Lateral-arm free flap for reconstruction in the head and neck.

OBJECTIVE: To describe the role of the lateral-arm free flap in reconstruction of head and neck defects following ablative oncologic surgery and to discuss the anatomy of this flap as well as indications for its use. DESIGN: A prospective study of all patients undergoing a lateral-arm free flap was performed. Up to 3 years of follow-up was obtained. SETTING: Tertiary referral centre. METHOD: A total of 12 lateral-arm free flaps were utilized to reconstruct defects ranging in size from 4 x 7 to 10 x 7 cm. Maximum width of the flap was 7 cm. A mean area of 55 cm2 was harvested. MAIN OUTCOME MEASURES: Flap survival, morbidity, speech intelligibility, and oral function and intake were assessed. RESULTS: The vascular pedicle was reliable with vessel diameters of 1.5 mm, and length of 6 to 7 cm. All flaps survived, and minimal donor site morbidity was encountered. Nine patients maintained good speech with adequate intelligibility while 10 patients maintained adequate oral intake. CONCLUSIONS: Functional results can be obtained with the lateral-arm free flap. A consistent pedicle of good length and size was found. It is our flap of choice in older, thinner individuals when the width of the donor site is less than 7 cm, which allows for primary closure.

The craniofacial approach to anterior skull base tumors.

The craniofacial approach for resection of tumors of the nose, paranasal sinuses and orbit is well established. The operation must combine good access, sound oncologic resection, and acceptable cosmesis. Many techniques have been described that encompass all of these factors. Usually some sacrifice in cosmesis is inevitable. Most techniques also suggest removal of a plate of bone with subsequent replacement. With the removal of the tumor there is a communication between the nasal chamber and the extradural space (or brain if dura has been resected). This is usually closed with an inferiorly based pericranial flap. We have utilized a technique that hinges the bone flap laterally on the temporalis muscle. This results in the bone flap remaining vascularized. By maintaining a viable vascular bone flap this may allow for better wound healing and a decreased incidence of complications. Furthermore, we describe a technique of a contralaterally-based pericranial flap that is more extensive than the anteriorly based flaps. It may also be inset without fear of vascular compromise. Use of this technique in four patients will be described.

Surgery and postoperative radiotherapy in the management of extensive cancer of the cervical lymph nodes from an unknown primary.

Over a 14-year period, from 1971 to 1985, there were 15 patients referred to the Princess Margaret Hospital in Toronto for postoperative radiotherapy to the cervical lymph nodes following radical neck surgery for metastatic cancer. An intensive investigation failed to yield a primary site in any patient. All of the patients had extensive neck disease with significant indications for postoperative radiotherapy (massive neck nodes, invasion of extra nodal structures or fixation to unresectable adjacent structures). Of this highly selected group of patients with advanced neck disease: 4/15 (27%) died within one year of uncontrolled local disease, a further 2/15 (13%) died within four years of metastatic/recurrent disease, 6/15 (33%) died of intercurrent disease and 3/15 (20%) were alive with at least four years follow-up. Although all patients presented with advanced disease, survival and significant palliation was possible in this select group of patients.

Carotid body tumors: a review.

Carotid body tumors are encountered rarely and can present a difficult surgical problem. We reviewed the records of 16 patients with 19 tumors, who were entered in the Head and Neck Tumour Registry of the University of Toronto. There were no functionally secreting tumors and no patients with metastases. Most tumors were identified pre-operatively by clinical examination and angiography. However, five were found at open biopsy and required a second procedure. The mortality rate was 0 following embolization. One patient suffered a severe CNS complication and one patient a TIA. The major morbidity resulted from cranial nerve palsies in seven out of 16 patients. Recently, we have utilized a new method for resection of these highly vascular tumors that results in less blood loss and an increased ease of removal.

Completion thyroidectomy in the management of well-differentiated thyroid carcinoma.

Completion thyroidectomy is the removal of any thyroid tissue that remains after less than total thyroidectomy. At our center, completion thyroidectomy is used when, on permanent sectioning, a frozen section diagnosis is revised from benign to malignant. We reviewed our experience with completion thyroidectomy to examine its indications and complications. We found that the carcinoma was misdiagnosed in 32 of 244 (13%) of cases. Twenty-five of these were initially designated follicular adenomas. The completion proved to be no more technically difficult than a routine hemithyroidectomy. There was one case of permanent hypoparathyroidism (3%). Transient vocal cord palsy occurred in one patient (3%) and transient hypocalcemia occurred in five patients (15%). Complete recovery occurred in all six of these patients. Focal areas of residual carcinoma were found in 8 of 32 (25%) of glands removed at completion. We found completion thyroidectomy to be a safe procedure with minimal morbidity. We recommend its use in those instances of well-differentiated thyroid carcinoma in which the frozen section diagnosis differs from the permanent section.

