Efficacy of S53P4 Bioactive Glass for the Secondary Obliteration of Chronically Discharging Radical Cavities.

Objective: Present the results of the secondary obliteration of chronically discharging radical cavities using S53P4 bioactive glass (BAG). Study Design: Retrospective cohort study. Setting: Single-center study. Methods: A single-center retrospective cohort study was conducted of all patients that underwent secondary obliteration of persistently draining radical cavities using S53P4 BAG between 2011 and 2022. Patients with middle ear cholesteatoma were excluded. The main outcome was postoperative otorrhea, as indicated by Merchant grading. Results: In total, 97 patients were included. The median postoperative follow-up time was 3.9 years (range 0.5-10.4). Average time between the original canal wall down surgery and the secondary obliteration was 25.3 years (SD 11.7, range 2-66). At the most recent follow-up visit, a Merchant grade of 0 to 1 was observed in 95% of the cases. There were no cases of sensorineural hearing loss or facial palsy, one case developed a retro auricular skin defect and 1 patient developed CSF leakage. Minor complications were seen in 10 patients (10%). Ossicular chain reconstruction with a titanium prosthesis was performed in 42 cases, resulting in a median improvement of 11.2 dB in air conduction thresholds. In 9/42 cases (21%), closure of the postoperative air-bone gap to ≤20 dB was achieved. Twenty-five percent of cases could be discharged from out-patient visits. Conclusion: Revision of persistently draining radical cavities with BAG obliteration is feasible and results in a dry and safe ear in 95% of the patients, thereby enabling wearing of a conventional hearing aid. Out-patient visits could be ceased in 25% of the cases.

Cholesteatoma surgery in the pediatric population: remaining challenges in the era of mastoid obliteration.

PURPOSE: To present the first pediatric study on the safety and efficacy of mastoid obliteration using S53P4 bioactive glass (BAG) for cholesteatoma surgery. METHODS: A single-center retrospective cohort study was conducted. Inclusion criteria were pediatric cases (≤ 18 years) and at least at least one year of follow-up including non-echo planar diffusion-weighted MRI to assess cholesteatoma recidivism. Both canal wall up (CWU) and canal wall down (CWD) procedures were evaluated. RESULTS: A total of 61 cases (56 patients) were included. Most cases had an otologic history before the development of the cholesteatoma. CWU procedure was performed in 18 cases (30%) and CWD procedure in 43 cases (70%). The cholesteatoma recidivism rate was 33% after a mean follow-up period of 58 months. Kaplan-Meier curve estimated a 5-year recidivism rate of 40%. Few complications were seen that were all minor and resolved spontaneously or after local or systemic treatment. Control of the infection (merchant grade 0-1) was achieved in 98% of the cases. Closure of the air-bone gap within 20 dB was achieved in 22% of the cases with complete audiometric evaluation. CONCLUSION: In this MRI-controlled study, we show the safety and efficacy of S53P4 BAG for mastoid obliteration in a pediatric cholesteatoma cohort. Postoperative complications were both rare and minor, and a dry ear was achieved in almost all patients. Nevertheless, persistent hearing loss and the apparent high recidivism rate reflect the challenging nature of pediatric cholesteatoma.

Mastoid Obliteration Using S53P4 Bioactive Glass in Cholesteatoma Surgery: A 10-Year Single-Center Experience in 173 Adult Patients with Long-Term Magnetic Resonance Imaging Controlled Follow-up.

