Stenting of the eustachian tube to prevent otitis media with effusion after maxillary swing approach nasopharyngectomy.

OBJECTIVES/HYPOTHESIS: Our previous report recommended that the management of ipsilateral otitis media with effusion (OME) after maxillary swing nasopharyngectomy was observation. The idea of introducing a stent into the eustachian tube (ET) at the nasopharyngeal side after nasopharyngectomy may prevent postoperative OME. The purpose of this study was to examine the feasibility of intraoperative ET stenting and the efficacy of preventing ipsilateral OME formation. STUDY DESIGN: Prospective cohort study. METHODS: From 2009 to 2011, 28 patients with nasopharyngectomy via the maxillary swing approach were recruited. Patients with curative resection were recruited (n = 21). ET stenting was performed intraoperatively using a 16-gauge Angiocath (BD Medical Systems, Franklin Lakes, NJ) with dimensions of 1.7 mm × 30 mm. The stent stays inplace indefinitely. The otologic status was evaluated using otoscopy, pure-tone audiogram, and tympanogram at 3 months, 6 months, and 1 year after the surgery. The outcomes were analyzed and compared with historical control. RESULTS: There were 9 (43%) patients with no OME at 6 months after surgery, and 15 (71%) patients had no OME at 1 year postoperatively. The results were statistically significant (P < .0001) when compared with our historical control of no ET stenting. There was no incidence of adverse effects of the stenting, such as acute otitis media, dislodgement of the stent, otalgia, and nasal pain. CONCLUSIONS: ET stenting was feasible after nasopharyngectomy. ET stenting prevented a significant number of patients from suffering from ipsilateral OME and alleviated the symptoms of unilateral aural fullness and unilateral conductive hearing impairment up to at least 1 year after the surgery. ET stenting is recommended in all patients after maxillary swing nasopharyngectomy.

The role of myringotomy and ventilation tube insertion in maxillary swing approach nasopharyngectomy: review of our 10-year experience.

OBJECTIVES/HYPOTHESIS: The use of myringotomy with ventilation tube insertion after maxillary swing nasopharyngectomy was originally described to prevent the occurrence of otitis media with effusion. The outcome of this otologic procedure has never been reviewed and discussed. The purpose of this study is to examine the role of myringotomy with ventilation tube insertion in this group of patients. STUDY DESIGN: Retrospective review. METHODS: One hundred forty-two patients with maxillary swing nasopharyngectomy were recruited from 1999 to 2008. The otologic status was evaluated using otoscopy, pure tone audiogram, and tympanogram at 3 months, 6 months, and then yearly after the operation. The results were reviewed periodically during that 10-year period. During this period, there were three groups; the first group had myringotomy with ventilation tube inserted, the second group had myringotomy alone, and the third group had no myringotomy performed. RESULTS: There were significantly (P < .0001) more patients in the myringotomy with ventilation tube insertion group who suffered from adverse otologic complications such as discharging grommet, discharging chronic suppurative otitis media, and perforated eardrum when compared with patients with myringotomy alone and patients without myringotomy at 3 months, 6 months, and 12 months. There were no differences in the incidence of acute otitis media among all three groups of patients. CONCLUSIONS: Patients who underwent maxillary swing nasopharyngectomy and myringotomy with ventilation tube insertions suffered from more otologic complications. The routine use of myringotomy with or without ventilation tube insertion for this group of patients is not recommended.

Anatomical study and clinical applications of free posterior tibial flap in the head and neck region.

BACKGROUND: The purpose of this study was to examine the anatomical features, clinical applications, and donor-site morbidities of the free posterior tibial flap. METHODS: The posterior tibial vascular system was examined in 30 fresh cadaver legs. This was followed by a clinical study involving patients with free posterior tibial flap reconstruction of defects in the head and neck region after tumor extirpation. Potential donor-site morbidities were studied at 1 year after surgery. RESULTS: The mean caliber of the posterior tibial artery and the venae comitantes in the cadaveric limbs was 2.7, 2.9, and 2.17 mm, respectively. The mean number of septocutaneous perforators was 2.85 per leg, clustering in the middle and distal thirds of the medial surface of the leg. The mean thickness of the skin and subcutaneous fat in the region was 4.43 mm. In the clinical study, 64 patients with superficial cutaneous and mucosal defects were recruited. The majority of the patients had carcinoma of the oral cavity. All flaps survived. Three patients (4.7 percent) developed mild infection of the donor site. None of the patients have problems walking on level ground. There was no significant reduction in range of ankle movement, nor was there evidence of vascular compromise of the lower limb, either at rest or after exercise. CONCLUSIONS: The free posterior tibial flap is reliable because of its constant vascular anatomy. It is thin and pliable, making it particularly suitable for resurfacing superficial cutaneous and mucosal defects. Although skin grafting is required to repair the donor site, the associated morbidity is low. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reconstruction of circumferential pharyngeal defects after tumour resection: reference or preference.

