. In rhinoscopy, the only conspicuous difference was nasal purulence in allergic patients (P = .002). CONCLUSION: Allergic and nonallergic rhinitis may contribute similarly to the development of CRS.

[Reconstruction of the head and neck with free osteoseptocutaneous flap in elderly heavy smokers]. / Agir sigara içici yasli hastalarin bas-boyun rekonstrüksiyonunda serbest osteoseptokutan flep uygulamalari.

OBJECTIVES: We evaluated complications of free flap reconstruction following oncological head and neck surgery in elderly patients who smoked heavily. PATIENTS AND METHODS: The study included eight patients (2 females, 6 males; mean age 68.5 years; range 65 to 74 years) over 65 years of age, who smoked heavily (at least 1 pack/day). All cases but one with mandibular ameloblastoma had intraoral squamous cell carcinoma. Two patients underwent reconstruction with free radial forearm osteoseptocutaneous flap following bilateral maxillary resection, and six patients with free fibular osteoseptocutaneous flap following mandibular resection. Postoperative complications, in particular those associated with the donor and recipient sites were evaluated. RESULTS: No partial or total flap loss was observed. Wound healing problems were seen in three patients (37%), which were at the donor site in two patients, and at the recipient site in one patient. Psychogenic disorders were observed in two patients (25%). No other complications were encountered. CONCLUSION: Aside from some recipient- and donor-site-related healing problems, heavy smoking and advanced age cannot be regarded as contraindications for free flap reconstruction.

Oncological results of surgical treatment of malignant tumors of the nasal vestibule.

OBJECTIVES: We evaluated functional results of surgical treatment for squamous cell carcinoma of the nasal vestibule. PATIENTS AND METHODS: A retrospective review of 2,763 patients treated for head and neck cancers between 1991 and 2000 revealed 10 cases of nasal vestibule tumors, with an incidence of 0.36%. All the patients were males with a mean age of 64.8 years (range 58 to 72 years). Based on the classification system of the AJCC 1992 for skin cancers, and the UICC classification for neck metastasis, three patients had T2, three patients had T3, and four patients had T4 tumors. Lymph node metastasis was present in three patients. Nine patients were treated with surgery as the primary treatment. One patient underwent surgical salvage following radiotherapy failure. The mean follow-up period was 3.65 years (range 6 months to 12 years). RESULTS: Three patients with metastatic neck disease and four patients with advanced tumors underwent radical neck dissection and selective supraomohyoid neck dissection, respectively. Seven patients underwent reconstruction with paramedian forehead flap (n=3), nasolabial flap (n=2), aural composite graft, or split thickness flap. Including the one with radiotherapy failure, two patients died within the first postoperative year due to local and neck recurrences. Another patient died in the postoperative third year due to metastatic squamous cell carcinoma of the lung. No cosmetic or functional complaints were observed in patients with early stage lesions. Two patients with advanced tumors had nasal ventilation problems and a secondary revision procedure was required in one. CONCLUSION: Surgery is a successful therapeutic modality for carcinoma of the nasal vestibule, especially when applied in conjunction with proper reconstruction techniques and, when necessary, neck dissection procedures.

Malignant peripheral nerve sheath tumor of the parotid gland.

Malignant peripheral nerve sheath tumors originating from the parotid gland are extremely rare. A 76-year-old male patient underwent an incisional biopsy for an ulcerated mass in the anteroinferior aspect of the left auricle. The diagnosis was made as malignant mesenchymal tissue sarcoma, but the patient refused treatment. Upon progressive growth of the mass within two months, he underwent a partial parotid gland resection. After three months, he was referred to our clinic with an aggressively growing parotid mass. Total parotidectomy and radical neck dissection were performed. Histopathological diagnosis was malignant peripheral nerve sheath tumor. Following radiotherapy, he has been under follow-up for five years.

Cricohyoidoepiglottopexy vs near-total laryngectomy with epiglottic reconstruction in the treatment of early glottic carcinoma.

OBJECTIVE: To compare functional and oncological outcomes of cricohyoidoepiglottopexy (CHEP) and near-total laryngectomy with epiglottic reconstruction (NTLER) techniques in early glottic carcinoma. DESIGN: Case series, clinical study. SETTING: Two tertiary care referral centers. PATIENTS: Seventeen patients with T1b glottic squamous cell carcinoma were treated with CHEP and 21 were treated with NTLER. MAIN OUTCOME MEASURES: Fundamental frequency, maximum phonation time, maximum phonation intensity, Voice Handicap Index, and GRBAS (grade, roughness, breathiness, asthenia, and strain) scale were used to evaluate voice. Nasogastric tube removal times and late postoperative aspiration scales were used to evaluate swallowing ability. RESULTS: Fundamental frequency (P=.78), maximum phonation time (P=.44), and maximum phonation intensity (P=.94) measurements were not significantly different in the 2 groups. There was also no significant difference in mean Voice Handicap Index score (P=.62), mean decannulation time (P=.25), time to nasogastric tube removal (P=.12), or clinical grades of late postoperative aspiration (P=.87) between the 2 groups. The mean Voice Handicap Index score was 55.58 in the CHEP group and 52.78 in the NTLER group. According to the GBRAS scale, overall voice quality was moderately altered in both groups. All patients were successfully decannulated. In the CHEP and NTLER groups, the mean decannulation times were 27 and 20 days, respectively, and the nasogastric tubes were removed after an average of 23 and 17 days. The overall (Kaplan-Meier) survival rate was 94% in the patients who underwent CHEP and 90% in the patients who underwent NTLER (P=.76). The disease-free survival rates were 100% and 76% in the CHEP and NTLER groups, respectively (P=.07). CONCLUSIONS: Functional and oncological results appear to be similar with both treatment methods. If open surgery is planned, the choice between these procedures mainly depends on the experience and preference of the surgeon.