OBJECTIVE: To present the long-term outcomes of mastoid obliteration in cholesteatoma surgery using S53P4 bioactive glass (BAG) in an adult population. STUDY DESIGN: Retrospective cohort study. SETTING: Single-center study. PATIENTS: All 173 adult patients who underwent primary or revision surgery for cholesteatoma with mastoid obliteration using S53P4 BAG with at least 1 year of follow-up including nonecho planar diffusion-weighted magnetic resonance imaging (MRI) (non-EP DWI MRI) and/or second-look surgery to evaluate recidivism. Both canal wall up (CWU) and canal wall down (CWD) procedures were included. INTERVENTIONS: Patients underwent CWU or CWD mastoidectomy using S53P4 BAG. MAIN OUTCOME AND MEASURES: Cholesteatoma recidivism, postoperative complications, Merchant grade, hearing outcome. RESULTS: Cholesteatoma recidivism was assessed by MRI in 97% of all cases and second-look surgery look surgery in 3% of cases. After a mean follow-up period of 53 months, cholesteatoma recidivism was seen in 10% of the cases (n = 18). Using the Kaplan-Meier curve to extrapolate, a 5-year recidivism rate of 12% was estimated. Only minor complications occurred, all resolving spontaneously or after minor treatment. Merchant grade of 0 to 1 was achieved 95% of the patients, no persistently wet ears were observed. Closure of the air-bone gap within 20 dB was possible in 32%. CONCLUSION: In this long-term (up to 10 yr) follow-up study, we demonstrated the safety of S53P4 BAG. Minimal and only minor postoperative complications were observed. The effectiveness of BAG was indicated by the low rate of recidivism, even when using non-EP DWI MRI, a sensitive and specific noninvasive technique to detect cholesteatoma recidivism.

Surgical Treatment of Chronic Parotitis

Abstract Introduction chronic parotitis (CP) is a hindering, recurring inflammatory ailment that eventually leads to the destruction of the parotid gland. When conservative measures and sialendoscopy fail, parotidectomy can be indicated. Objective to evaluate the efficacy and safety of parotidectomy as a treatment for CP unresponsive to conservative therapy, and to compare superficial and near-total parotidectomy (SP and NTP). Methods retrospective consecutive case series of patients who underwent parotidectomy for CP between January 1999 and May 2012. The primary outcome variables were recurrence, patient contentment, transient and permanent facial nerve palsy and Frey syndrome. The categorical variables were analyzed using the two-sided Fisher exact test. Alongside, an elaborate review of the current literature was conducted. Results a total of 46 parotidectomies were performed on 37 patients with CP. Neartotal parotidectomy was performed in 41 and SP in 5 cases. Eighty-four percent of patients was available for the telephone questionnaire (31 patients, 40 parotidectomies) with a mean follow-up period of 6,2 years. Treatment was successful in 40/46 parotidectomies (87%) and 95% of the patients were content with the result. The incidence of permanent and transient facial nerve palsy was 0 (0%) and 12 (26.1%), respectively. Frey syndrome manifested in 20 (43.5%) patients. Neither this study nor careful review of the current literature resulted in evident difference between SP and NTP regarding the primary outcome variables. Conclusion parotidectomy is a safe and effective treatment for CP in case conservative therapy fails. There is no evidence of a distinct difference between SP and NTP regarding efficiency, facial nerve palsy or Frey syndrome. (AU)

Surgical Treatment of Chronic Parotitis.

Introduction chronic parotitis (CP) is a hindering, recurring inflammatory ailment that eventually leads to the destruction of the parotid gland. When conservative measures and sialendoscopy fail, parotidectomy can be indicated. Objective to evaluate the efficacy and safety of parotidectomy as a treatment for CP unresponsive to conservative therapy, and to compare superficial and near-total parotidectomy (SP and NTP). Methods retrospective consecutive case series of patients who underwent parotidectomy for CP between January 1999 and May 2012. The primary outcome variables were recurrence, patient contentment, transient and permanent facial nerve palsy and Frey syndrome. The categorical variables were analyzed using the two-sided Fisher exact test. Alongside, an elaborate review of the current literature was conducted. Results a total of 46 parotidectomies were performed on 37 patients with CP. Near-total parotidectomy was performed in 41 and SP in 5 cases. Eighty-four percent of patients was available for the telephone questionnaire (31 patients, 40 parotidectomies) with a mean follow-up period of 6,2 years. Treatment was successful in 40/46 parotidectomies (87%) and 95% of the patients were content with the result. The incidence of permanent and transient facial nerve palsy was 0 (0%) and 12 (26.1%), respectively. Frey syndrome manifested in 20 (43.5%) patients. Neither this study nor careful review of the current literature resulted in evident difference between SP and NTP regarding the primary outcome variables. Conclusion parotidectomy is a safe and effective treatment for CP in case conservative therapy fails. There is no evidence of a distinct difference between SP and NTP regarding efficiency, facial nerve palsy or Frey syndrome.

