Care in the time of coronavirus: Ethical considerations in head and neck oncology.

As COVID-19 continues to challenge the practice of head and neck oncology, clinicians are forced to make new decisions in the setting of the pandemic that impact the safety of their patients, their institutions, and themselves. The difficulty inherent in these decisions is compounded by potentially serious ramifications to the welfare of patients and health-care staff, amid a scarcity of data on which to base informed choices. This paper explores the risks of COVID-19 incurred while striving to uphold the standard of care in head and neck oncology. The ethical problems are assessed from the perspective of the patient with cancer, health-care provider, and other patients within the health-care system. While no single management algorithm for head and neck cancer can be universally implemented, a detailed examination of these issues is necessary to formulate ethically sound treatment strategies.

Head and neck oncology during the COVID-19 pandemic: Reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks.

The COVID-19 pandemic demands reassessment of head and neck oncology treatment paradigms. Head and neck cancer (HNC) patients are generally at high-risk for COVID-19 infection and severe adverse outcomes. Further, there are new, multilevel COVID-19-specific risks to patients, surgeons, health care workers (HCWs), institutions and society. Urgent guidance in the delivery of safe, quality head and neck oncologic care is needed. Novel barriers to safe HNC surgery include: (1) imperfect presurgical screening for COVID-19; (2) prolonged SARS-CoV-2 aerosolization; (3) occurrence of multiple, potentially lengthy, aerosol generating procedures (AGPs) within a single surgery; (4) potential incompatibility of enhanced personal protective equipment (PPE) with routine operative equipment; (5) existential or anticipated PPE shortages. Additionally, novel, COVID-19-specific multilevel risks to HNC patients, HCWs and institutions, and society include: use of immunosuppressive therapy, nosocomial COVID-19 transmission, institutional COVID-19 outbreaks, and, at some locations, societal resource deficiencies requiring health care rationing. Traditional head and neck oncology doctrines require reassessment given the extraordinary COVID-19-specific risks of surgery. Emergent, comprehensive management of these novel, multilevel surgical risks are needed. Until these risks are managed, we temporarily favor nonsurgical therapy over surgery for most mucosal squamous cell carcinomas, wherein surgery and nonsurgical therapy are both first-line options. Where surgery is traditionally preferred, we recommend multidisciplinary evaluation of multilevel surgical-risks, discussion of possible alternative nonsurgical therapies and shared-decision-making with the patient. Where surgery remains indicated, we recommend judicious preoperative planning and development of COVID-19-specific perioperative protocols to maximize the safety and quality of surgical and oncologic care.

Systematic Review of Supraclavicular Artery Island Flap vs Free Flap in Head and Neck Reconstruction.

OBJECTIVE: The aim of this systematic review is to compare the surgical outcomes of supraclavicular artery island flap (SCAIF) and free tissue transfer (FTT) in head and neck reconstruction. DATA SOURCES: PubMed, Web of Science, and EMBASE databases. REVIEW METHODS: Independent screening and data extraction were performed by 2 authors. Only studies that directly compared SCAIF and FTT were included. Data were pooled with random-effects meta-analysis to determine the standardized mean differences (SMDs), risk differences, and 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistics. The Methodological Index for Non-Randomized Studies tool was used to evaluate extent of bias in studies. RESULTS: The initial query yielded 661 results, of which 4 comparative studies remained for final analysis. The pooled sample sizes for the SCAIF and FTT cohorts were 100 and 84, respectively. SCAIF was associated with reduction of operative time by a large effect size (SMD, 1.65; 95% confidence interval, 0.78-2.52). The harvested flap areas and perioperative complications, including rates of total flap loss, partial flap necrosis, and recipient/donor site dehiscences, were comparable between the 2 procedures with low to high heterogeneity among studies. CONCLUSION: SCAIF requires less operative time and has comparable short-term perioperative results to FTT. The findings of this study support the viability of SCAIF as an alternative to FTT and provide evidence for its inclusion in the reconstructive armamentarium of major head and neck ablation and trauma.

Subcutaneous vs intramuscular botulinum toxin: split-face randomized study.

