Immediate postoperative care on high dependency unit or ward following microvascular free tissue transfer: lessons learnt from a change in practice imposed during the COVID-19 pandemic.

The COVID-19 pandemic resulted in sudden changes to the established practice of using the high dependency unit (HDU) for the first night of postoperative care following microvascular free tissue transfer. Patients were managed instead on the head and neck ward. This retrospective case-note review aimed to report outcomes in consecutive patients treated before and during the pandemic, and to reflect on the implications of ward-based rather than HDU care. A total of 235 patients had free tissue transfer between 3 January 2019 and 25 February 2021: 125 before (lockdown 23 March 2020), and 110 during the pandemic (52 ward-managed and 58 HDU-managed). There were subtle case-mix differences during the pandemic, with 92% of ward-treated patients having oral cancers compared with 64% of HDU patients, and 73% of ward patients having a tracheostomy compared with 40% of HDU patients. Ward patients were less likely to receive electrolyte replacement (45% HDU vs 0% ward) and inotropes (12% HDU vs 2% ward). There were fewer returns to theatre for evacuation of a haematoma or re-anastomosis during the pandemic than there were before it. Other than fewer haematoma complications during the pandemic, the nature of complications was similar. In conclusion, the dramatic changes imposed by the pandemic have shown that the ward is a safe place for patients to be cared for immediately postoperatively, and it alleviates the bed pressures experienced in HDU. Careful case selection and clear criteria are required to identify patients who need the HDU.

Outcomes of microvascular composite reconstruction for mandibular osteoradionecrosis.

The aim of this retrospective study was to compare outcomes and reconstruction-related complications in patients receiving a composite free flap reconstruction of the mandible for ORN with those reconstructed for other indications. The records of all patients who underwent composite reconstruction of a mandibular defect at Aintree University Hospital, Liverpool, were reviewed and analysed. Based on radiotherapy exposure and ORN history, the study cohort was divided into three separate case-matched groups. Local wound healing issues were markedly more common in the ORN setting, as was infection and subsequent osteosynthesis plate(s) removal. Free flap survival was similar among all three case-matched groups. Advanced mandibular ORN may be safely and predictably reconstructed with composite free flaps, and that while the rate of local complications is greater than non-irradiated, and non-ORN case-matched controls, the free flap survival rate compares favourably.

Clinical characteristics, treatment intent, and outcome in a consecutive 10-year cohort of oral cancer patients aged 75 years and older.

The prevalence of oral squamous cell carcinoma (OSCC) in the elderly is expected to increase by nearly a third in the next decade. Its management in older patients is potentially more challenging due to their pre-existing medical comorbidities, frailty, reduced life expectancy, and social issues. The aim of this retrospective review was to report on treatment given to patients aged 75 years and over, case mix, and survival. All patients aged 75 years and over who were diagnosed with OSCC in Merseyside between 1 January 2007 and 31 December 2016, and treated with either curative or palliative intent, were included. Their hospital notes were reviewed. Fisher's exact test and Kaplan-Meier analysis were used for data analysis. There were 236 patients (median (IQR) age 81 (78-86) years); 67% were treated curatively and 33% palliatively. Factors associated with palliation included older age, advanced tumour stage, cognitive impairment, and residence in a nursing or residential home. Of the 165 patients who were offered curative treatment, six (4%) declined due to personal or family reasons. Overall survival for palliative patients was 12% at one year and 7% at two years, whereas for patients treated curatively it was 74% at one year, 56% at two years, and 34% at five years. Patients over 85 years of age were less likely to have composite free flaps and postoperative radiotherapy. Perioperative mortality was 2.6%. Improvements in surgical techniques and perioperative management have enabled clinicians to offer treatment with curative intent to older frail patients, and with careful case selection outcomes can be very good.

Health-related quality of life in patients with T1N0 oral squamous cell carcinoma: selective neck dissection compared with wait and watch surveillance.

Management of the neck in patients with clinical T1N0 oral squamous cell carcinoma (SCC) is controversial. The aim of this study was to report the health-related quality of life (HRQoL) in a consecutive group of patients with stage 1 disease at a time closest to two years after primary surgery. Of 216 patients treated between 2007 and 2012 (after excluding early death and regional recurrence), 195 were eligible. HRQoL was measured using the University of Washington quality of life questionnaire version 4. The overall response rate was 65% (126/195). HRQoL outcomes were good, but compared with patients in the wait and watch group, those who had selective neck dissection (SND) had more problems regarding appearance (14% compared with 1%, p=0.008) and pain (19% compared with 6%, p=0.04). Similar trends were seen for shoulder (14% compared with 8%), mood (16% compared with 8%), and speech (5% compared with 1%), and for poorer overall QoL (30% compared with 16%). It is difficult to establish why patients did or did not have neck dissection in a retrospective sample, but it is likely that those who had SND had larger tumours. The findings highlight the impact that SND has on HRQoL in domains such as appearance, pain, speech, swallowing, and chewing. Previous studies on SND have tended to focus on injury to the accessory nerve and shoulder function, but these new data emphasise the need to include other domains in future trials that compare wait and watch, SND, and sentinel lymph node biopsy.

