Free-flap reconstruction methods in head-and-neck oncologic surgery: A CROSS practice survey of members of the French GETTEC Head-and-Neck Tumor Study Group.

OBJECTIVE: To survey practices concerning the use of anticoagulants and antiplatelets in microvascular free-flap reconstruction following oncological surgery of the head and neck. METHODS: A survey of practices was carried out between September 2022 and March 2023. An online questionnaire was sent to members of the French GETTEC Head-and-Neck Tumor Study Group in all French centers practicing head-and-neck cancer surgery with reconstruction using microvascular free-flaps. The questionnaire asked surgeons about their practices regarding the use of intra- and postoperative anticoagulants and antiplatelets, preoperative management of comorbidities, and prevention of postoperative complications. RESULTS: Sixty-one percent of the 38 respondents (23/38) used intraoperative intravenous heparin injection, associated to flap irrigation with heparin for 76% of surgeons (29/38) and/or a heparin solution bath for 37% (14/38). Postoperative anticoagulation was used by 95% of surgeons (36/38), and antiplatelets by 40% (15/38). Postoperatively, 40% (15/38) carried out monitoring using an implantable micro-Doppler probe, associated to analysis of clinical characteristics of the flap. CONCLUSION: Reconstructive surgery using microvascular free-flaps involves numerous factors that can influence success. Prospective studies, particularly concerning the management of anticoagulants, could enable a national consensus on methods for free-flap reconstruction.

Occult nodal metastases in T1-T2cN0 oral squamous cell carcinoma: Correlation between sentinel node positivity and completion neck dissection analysis.

OBJECTIVES: Sentinel node procedure (SN) is a standard procedure that has shown its safety and effectiveness for T1/T2 cN0 oral squamous cell carcinoma (OSCC), with completion neck dissection (CND) for patients with positive SN. The aim of this study was to characterize the nodal involvement in a cohort of SN + OSCC. MATERIALS AND METHODS: Patients with T1/T2 cN0 OSCC with positive SN with CND were included in this single-center, prospective cohort study between 2000 and 2013. RESULTS: 54/301 patients had at least one positive SN. In 43/54 (80 %) cases, only the SN(s) were invaded; with only one SN involved (SN+=1) in 36/54 (67 %) cases. No predictive factors of nodal involvement in the CND were found considering the followings: SN micro/macrometastases, primary tumor's depth of invasion (DOI), perineural spread, lymphovascular involvement, primary tumor location, T stage and extranodal extension. The SN micrometastatic involvement (n = 22) was significantly associated with only one SN + CND- (p = 0.017). In the group of patients with unique micrometastatic involvement in the SN (n = 20/54), there was a higher isolated nodal recurrence free time (p = 0.017). CONCLUSION: 80% of T1/T2 cN0 OSCC with positive SN had no other lymph node metastases in the CND, questioning the potential benefits of this procedure. Predictive factors such as the size of the SN metastasis need to be tested to stratify the risk of positive non-SN lymph nodes leading to a personalized treatment, lowering the therapeutic morbidity while maintaining the oncologic safety.

Replacement of lip-split mandibulotomy by pull-through approach for T3-4 oral carcinomas.

At the study hospital, the lip-split mandibulotomy (LSM) has progressively been replaced by a pull-through (PT) approach. This study compared the outcomes of the LSM and PT approaches in a series of 192 patients with T3-T4a oral tongue and floor of the mouth squamous cell carcinoma treated over the two last decades. No difference in margin status (P = 0.254), rate of early complications (local infections) (P = 0.867), haematoma/haemorrhage (P = 0.221), delayed wound healing (P = 0.438), re-operation (P = 0.083), or Clavien-Dindo classification (P= 0.5281) was found. The LSM approach was associated with a higher rate of late complications such as pseudarthrosis (14.5% vs 0.9%; OR 17.89, P = 0.0005) and trismus (35% vs 13.8%; OR 3.32, P = 0.025), and a trend towards a higher rate of fistulas (24.6% vs 13.1%; OR 2.16, P = 0.088). The quality of life of long-term survivors (median 132 months) was similar in the two groups, with a mean QLQC30 score of 59.7 (P = 0.099) and mean MDADI score of 57.4 (P = 0.213). The 5-year local control rate was 86.4% in the PT group and 86.2% in the LSM group (P = 0.878), while the 5-year overall survival rates were 50.0% and 48.3%, respectively (P = 0.68). In our experience, replacement of LSM by a PT approach in oral carcinoma was associated with decreased rates of late complications such as pseudarthrosis, fistula, and trismus, without any difference in oncological outcomes.