BACKGROUND: Reconstruction of circumferential hypopharyngeal defects is often challenging. The aim of the study is to examine the result of our experience and to formulate improved management guidelines. METHOD: Between 1980 and 2009, all patients who have circumferential pharyngectomy were recruited. Data were recorded prospectively for analysis. RESULTS: A total of 202 patients were recruited. Majority had primary tumour in the hypopharynx (n=165), and the remaining patients had recurrent laryngeal carcinoma. Radiotherapy was given preoperatively in 72 patients and postoperatively in 108 patients. A pectoralis major (PM) flap was used in 92 (45.5%) patients, a free anterolateral thigh (ALT) flap in 24 (11.9%) patients and a free jejunal flap in 86 (42.6%) patients. Early fistula rate was 23.9% in the PM flap group, 12.5% in the ALT group and 4.6% in the jejunum group. Late anastomotic stricture rate was 27.2% in the PM flap group, 12.5% in the free ALT group and 2.3% in the jejunum group. Early fistula formation significantly increased the risk of subsequent anastomotic stricture (p=0.023). In patients with no stricture, 61.9% of them in the jejunal group were able to resume solid diet, compared with 35.8% and 38.1% in the PM and ALT groups. After PM flap harvesting, 34.8% of the chest wall defects could not be closed primarily, which were best repaired using the lateral thoracic flap. The donor-site morbidity of ALT and jejunal flap was low. CONCLUSION: In suitable patients, free jejunal flap reconstruction of circumferential pharyngectomy defects achieves the best functional outcome with minimal donor-site morbidity.

Current management of cervical esophageal cancer.

BACKGROUND: Pharyngo-laryngo-esophagectomy (PLE) has been regarded as a standard treatment for cervical esophageal cancer, but the morbidity and mortality rates associated with PLE are substantial. Chemoradiation (CTRT) is widely used to treat esophageal cancer; however, its role in managing cervical esophageal cancer has not been fully elucidated. It was hypothesized that up-front CTRT could be an effective alternative treatment option to PLE. The purpose of this study was to compare the outcomes of patients with cervical esophageal cancer treated with these two methods. METHODS: Patients with cervical esophageal cancer from 1995 to 2008 were studied. Three main groups were identified: those treated with PLE, those managed with up-front concurrent chemoradiation, and those not suitable for either PLE or chemoradiation but to whom palliative treatment was offered. The demographics, management strategies, and outcomes of these patients were studied and analyzed. RESULTS: A total of 107 patients were studied: 87 (81.3%) were men, and the median age was 64 years (range 17-92 years). There were 62 patients who underwent PLE as the primary treatment, 21 had up-front chemoradiation, and the others had palliative treatment. In the PLE group, curative resection was achieved in 37 (59.7%) patients, 20 of whom had either adjuvant chemoradiation or radiotherapy. The hospital mortality rate was 7.1%. In the chemoradiation group, 10 (47.6%) had tumor down-staging, 6 of whom achieved a clinically complete response. Among the 11 patients with poor response, 5 required salvage PLE for palliation. Chemoradiation-associated morbidities included oral mucositis, bilateral vocal cord palsy, esophageal stricture, carotid artery blowout, and permanent hypothyroidism and hypoparathyroidism. The median survival durations of patients in the PLE and chemoradiation groups were 20 and 25 months respectively (P = 0.39). CONCLUSIONS: Up-front chemoradiation can be an alternative therapeutic strategy to PLE. However, this method is not without drawbacks. A significant proportion also requires salvage surgery. Both PLE and chemoradiation have significant curative as well as palliative role in the management of cervical esophageal cancer and treatment should be individualized.