Synovial chondromatosis of the temporomandibular joint with extension into the middle cranial fossa and internal carotid canal.

This report presents the case of an extensive synovial chondromatosis of the temporomandibular joint (TMJ), with extension into the middle cranial fossa, middle ear, and carotid canal. Synovial chondromatosis of the TMJ is rare, particularly when associated with intracranial involvement. This case is unique owing to its size and the involvement with the internal carotid artery. The importance of a multidisciplinary approach in the surgical management of such a rare and complex form of this condition is highlighted.

Health related quality of life following the treatment of oropharyngeal cancer by transoral laser.

In 2006, our Institution changed the treatment strategy for small volume primary oropharyngeal tumours to transoral laser microsurgery (TOLM). The main aim of this cohort study was to report the health related quality of life (HRQOL) at around 2 years following TOLM in consecutive patients treated from July 2006 through April 2013. The University of Washington Quality of Life (UW-QOL) questionnaire was administered annually up to Spring 2014 and adjusting for mortality the overall response rate was 71 % (108/153). Tonsil primary site characterised 60 % (98) of patients, base of tongue 25 % (40), soft palate 13 % (21) and others 2 %, (3). Most patients had TOLM, neck dissection and adjuvant radiotherapy, with 21 % (34) of tumours at stage 1 or 2, 25 % (40) at stage 3 and 54 % (88) at stage 4. Kaplan-Meier estimates of overall survival were 94 % at 1 year, 88 % at 2 years and 68 % at 5 years after TOLM. Three-quarters (76 %) reported their overall QOL as being good, very good or outstanding, and by domain a clear majority of patients (range 57-94 %, median 79 %) reported none or only minor problems, most notably for swallowing, chewing and speech. The main dysfunction was in saliva (39 %). In conclusion, the outcomes in TOLM for oropharyngeal squamous cell carcinoma are very encouraging. The data supports the current treatment strategy in the Unit. Further outcomes research is required to help refine patient selection to help optimise the survival and HRQOL benefit of TOLM.

Rationale for the use of the implantable Doppler probe based on 7 years' experience.

In head and neck microvascular reconstruction, a proportion of patients are at a higher risk of flap failure. These include salvage surgery after chemoradiotherapy, reconstruction for osteoradionecrosis and when difficulty is encountered in achieving flap perfusion intraoperatively. Several studies have shown that the Cook-Swartz Doppler (Cook Medical Inc, Bloomington, USA) enabled earlier detection of a compromised flap. We retrospectively reviewed microvascular reconstructions monitored with the Cook-Swartz implantable Doppler (2006-2012) and included patients' characteristics, comorbidity (American Society of Anesthesiologists' (ASA) grade), indication for operation, type of reconstruction, and indication for implantable Doppler. We also included details of surgical exploration, free flap salvage, and outcomes of flap salvage. These outcomes were compared with a group of low-risk patients (2005-2009) whose flaps were monitored clinically. A total of 75 free flaps in 73 patients were monitored with the implantable Doppler: 40 (53%) were in cases which required reconstruction following previous surgery/radiotherapy or flap perfusion difficulties, 10 (13%) buried flaps, 13 (17%) as routine flap monitors and 12 (17%) for other indications. The false negative rate was 5%, sensitivity 67%, the false positive rate was 25%, and specificity was 95%. Higher risk flaps monitored with the doppler had a higher return to theatre rate, 21% compared with 4% (p<0.001) and flap failure rate, 7% compared with 1% (p=0.002). Salvage rates for free flaps were similar in both groups (62% compared with 60%, p=1.0). There is not enough evidence to suggest that the implantable doppler reduces the rate of failed flaps in routine low-risk cases, and its value in monitoring high-risk reconstructions require evaluation in a prospective randomised study.

Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992-2009).

Reconstruction of surgical defects in the head and neck using microvascular free tissue transfer is reliable with success rates in excess of 95%. Our previous audit (1992-1998) showed that 16% of patients required an early return to theatre, and the overall free flap salvage rate was 73%. The medical records of 37 patients who had required early return to theatre (within 7 days) after free tissue transfer were analysed to ascertain the indication for reoperation, and whether surgical intervention had been successful, taking into account the timing and cause of compromise. The results of a retrospective re-audit (1999-2004 and 2005-2009) showed that the return to theatre rate had reduced to 4% overall because of a reduction in the number of cases: those that required evacuation of a neck haematoma, and venous compromise of fasciocutaneous or perforator free flaps. Salvage of flaps was most successful when done within the first 24h, and in cases of venous compromise. Three percent of free flaps failed without attempted salvage; most were late failures. Overall survival (1992-2009) for composite free flaps (93%) was lower than for fasciocutaneous or perforator free flaps (96%). Between 2005 and 2009 our overall free flap survival rate was 98%.

Systematic review of the current evidence in the use of postoperative radiotherapy for oral squamous cell carcinoma.