Unusual presentation of a first Branchial cleft cyst associated with an abnormal bony canal -a case report.

BACKGROUND: First branchial cleft anomalies are rare, accounting for only 10% of all branchial cleft anomalies. We report an even more rare and unique case of a branchial cleft cyst with features of both first and second arch derivatives. CASE PRESENTATION: A 6-year-old boy presented to us with a left conductive hearing loss associated with pre-tympanic keratin debris and an ipsilateral painful cervical mass. He had a past medical history of left ear surgery for presumed cholesteatoma 2 years prior and left neck abscess drainage 6 months prior. CT and MRI revealed a lesion originating in the external auditory canal and extending cervically through a bony canal located medial to the facial nerve and terminating as a parapharyngeal cyst. The complete removal was accomplished in one surgical stage consisting of three distinct steps: robotic assisted transoral resection of the pharyngeal cyst, an endaural approach and a parotidectomy approach. CONCLUSION: We believe that our detailed description of this rare first branchial cleft cyst with pharyngeal extension, possibly a hybrid case between a first and second branchial cyst, can serve as a valuable tool to Otolaryngologists - Head and Neck Surgeons who come across a similar unusual presentations.

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group.

BACKGROUND: Cervical spondylodiscitis is a rare but severe complication of pharyngeal surgery. MATERIAL AND METHODS: This multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017. OBJECTIVES: To describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications. RESULTS: Seven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6days. The interval between surgery and spondylodiscitis diagnosis ranged from 20days to 4.5months, for a mean 2.1months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%). CONCLUSION: This French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.

Regulatory aspects of prospective and retrospective clinical research in France in 2018.

In France, the so-called "Jardé law" (named for its proposer) on human research, implemented since 2016, defines the regulatory and legal framework for "prospective" studies, formerly known as "biomedical research" or "common care". Three categories are distinguished: type 1 is at-risk drug or non-drug interventional research, type 2 is low-risk, low-burden interventional research, and type 3 is non-interventional research. The decrees of April 12, 2018 precisely define a list of research categories for types 2 and 3, thereby clarifying the regulatory procedures. The Sponsor registers the trial on the database of the National Drug Safety Agency (ANSM), or the European EudraCT database for drug studies, to obtain an identification number. Regulatory procedures are undertaken with the IRB and ANSM and then the Data Protection Commission (CNIL). Retrospective research on previously collected data (other than genetic) does not come under the Jardé law, and is governed by the 1978 data protection law, updated by the application decree of December 2016 and the law No. 2018-493 of June 20, 2018 on protection of personal data. This article presents a clarification of the key methodologic and regulatory steps.

Assessment of swallowing function after circumferential pharyngolaryngectomy. A multicenter study by the GETTEC group.

OBJECTIVE: Circumferential pharyngolaryngectomy is performed for advanced pharyngeal tumor or in a context of postradiation recurrence. Several free or pedicle flaps have been described for pharyngeal defect reconstruction, with choice at the surgeon's discretion. The aim of this study was to evaluate long-term swallowing function according to the type of flap used for reconstruction. MATERIAL AND METHOD: A multicenter retrospective study was conducted from January to September 2016 within the French GETTEC head and neck tumor study group. All patients in remission after circumferential pharyngolaryngectomy were included and filled out the Deglutition Handicap Index (DHI) questionnaire and underwent swallowing function fiberoptic endoscopy assessment. 46 patients (39 men, 7 women) were included. Reconstruction used a tubularized forearm free flap (FFF group) in 19 cases, pectoralis major myocutaneous flap (PMMF group) in 15 cases and free jejunum flap (FJF group) in 12 cases. RESULTS: Mean DHI was 24: 20 in the FFF group, 23 in the FJF group and 25 in the PMMF group, without significant differences. 27 patients had normal swallowing, 9 mixed diet, 8 liquid diet and 3 were fed by gastrostomy. On endoscopy, free flaps (FJF and FFF) were associated with significantly greater rates of normal swallowing of saliva and yogurt than in the PMMF group (P=0.04). CONCLUSION: Type of flap reconstruction after circumferential pharyngolaryngectomy had no significant impact on postoperative swallowing function assessed on the self-administered DHI questionnaire.