Epidermoid cysts of the cranial bones.

Ectodermally derived tissue in ectopic sites is seen in the head and neck. Extracranial dermoid and epidermoid tumors are relatively rare. While most otolaryngologists are familiar with the cholesteatoma of the otic area, not very many are exposed to this lesion in other sites. Those of the cranial bones are even rarer still. These tumors may expand (1) laterally in the cranial bones, (2) externally to present as masses in the scalp or facial region, or (3) internally to involve the intracranial contents. A patient with a frontal bone epidermoid, whose tumor had expanded in all three directions to erode both inner and outer cortex of cranium and laterally to rupture into the frontal sinus, is discussed. The literature is reviewed and the management of these rare masses is discussed.

Management of substernal goitre.

Goitres of the thyroid gland whose major component resides substernally would appear to have a different presentation and management protocol than those goitres that reside mainly in the neck. These goitres, as opposed to their supraclavicular counterparts, usually present with symptoms referrable to compression of the trachea or esophagus. Even in those patients who are asymptomatic, a precise history may elicit pertinent findings. Furthermore, these goitres do not respond to suppression and require surgical removal. The trans-cervical approach is the most desirable, but the surgeon must be willing to enter the chest on that rare occasion. We reviewed the charts of 938 patients undergoing thyroid surgery who were registered in the Head and Neck Tumour Registry of the University of Toronto. Approximately 2.4% of patients had substernal goitres. Their history, pathology and ultimate surgical management will be discussed.

The use of fibrin tissue glue in thyroid surgery: resource utilization implications.

Current hospital resource limitations prompted efforts to shorten the postoperative in-hospital recovery time after thyroid and parathyroid surgery by hastening the removal of wound drains. Thirty patients' wounds were closed with fibrin tissue glue (Tisseel) and sutures. These were retrospectively compared with 30 randomly selected patients undergoing identical procedures and standard suture closures. Mean drainage the first postoperative night was 18 ml in the test group versus 39 ml in the controls. The average times to drain removal were 1.6 days and 2.2 days respectively. The mean test postoperative hospital stay was reduced by 0.9 days in test patients (2.8 days versus 3.7 days). There was no difference in the complication rate between the two groups. Using this technique, significant increases in the efficiency of resource utilization appear to be possible. A randomized prospective trial of fibrin glue versus traditional closure is required at this time to verify the usefulness of fibrin tissue glue in thyroid surgery.

T3N0M0 glottic carcinoma--a failure analysis.

There is at present considerable controversy regarding the appropriate management of a patient who presents with a T3N0M0 glottic carcinoma. This paper presents the results for 141 patients presenting clinically with T3N0M0 glottic carcinoma between 1964 and 1981 and treated with primary radiotherapy reserving surgery for residual or recurrent disease. The actuarial survival for the entire group of patients was 50.5% at 5 yr; 28% of the patients died of glottic cancer. The local relapse-free rate achieved with radiotherapy was higher in female patients (68%) than male patients (41%) (P = 0.04); the local relapse-free rate was higher in males 60 yr of age or older (46%) than in males 59 yr of age or younger (31%) (P = 0.02). Involvement of all three laryngeal regions and initial tracheotomy were associated with a high primary failure rate. Fifty-nine per cent of patients alive at 5 yr retained and intact and functioning larynx. The time up until diagnosis of recurrence and the number of endoscopies required to establish recurrent or residual disease were all assessed with respect to their effects on survival and were shown to have no significant impact. Methods of improving the results of treatment for those patients with a high primary failure rate following radiotherapy are discussed.

The role of surgery in the treatment of squamous cell carcinoma of the nasal vestibule.