IMPORTANCE Much has been published regarding rejuvenation of the upper face with botulinum toxin A injection; however, the optimal target tissue layer has not been specifically examined. OBJECTIVE To seek a difference between subcutaneous (SC) and intramuscular (IM) administration. DESIGN, SETTING, AND PARTICIPANTS Prospective, randomized study at a tertiary care university facial plastic surgery practice. Nineteen patients who underwent botulinum toxin A treatment to the forehead were randomized so that each patient received IM injection on one side of the face and SC injection on the contralateral side. INTERVENTION Patients were assessed on the basis of eyebrow elevation before treatment, and at 2 weeks, 2 months, and 4 months following injection. Patients also completed a subjective questionnaire examining discomfort during injection, bruising, and tenderness, as well as their perception of their appearance after treatment. MAIN OUTCOME AND MEASURE Eyebrow height measurements between SC and IM techniques. RESULTS There was no difference in eyebrow height measurements between SC and IM techniques (0.00 [95% CI, -0.02 to 0.02]). Patients did report greater discomfort when receiving IM injections compared with SC injections (-0.76 [95% CI, -1.53 to 0.0005]). Patient satisfaction scores did not demonstrate a statistically significant difference between IM and SC techniques when measured on the first and second posttreatment visits; however, there was a trend toward significance on the final follow-up visit. CONCLUSIONS AND RELEVANCE Subcutaneous injection of botulinum toxin A is equally effective in achieving paralysis of the underlying frontalis muscle as IM botulinum toxin A administration. In addition, the SC route may result in less pain to patients receiving botulinum toxin A injection for rejuvenation of the upper face.

Microvascular free tissue reconstruction in the patient with multiple courses of radiation.

OBJECTIVES/HYPOTHESIS: To assess the feasibility of microvascular free tissue transfer in the multiply irradiated patient. STUDY DESIGN: Retrospective cohort analysis of 48 patients in a tertiary care, private practice setting. METHODS: Inclusion criteria were defined as patients who received multiple courses of radiation and underwent subsequent free tissue reconstruction to manage treatment-related complications (n = 24) or defects following additional oncologic surgery (n = 24). The main outcome measures included total and partial flap necrosis, hardware exposure, and pharyngocutaneous fistula. The minimum follow-up was 6 months. RESULTS: One case of total flap failure, two cases of partial skin paddle necrosis, one case of poor wound healing of the surrounding tissue to the flap, six cases of hardware exposure, 11 cases of fistula with eight requiring operative intervention, three cases requiring and additional free flap to supplement reconstruction, and one stroke. CONCLUSIONS: Microvascular free tissue transfer to the head and neck is expected to provide a successful reconstruction in patients who have received multiple courses of radiation and who develop second primary tumors, recurrence of disease, or who suffer from late complications of their radiation therapy.

Reconstruction of the radial forearm free flap donor site using integra artificial dermis.

Autologous skin grafting to the donor site in patients who undergo radial forearm free flap reconstruction (RFFF) is associated with cosmetic and functional morbidity. Integra artificial dermis (Integra Lifesciences, Plainsboro, NJ) is a bovine collagen based dermal substitute that can be used as an alternative to primary autologous skin transplantation of the donor site. We describe a staged reconstruction using Integra followed by ultrathin skin grafting that results in highly aesthetic and functional outcomes for these defects. A retrospective review of 29 patients undergoing extirpative head and neck oncologic resection were examined. Integra graft placement was performed at the time of RFFF harvest followed by autologous split thickness skin grafting at 1 to 5 weeks postoperatively. Healing fully occurred within 4-6 weeks with negligible donor site complications, excellent cosmesis, and minimal scar contracture. Composite reconstruction with Integra artificial dermis offers advantages over traditional methods of coverage for select cases of radial forearm free flap donor site closures.

Parotid gland trauma.

Parotid trauma can lead to both short and long-term complications such as bleeding, infection, facial nerve injury, sialocele, and salivary fistula, resulting in pain and disfigurement. Facial injuries inferior to a line extended from the tragus to the upper lip should raise concern for parotid injury. These injuries can be stratified into three regions as they relate to the masseter muscle. Injuries posing the greatest risk of damage to Stensen's duct include those anterior to the posterior border of the masseter and necessitate exploration. When the duct is disrupted, emphasis should be placed on primary repair or re-creation of the papilla; however, proximal ductal lacerations can be treated by ligation of the proximal segment. Isolated parenchymal injury can be treated with more conservative means. Sialocele and salivary fistula can frequently be managed nonoperatively with antibiotics, pressure dressings, and serial aspiration. Anticholinergic medications and the injection of botulinum toxin represent additional measures before resorting to surgical therapies such as tympanic neurectomy or parotidectomy.