Sentinel node biopsy in early oral squamous cell carcinomas: Long-term follow-up and nodal failure analysis.

OBJECTIVES: Evaluate the reliability of sentinel node biopsy (SNB) in T1/T2 cN0 oral squamous cell carcinoma (OSCC), and compare recurrence-free time (RFT) and overall survival (OS) between patients undergoing SNB and neck dissection (ND). PATIENTS AND METHODS: Patients with T1/T2 cN0 OSCC underwent SNB followed by systematic ND in the first cohort and SNB followed by selective ND in case of positive sentinel nodes (SN) in the second cohort. RESULTS: A total of 229 patients were followed (first cohort 50, second cohort 179). SNs were successfully detected in 93.9% (215/229) of cases. Median follow-up was 5.6 years. Recurrence occurred in 38/215 patients, with isolated nodal recurrence in 18/215 patients. At 5 years, the rate of recurrence-free patients was 80.0% and the rate of patients without isolated nodal recurrence was 90.4%. Negative predictive value of SNB was 92.7%. No statistically significant difference was observed between the two groups regarding RFT and OS. In 83% (10/12) of ipsilateral isolated nodal recurrences, primary tumor was located in anterior part of oral cavity. Only 43% (3/7) of SN+ patients with nodal recurrence were eligible for salvage surgery, compared to 91% (10/11) of SN- patients. SNB resulted in fewer complications than ND (8% vs 28%, p < 0.0001). CONCLUSION: SNB is a reliable staging tool for T1/T2 cN0 OSCC, without adverse effect on patient survival and fewer complications. No late recurrences occurred in long-term follow-up. Close follow-up is mandatory for SN+ patients, who are at higher risk of nodal recurrence and have worse prognosis.

Cervical-transoral robotic oropharyngectomy and thin anterolateral thigh free flap.

The transoral robotic oropharyngectomy surgical technique was initially described for resection of small stage T1 or T2 lesions and the surgical defect is usually allowed to heal by secondary intention. We propose a refined surgical approach adapted to more complex situations such as salvage surgery and surgery in an irradiated field, based on previous experience in open approaches for oropharyngeal cancer. Via a combined cervical-transoral approach, we perform en bloc resection of the parapharyngeal space combined with transoral robotic lateral oropharyngectomy. Reconstruction of the surgical defect is performed with a thin anterolateral thigh free flap.

[The thin ALT perforator flap for oropharyngeal robotic-assisted reconstruction]. / Le lambeau libre perforant antérolatéral de cuisse fin dans les reconstructions oropharyngées robot-assistées.

Since a few years, the transoral robotic surgery reduced the morbidity of oropharyngeal tumors excision. Large posterior tumors can now be removed without any scar visible on the face. In this context and to respect the thinness required for reconstructions at the junction of the upper aerodigestive tract, the free radial forearm flap still remains the solution of choice. However, if the transoral robotic surgery respects the anatomy and the aesthetics of patients at the visible and social area that represents the face, the forearm flap provides visible scars on the other region of social interaction that represents the upper limb. The aim of our work was to prove the feasibility and the benefits in terms of reducing sequelae when using a thin anterolateral perforator flap harvested above the plane of the superficial fascia. We present this new original method in detail and the advantages it offers to patients after surgery.

[Oral cavity cancers among young people: Clinical results and prognostic analysis]. / Cancers de la cavité buccale chez les sujets jeunes: résultats thérapeutiques et analyse de facteurs pronostiques.