A retrospective analysis of 61 patients who were treated for squamous cell carcinoma of the nasal vestibule is presented. The general policy was to treat these carcinomas with radiation therapy, in view of the perception that this leads to a more acceptable cosmetic result. The primary nasal carcinoma was treated by surgery in five patients and by radiation in 56 patients. Surgical salvage of recurrent carcinoma in the nasal vestibule was performed without complications in 12 patients and resulted in local control in seven. Regional node metastases present at the time of diagnosis in two patients were not controlled by combined radiation and surgery. Late-developing regional node metastases were successfully managed by node dissection in three of four patients. The policy of initial treatment of the primary tumor by radiation, reserving surgery for the management of residual or metastatic cancer, resulted in good control rates and cosmesis.

External irradiation for squamous cell carcinoma of the nasal vestibule.

A retrospective analysis of 56 patients who underwent primary external irradiation for squamous cell carcinoma of the nasal vestibule between 1958 and 1983 is presented. The overall 5 year actuarial survival and cause specific survival rates were 64 and 87%, respectively. The 5-year local relapse-free rate after primary irradiation was 80%. Prognostic factors which lowered the local control rate after irradiation included a primary tumor size of 2 cm or more, or involvement of the skin of the ala nasi, columella, lip, cartilage, or bone. Local control was improved in patients who received a tumor dose equivalent to, or greater than, 5500 cGy/25 fractions/5 weeks. Only two patients in whom the primary tumor was controlled developed regional nodal metastases, and elective regional nodal irradiation is not recommended. Four patients (9%) developed significant late morbidity after irradiation. External irradiation is effective treatment for squamous cell carcinoma of the nasal vestibule, and produces high local control and cure rates and good cosmetic results.

Frontal sinusitis--a 10 year experience.

Frontal sinusitis follows upper respiratory infections, sinus trauma, and swimming. Complications, often life threatening, still occur although less frequently than in the pre-antibiotic era. The course of 40 patients admitted to St. Michael's Hospital with a diagnosis of frontal sinusitis between the years 1973-83 is reviewed. The regional complications as well as the surgical procedures required to manage these problems are discussed. The osteoplastic flap with obliteration of the sinus cavity by osteoneogenesis has become the procedure of choice in dealing with most cases of chronic frontal sinusitis.

Expansion of myocutaneous flaps.

The controlled expansion of myocutaneous flaps offers a potential means of increasing their size. The pectoralis major flap was successfully expanded in pigs, giving mean percentage increases in the axial lengths of 32% and widths of 51% over nonexpanded controls. Angiographic and histomorphologic studies of the expanded flaps demonstrated the vascular and histologic changes that resulted. This new surgical technique should prove valuable in extending the field of head and neck reconstruction in man.

The management of severe nasal septal deformities.

Severe septal injuries associated with nasal deformities are a challenge both functionally and esthetically. Serious septal injuries may include comminuted caudal border fractures, septal crushes, and saddling with loss of septal height. These may result from trauma or previous ill-considered surgery. A series of 60 cases involving radical removal of the septum with caudal and dorsal border reconstructions is reviewed. An external approach septorhinoplasty was utilized in the majority of these patients. The anterior septum was usually replaced by straight posterior septum or septal fragments. In a number of cases the septum was replaced by a centre cut of rib cartilage. Upon occasion the upper laternal cartilages were replaced by composite conchal grafts with or without septal replacement. An attempt has been made to evaluate critically the results with a longterm follow-up over a number of years, as regards both functional and esthetic results.

Refinement of the pectoralis major myocutaneous flap.

The pectoralis major myocutaneous flap has become the primary reconstructive flap in head and neck surgery. We have reviewed our experience and describe some modifications of incisions for elevation of this flap which will improve cosmetic results in both male and female patients. The technique for elevation of this flap is reviewed as well as some of the problem areas including the female with a large breast and the elevation of vascularized rib with the myocutaneous flap.

Late post radiation necrosis and fibrosis of the larynx.

Radiation has been used to treat carcinoma of the larynx for some 60 years. We have seen some very late complications of radiation to this region. In this paper we present three patients who had radiation-induced necrosis and fibrosis 13, 19, and 22 years after initial treatment. The problem exists of diagnosing and differentiating perichondritis/fibrosis from recurrent carcinoma. However, many times it is impossible to make this distinction clinically, endoscopically, radiologically, or even pathologically. The pathogenesis, clinical features, and treatment of this rare late complication of radionecrosis and/or fibrosis are presented.

Inverted ductal papilloma of the parotid gland.

A case of inverted ductal papilloma arising in a major salivary gland is reported. To the best of the authors' knowledge, no similar case could be found in the literature. Histologic appearance and cytologic origin of this neoplasm, unique at this site, are discussed.