Improved disease-free survival for oral squamous cell carcinoma (SCC) with the use of postoperative radiotherapy (PORT) has to be balanced against the risk of recurrence, the relative morbidity of radiotherapy, reduced options for treatment, and survival with recurrent disease. In the absence of randomised trials, a review of current evidence is timely because of increasing differences in outcome and response to treatment for cancers of the larynx, oropharynx, and oral cavity. From a search of 109 papers, 25 presented relevant data in tabular form, and reported local, regional, and total recurrence, and overall survival. Most data come from non-randomised studies that compared the effects of interventions with previous or historical information. A summary of the results shows local recurrence of 11%, 17%, and 15% for early, late, and all stages after operation alone, compared with 13%, 16%, and 19% after PORT. Regional recurrence is reported as 13%, 12%, and 11% for early, late, and all stages after operation alone compared with 6%, 11%, and 9% after PORT. Overall survival is reported as 76%, 74%, and 77% for operation alone compared with 65%, 62%, and 62% for early, late and all stages of oral SCC, respectively. It is acknowledged that this is a weak level of evidence as patients who have PORT probably have a high pathological-stage of disease. Knowing that PORT increases morbidity and reduces salvage rates and options for treating recurrent disease, this difference in overall survival emphasises the need for randomised studies or a re-evaluation of our current protocols.

Adjuvant radiotherapy and health-related quality of life of patients at intermediate risk of recurrence following primary surgery for oral squamous cell carcinoma.

Controversy surrounds who should receive adjuvant radiotherapy in patients with intermediate risk of recurrence of oral squamous cell carcinoma following primary surgery. The aim of this study was to compare health-related quality of life (HRQOL) outcomes of those who received adjuvant radiotherapy to those who did not in patients at intermediate-risk of recurrence. A total of 765 oral cancer patients were treated at the Regional Maxillofacial Unit, Liverpool from 1995 to 2007. After excluding 124 patients (87 primary radiotherapy, 23 died within 90 days, 14 had insufficient information for determining risk group status), 169 were low-risk, 271 intermediate-risk and 201 were high-risk. In the intermediate-risk group, 33% had adjuvant radiotherapy. Allowing for attrition, more than 70% had University of Washington quality of life data (UW-QOL). Cumulative survival was similar in those with and without adjuvant radiotherapy in a subset of patients at intermediate risk. There was little difference in overall HRQOL scores and in the socio-emotional subscale scores of the UW-QOL. However, there was a significant difference in physical subscale scores and the issue most affected was saliva. These findings support better stratification of risk in the intermediate group, and the plausibility of withholding radiotherapy without compromising survival. This can have dramatic positive benefits on patient physical outcomes, in particular saliva. Where adjuvant radiotherapy is necessary, it is appropriate to minimise adverse effects through measures such as intensity-modulated radiation therapy.

Tracheostomy tape: more trouble than it's worth?

In many units where microvascular free-tissue transfer in the head and neck region is practised, tracheostomy is completed with the suturing of the tube in place and the removal of the supporting struts from the tube flange. The thinking is that in removing the struts the risk of occlusion of the vascular pedicle of the free flap, as it lies in the neck, is reduced as the cervical tape cannot be applied. The evidence base for vascular obstruction resulting from a correctly positioned tape is lacking. Presented here is a case in which potential flap failure, as a result of a cervical tracheostomy tape, was avoided by early detection of ischaemia using microdialysis.

Chondroradionecrosis of larynx following radiotherapy for metastatic neck disease originating from oral carcinoma.

Chondroradionecrosis of larynx is a rare but serious complication of radiotherapy. Here is described a case of chondroradionecrosis after 20 years of completion of radiotherapy for oral cancer. The patient underwent excision of necrotic anterior skin of the neck, together with devitalized thyroid cartilage and most of the cricoid cartilage, and reconstruction with pectoralis major muscle transposition. This resulted in preservation of laryngeal function, and avoided further exploration of the irradiated neck and possible further skin loss.

Use of Palacos R-40 with gentamicin to reconstruct temporal defects after maxillofacial reconstructions with temporalis flaps.

The temporalis muscle flap is a useful flap for the reconstruction of oral ablative defects. A complication of its use that was overlooked was the crater-like defect created when the muscle is stripped from its attachment on the temporal fossa. The cold-cure acrylic we use is Palacos R-40 with Gentamicin (Heraeus Kulzer GmbH). This material is radio-opaque, rapidly setting and contains gentamicin. We present a total of 41 cases over an 11-year period (1994-2005). We have a 97.6% (n = 40) success rate. Infection developed in only one case, which leads to the removal of the acrylic implant. The use of Palacos R-40 with Gentamicin is easy to use, it can be custom-moulded to fit and fill the defect any of shape and size. It has minimal complications and high success rate with acceptable results to the patients.

Surgical emphysema following dental treatment: two cases.

Surgical emphysema is an uncommon complication of dental treatment despite the frequent use of air-driven handpieces and high-speed water-cooled equipment in dental practice. As a consequence it may either go unrecognized or be misdiagnosed. Although most cases resolve spontaneously, some patients require emergency intervention. This article outlines the condition and its management and describes two cases that arose during routine dental treatment.