PURPOSE: Squamous cell carcinomas of the oral cavity occurring in young people represent a specific entity. Its management and prognosis are controversial. We performed a retrospective chart review of all patients aged less than 40 years old and treated at Gustave-Roussy Cancer Centre for a squamous cell carcinomas of the oral cavity between 1999 and 2011. METHODS: Patients and tumour characteristics, type of treatment and follow-up data were collected. Survival data were analysed according to the methods of Kaplan-Meier and both univariate and multivariate analyses were performed to look for prognostic factors regarding overall survival and progression-free survival. RESULTS: Sixty-three patients were identified. Median follow-up was 64 months. Most of the tumours were initially located in the mobile tongue (n=54, 85.7%). Overall 17 patients had died, including 15 from the treated cancer. Overall and progression-free survival rates at 5 years were respectively 79.6% and 68.6%. The corresponding 5 years local, regional and metastatic relapse free survival rates were 80%, 91% and 89% respectively. In the multivariate analysis only the absence of initial surgery (hazard ratio [HR]: 13.5 [2.0; 90.5]; P=0.007) was prognostic for overall survival, while alcohol abuse (HR: 0.37 [0.15; 0.9]; P=0.03) and the absence of surgery (HR: 13.6 [2.5; 74.2]; P=0.002) were associated with a decreased progression-free survival. A younger age (less than 30 year old) was not associated with the risk of recurrence or death. CONCLUSION: Survival rates and tumour control probabilities are relatively high among young patients suffering from squamous cell carcinomas of the oral cavity treated at a tertiary centre. The early identification of patients at risk of relapse is currently difficult. The balance between recurrence and treatment toxicity warrants further studies, both on the clinical level and for the development of prognostic biomarkers.

Vocal fold mobility as the main prognostic factor of treatment outcomes and survival in stage II squamous cell carcinomas of the glottic larynx.

OBJECTIVE: This study aimed to assess the influence of supra- and subglottic extensions and vocal fold mobility on outcome in a large monocentric cohort of 148 patients treated for tumour-node-metastasis stage T2N0 glottic carcinomas. METHODS: In all, 107 glottic carcinoma patients had normal vocal fold mobility (T2aN0), and 41 had impaired vocal fold mobility (T2bN0). Treatment decisions were made by a multidisciplinary team. RESULTS: Vocal fold mobility was associated with overall survival, disease-free survival, local control, larynx preservation and laryngectomy-free survival. For patients with T2a lesions, local control, laryngectomy-free survival and disease-free survival improved after surgery but overall survival did not. For patients with T2b lesions, local control, laryngectomy-free survival, disease-free survival and overall survival were all higher after surgery than after radiotherapy. CONCLUSION: This study highlights for the first time the importance of vocal fold mobility in treatment outcomes and is the first to assess its influence on survival. Updated tumour-node-metastasis classifications should consider the distinction between T2a and T2b lesions.

Airway fire during tracheostomy.

INTRODUCTION: Twenty-five cases of airway fire during tracheostomy have been reported in the literature. The authors describe a case observed in their centre 3 years ago, discuss the causes and preventive management and propose guidelines for prevention of this complication. CASE REPORT: A 66-year-old woman was intubated and ventilated with 100% oxygen during general anaesthesia for tracheostomy. On opening the trachea by monopolar diathermy, the oxygen present in the endotracheal tube caught fire, inducing combustion of the tube spreading to the lower airways. This airway fire was responsible for severe acute respiratory failure and the formation of multiple laryngotracheal stenoses. DISCUSSION: Combustion of the endotracheal tube due to ignition of anaesthetic gases induced by the heat generated by diathermy is responsible for airway fire. These various phenomena are discussed. Prevention is based on safety measures and coordination of surgical and anaesthetic teams.

Tacrolimus enhances the recovery of normal laryngeal muscle fibre distribution after reinnervation.

OBJECTIVES: To assess the recovery of various muscle fibre types in the posterior cricoarytenoid muscle after laryngeal reinnervation in the rat, and to determine the influence of tacrolimus on this process. METHODS: Four groups of rats underwent resection and anastomosis of the left vagus nerve, and were administered either tacrolimus at a low dose or an immunosuppressive dose, or cyclosporin A at a low dose or an immunosuppressive dose. A fifth group received surgery alone, and a sixth group received neither surgery nor drug treatment (healthy group). Muscles were removed for immunohistochemical analysis 45 days after surgery. RESULTS: There was no difference in the proportion of types 1, 2a and 2b muscle fibres, comparing the immunosuppressive tacrolimus group and the healthy group, whereas there were fewer type 1 fibres in the group receiving surgery alone, compared with the healthy group (7 vs 12.1 per cent, respectively; p = 0.0303). CONCLUSION: Tacrolimus enhanced the recovery of normal laryngeal muscle fibres after reinnervation in the rat, indicating a possible role in laryngeal transplantation.

Acute mastoiditis in children: 10 years experience in a French tertiary university referral center.