18F-NaF PET/CT imaging of bone formation induced by bioactive glass S53P4 after mastoid obliteration.

PURPOSE: Bioactive glass has been successfully used for surgical treatment of chronic infections in bone and bone cavities. Besides infection control, new bone formation is induced by the bioactive glass which is considered to have osteoconductive properties. Evaluation of postsurgical changes after bone graft surgery is generally performed with conventional radiographs or CT/MR imaging, but 18F-NaF PET/CT might be more suitable since it has a high and rapid bone uptake, accompanied by a fast blood clearance leading to a high bone to background ratio. CASE: Obliteration with S53P4 bioactive glass of the mastoid and middle ear was performed in a patient suffering from chronic otitis media. Control of the chronic otitis media was achieved, and follow-up imaging after 3 years with 18F-NaF PET/CT showed increased uptake in the obliterated cavity indicating new bone formation. CONCLUSION: 18F-NaF PET/CT is able to detect new bone formation after obliteration of the mastoid with S53P4 bioactive glass.

Mastoid obliteration with S53P4 bioactive glass in cholesteatoma surgery.

CONCLUSION: Evaluation of the follow-up of 67 patients shows that S53P4 bioactive glass (BAG) granules are safe and effective as obliteration material in cholesteatoma surgery. OBJECTIVES: To investigate the safety and efficacy of mastoid obliteration using S53P4 BAG in cholesteatoma surgery. Clinical outcomes were infection control (Merchant's grading), cholesteatoma recidivism, and audiometric performance. METHODS: Retrospective follow-up study at the Diakonessenhuis, Utrecht, the Netherlands. Eighteen young (age <17 years) and 49 adult (age ≥17 years) patients treated for cholesteatoma underwent tympanomastoidectomy with mastoid obliteration using S53P4 BAG in the period 2012-2015. Outcome was monitored with clinical otoscopy, otorrhea incidence measurement (Merchant's grading), DW-MRI, and audiographic performance analyses (pure tone average and air bone gap). RESULTS: During the follow-up period (mean = 22 months; range = 12-54 months) cholesteatoma recidivism was observed in 6% of the patients (four ears), mostly in young patients (three ears). An acceptably dry ear (Merchant grade 0-1) was achieved in 96% of all cases. The remaining 4% of cases scored a Merchant grade 2. Overall, both air conduction thresholds and air bone gap were slightly lowered when comparing post-operative values to pre-operative values and significantly in the case of ossicular reconstruction. In none of the patients (0%) did post-operative wound infections occur.

[Hypoxaemia and bradycardia in children during guillotine adenotonsillectomy without intubation]. / Hypoxemie en bradycardie bij kinderen tijdens adenotonsillectomie volgens Sluder zonder intubatie.

OBJECTIVE: To study the incidence of hypoxaemia and bradycardia in children who undergo guillotine adenotonsillectomy in a sitting position, without intubation and under inhalation anaesthesia. DESIGN: Retrospective study. METHOD: Analysis of age, weight, sex, oxygen saturation, heart rate and subsequent bleeding in all children up to the age of 11 years who underwent guillotine adenotonsillectomy in the period December 1999 to December 2007. Hypoxaemia was defined as oxygen saturation of less than 85% for longer than 60 s. Bradycardia was defined as a heart rate of less than 60/min for longer than 30 s. RESULTS: We analysed data from 2963 patients. The mean age was 4.7 years and mean weight 18.8 kg. There was no significant relationship between age, weight and the onset of incidental desaturation or bradycardia. A total of 132 patients (4.5%) had hypoxaemia and 280 patients (9.4%) had bradycardia. Twenty-five patients had both hypoxaemia and bradycardia, of whom 3 (0.1%) had bradycardia immediately following hypoxaemia. In none of the recorded episodes of hypoxaemia and bradycardia did this lead to peri- or postoperative complications. CONCLUSION: Hypoxaemia and bradycardia occurred during guillotine adenotonsillectomy in non-intubated children in a sitting position under inhalation anaesthesia. The simultaneous onset of hypoxaemia and bradycardia is rare, however, and does not lead to perioperative complications. A further study is required using adenotonsillectomy with a large number of intubated and non-intubated children in order to compare the incidence of hypoxaemia and bradycardia and the occurrence of complications.