Acute mastoiditis have been increasingly reported in the last decade, with bacteriologic modifications and new therapeutic guidelines. This study is a retrospective review of 36 children hospitalized for acute mastoiditis in a French tertiary university referral center from 1999 to 2009, to assess incidence, bacteriology of pathogens and management. There were 10 periosteitis and 26 subperiosteal abscesses. There was a trend toward increased incidence over the past 10 years. The mean age of the patients was 31.8 months. A total of 63.2% children received 7.2 days antibiotic prior to hospitalization for acute otitis media, with sensitive pathogens in 80%. The pathogens were Streptococcus pneumoniae (36.1%), S. pyogenes A (13.9%), Staphylococcus coagulase-negative (13.9%), Pseudomonas aeruginosa (8.3%), Fusobacterium necroforum (8.3%) and Haemophiluss influenzae (2.8%). Cultures were negative in 16.7%. All patients received intravenous antibiotics. Eleven patients underwent bilateral myringotomy with or without tympanostomy tubes. Mastoidectomy was performed in 24 patients. Decrease in the length of hospitalization and delay from admission to surgery were significantly correlated. We observed a trend in the increase of acute mastoiditis at our center. The pathogens were dominated by S. pneumoniae. F. necroforum and P. aerguginosae were pathogens found in children over 2 years of age. Mastoidectomy was performed in 92.3% of subperiostal abscesses. However, there has been a trend toward conservative nonsurgical treatment in recent reported studies and further prospective studies are warranted to evaluate the long-term sequelae.

Transoral robotic surgery in head and neck cancer.

Robots have invaded industry and, more recently, the field of medicine. Following the development of various prototypes, Intuitive Surgical® has developed the Da Vinci surgical robot. This robot, designed for abdominal surgery, has been widely used in urology since 2000. The many advantages of this transoral robotic surgery (TORS) are described in this article. Its disadvantages are essentially its high cost and the absence of tactile feedback. The first feasibility studies in head and neck cancer, conducted in animals, dummies and cadavers, were performed in 2005, followed by the first publications in patients in 2006. The first series including more than 20 patients treated by TORS demonstrated the feasibility for the following sites: oropharynx, supraglottic larynx and hypopharynx. However, these studies did not validate the oncological results of the TORS technique. TORS decreases the number of tracheotomies, and allows more rapid swallowing rehabilitation and a shorter length of hospital stay. Technical improvements are expected. Smaller, more ergonomic, new generation robots, therefore more adapted to the head and neck, will probably be available in the future.

[Unilateral laryngeal paralysis after intra capsular loboisthmectomy without laryngeal nerve dissection]. / Paralysie laryngée unilatérale après lobo-isthmectomie intra capsulaire sans repéérage du nerf laryngé inférieur.

OBJECTIVES: To document the incidence, outcome and variables that increase the risk for unilateral laryngeal paralysis after loboisthmectomy performed according to the intracapsular dissection technique. MATERIALS AND METHODS: A retrospective analysis of an inception cohort of 317 loboisthmectomies consecutively performed at a single institution by the same surgeon during the years 2002-2007 using the intra capsular dissection without laryngeal nerve dissection, neuromonitoring and modern hemostasis techniques (Ligasure, Ultracision). The immediate and definite rate for unilateral laryngeal nerve paralysis is documented. A statistical analysis is performed for potential relation between these events and the following variables: age, gender, comorbidity, tracheal compression and intrathoracic characteristics of the thyroid lesion, side of the loboisthmectomy, etiology of the thyroid lesion (benign, malignant, hyperthyroidy), associated thyroiditis, size of the largest resected nodule and weight of the resected lobe. RESULTS: The immediate unilateral laryngeal nerve paralysis incidence was 1,2%. Recovery of motion occurred by the 1st, 3rd, 5th or 9th post operative month resulting in a 0% incidence for definitive unilateral laryngeal nerve paralysis. No significant statistical relation was noted between immediate unilateral laryngeal nerve paralysis and the variables under analysis. CONCLUSION: Based on the current series and the review of the medical literature, it appears that the loboisthmectomy according to the intra capsular technique without inferior laryngeal nerve identification, in patients not previously operated, performed according to is a surgical technique whose goal is to ascent the thyroid lobe and dissect the region of the nerve penetration within the larynx by the end of the resection, does not increase the risk for transient or permanent unilateral laryngeal nerve paralysis.