Donor site morbidity of the fasciocutaneous radial forearm flap: what does the patient really bother?

The objective of this study was the evaluation of donor site morbidity in head and neck cancer patients after reconstruction using a free vascularized radial forearm flap with emphasis on subjective complaints. Fifty patients who underwent at least 6 months before a reconstruction using a free vascularized radial forearm flap were asked to fill out two questionnaires regarding cosmetics and sensibility and forearm disabilities. Furthermore, a function test including movement extensions (flexion-extension, ulnar-radial deviation and pronation-supination), strength (pinch and grip) and temperature (digiti I and V) of the donor and non-donor site were measured and compared. Thirty-five percent of the patients reported no complaints regarding cosmetics and sensibility and 75% mentioned no forearm disabilities. There was no difference in movement extensions, temperature and grip strength between donor and non-donor sites. The difference in pinch strength appeared to be significant (p < 0.001). The total score of the questionnaire on forearm disabilities correlated significantly with extension, pronation and grip strength of the donor arm. Donor site morbidity of the radial forearm flap measured by objective functional tests was limited but subjective self-ratings revealed complaints regarding cosmestics and sensibility and to a lesser extent regarding forearm disability. The present data may be used for solid patient counselling.

Evaluation of donor site function and morbidity of the fasciocutaneous radial forearm flap.

OBJECTIVE: To assess the results of the use of the free radial forearm flap in terms of objective morbidity and subjective patient response. STUDY DESIGN: The donor sites were examined from 37 patients who underwent reconstruction with a free fasciocutaneous radial forearm flap in the head and neck after ablative tumor surgery. METHODS: Patients were asked to fill in a written questionnaire. The following additional tests were performed: resting skin temperature of digits I and V, temperature after submersion in iced water, grip and pinch tests, and goniometry. RESULTS: Resting skin temperature was slightly decreased for donor hands 0.69 degrees C (P < .001) and 0.31 degrees C (P = .048) for digits I and V, respectively, but recovery after submersion in iced water showed no differences. The strength tests and goniometry revealed no statistically significant findings between donor and control sides. On the questionnaire, 9 patients (24%) reported slightly impaired function, 14 (38%) could not wear their watch or bracelet, 17 (46%) reported numbness, 5 (14%) reported soreness, 5 (14%) reported itching, 6 (16%) reported cold intolerance, 5 (14%) reported bad cosmetic appearance, and 9 (24%) expressed the opinion that they were insufficiently counseled. CONCLUSION: There is a negligible objective morbidity of a free radial forearm flap harvest procedure, but a number of patients have subjective complaints when asked. Elaborate presurgical counseling can probably reduce these complaints.

Severe atherosclerosis of the radial artery in a free radial forearm flap precluding its use.

The free radial forearm flap is the most frequently used free flap for head and neck reconstructions. Survival of free flaps is dependent on adequate blood supply. A 69-year old woman was scheduled for excision of a T3N0M0 oropharyngeal carcinoma, neck dissections and reconstruction with a free vascularized radial forearm flap. During the operation it appeared that the entire radial artery was almost completely obstructed by atherosclerotic plaques precluding microvascular anastomosis. Despite systemic risk factors certain artery types are more prone to develop clinically manifest atherosclerosis. There are no reports on the pathology of the radial artery in free flap reconstructions. In head and neck cancer patients severe atherosclerosis of the radial artery is very rare, but if present makes free radial forearm flap reconstruction impossible. Therefore, in patients with risk factors for peripheral vascular disease screening for radial artery stenosis should be considered.

Comorbid condition as a prognostic factor for complications in major surgery of the oral cavity and oropharynx with microvascular soft tissue reconstruction.

BACKGROUND: Identification of factors, especially comorbidity, that affect the incidence and severity of complications in head and neck cancer patients. METHODS: One hundred patients with an oral/oropharynx carcinoma undergoing composite resection and microvascular soft tissue transfer were analyzed. Patient data and tumor and treatment factors were recorded. Comorbidity was graded by an Adult Comorbidity Evaluation 27 (ACE-27) test. Postoperative complications were scored according to their severity. RESULTS: Comorbidity score ACE-27 grade 2 or higher was present in 47% of patients, whereas 33% had a clinically important complication develop. A comorbidity score of ACE-27 grade > or =2 was a strong predictor for complications (p <.001). There were no other predictors for postoperative complications. CONCLUSIONS: Comorbidity is of great importance for prediction of postoperative complications in head and neck cancer patients, especially an ACE-27 grade > or =2. It may be concluded from these results that prevention of complications should focus on comorbidities.

Larynx preservation surgery for advanced posterior pharyngeal wall carcinoma with free flap reconstruction: a critical appraisal.

To report the functional and oncologic results of larynx preservation surgery with free flap reconstruction for posterior pharyngeal wall carcinoma. Retrospective medical chart review. Tertiary care referral center. We present a series of seven patients, who were treated for an advanced stage posterior pharyngeal wall carcinoma between 1995 and 1998. All patients underwent posterior pharyngectomy with larynx preservation via a suprahyoidal approach for carcinoma of the posterior pharyngeal wall, with radial forearm free flap reconstruction. Complications occurred in three patients with grade 3 comorbidity, one of whom suffered flap loss. After a mean follow-up of 48 months, three patients are alive without disease. One patient is alive with a second primary tongue carcinoma. Two patients died of disease, whereas one patient died of another cause. All patients could be decannulated and maintain their voice. Six out of seven patients were able to take oral nutrition, although four patients needed additional PEG-tube feeding. Posterior pharyngectomy with larynx preservation and radial forearm free flap reconstruction is feasible in selected patients, with acceptable functional results and survival. However, the patient must be aware of the risk of chronic aspiration and the possibility of long-term PEG feedings.

Reinfusion of unprocessed, granulocyte colony-stimulating factor-stimulated whole blood allows dose escalation of 186Relabeled chimeric monoclonal antibody U36 radioimmunotherapy in a phase I dose escalation study.

PURPOSE: In an earlier Phase I radioimmunotherapy (RIT) study with rhenium-186-labeled chimeric monoclonal antibody (cMAb) U36 in patients with refractory head and neck squamous cell carcinoma, the maximum tolerated activity was established at 1.0 GBq/m2, at which bone marrow doses ranged from 0.7 to 1.1 Gy. In the present study, further dose escalation in RIT was evaluated using a facile method of reinfusion of granulocyte colony-stimulating factor (G-CSF)-stimulated unprocessed whole blood. EXPERIMENTAL DESIGN: Nine patients with recurrent or metastatic head and neck squamous cell carcinoma were treated at radiation dose levels of 1.0, 1.5, and 2.0 GBq/m2. Before RIT, G-CSF (10 microg/kg/day) was administered s.c. at home during 5 days. On day 6, just before administration of 186Relabeled cMAb U36, 1 liter of whole blood was harvested and kept unprocessed at 4 degrees C until reinfusion after 72 h. Blood samples were taken for analysis of pharmacokinetics and bone marrow dosimetry. Patients were evaluated for myelotoxicity and tumor response. RESULTS: Blood harvesting, RIT, and reinfusion of whole blood were well tolerated by all patients. G-CSF stimulation resulted in a mean of 0.41 x 10(6) CD34+ cells/kg (range, 0.15-0.83 x 10(6) CD34+cells/kg) and a mean committed colony-forming units granulocyte macrophage count of 5.62 x 10(4)/kg (range, 0.62-13.37 x 10(4)/kg). The mean biological half-life of 186Relabeled cMAb U36 in blood was 72.6 +/- 16.0 h, and bone marrow doses ranged from 2.1 to 2.8 Gy at the highest dose level. Myelotoxicity exceeding grade 3 was not observed. Stable disease was observed in five of nine patients, ranging from 3 to 5 months, and was still ongoing in one of these patients. CONCLUSIONS: This study indicates that a doubling of the maximum tolerated activity and bone marrow dose of 186Relabeled cMAb U36 can be achieved using reinfusion of G-CSF-stimulated unprocessed whole blood.