Surgical salvage of persistent or recurrent nasopharyngeal carcinoma with maxillary swing approach - Critical appraisal after 2 decades.

BACKGROUND: The purpose of this study was to report on our experience on salvage nasopharyngectomy using the maxillary swing approach for persistent or recurrent nasopharyngeal carcinoma after primary treatment. METHODS: Over the past 2 decades, we have performed salvage nasopharyngectomies for 246 patients. Thirty-seven patients (15%) had persistent disease and 209 (85%) had recurrent tumors. RESULTS: All patients survived the operation with minimal morbidity. Negative resection margins were achieved in 191 patients (78%), and 55 patients (22%) had microscopic residual disease. The median follow-up was 38 months. The 5-year actuarial control of disease in the nasopharynx was 74%. The 5-year disease-free survival was 56%. Cox regression model identified the negative resection margin and the size of the tumor as 2 independent factors that affected local control of disease and survival. CONCLUSION: Maxillary swing nasopharyngectomy is an effective salvage procedure for a small, persistent, or recurrent tumor in the nasopharynx after primary therapy.

Early resection and reconstruction of head and neck masses in infants with upper airway obstruction.

OBJECTIVE: Congenital airway obstruction can be caused by tumors or lesions arising from the neck, tongue and oral cavity. Neonates may require prolonged intubation or tracheostomy before curative resection and reconstruction. The aim of the study was to carry out surgical resection and reconstruction with locoregional flap and free bone graft in the neonatal and early infantile period for definitive management of head and neck masses and treatment of potential airway obstruction. METHODS: Newborns with obstructive head and neck masses in Queen Mary Hospital, University of Hong Kong Medical Centre between 2006 and 2009 were operated on in the neonatal period. RESULTS: There were one obstructive neck teratoma, two intraoral teratomas and one neuroglial heterotopia. All tumors were resected within the first 3 months of life without major complication. A local cervical cutaneous flap was first used to reconstruct the lateral pharyngeal wall defect in a neonate with a huge neck teratoma, followed by another infant with a neuroglial heterotopia. A piece of cranial bone was used for reconstruction of the skull base defect. None of them required tracheostomy or prolonged intubation. Oral feeding was resumed in the early postoperative period. CONCLUSION: Surgical resection and reconstruction with locoregional flap and bone graft can be performed safely in neonatal and early infantile period as management of head and neck masses and treatment of upper airway obstruction.

Pediatric liver transplantation in Hong Kong-a domain with scarce deceased donors.

AIM: The study aimed to assess the outcome of live-donor liver transplantation for pediatric patients in a region with limited access to deceased donors. PATIENTS AND METHODS: From September 1993 to September 2008, 78 pediatric patients aged between 73 days and 17 years (mean, 40 months) received 83 liver transplants. Sixty-two were living-related liver transplantations (LRLTs), and 21 were deceased-donor liver transplantations (DDLTs). The mean follow-up period was 6.5 years. The prospectively collected data of these patients were analyzed retrospectively. RESULTS: The 1-, 2-, and 5-year survival rates of patients and grafts were 91%, 90%, 88% and 87%, 86%, 83%, respectively. The survival rates of LRLT patients and DDLT patients were 89%, 89%, 87%, and 90%, 86%, 86%, respectively (P = .58). The survival rates of patients aged 12 months or younger and patients older than 12 months were 95%, 92%, 90% and 90%, 90%, 87%, respectively (P = .65). One live donor developed temporary peroneal palsy, and another developed lung collapse (3%, 2/62). All live donors resumed their normal activities with no difficulty. CONCLUSION: With meticulous surgical techniques and postoperative care, it is justifiable to accept donated livers from voluntary live donors for transplantation to save pediatric patients in a place with scarce deceased donors.

Prospective randomized study of selective neck dissection versus observation for N0 neck of early tongue carcinoma.

BACKGROUND: There are controversies on the benefits of elective neck dissection (END) for oral tongue carcinoma. METHOD: This is a prospective randomized study of elective selective I, II, III neck dissection versus observation for N0 neck of stage I to II oral tongue carcinoma. There were 35 patients on the observation arm and 36 patients on the END arm. The main outcome assessment parameters are node-related mortality and disease-specific survival rate. RESULTS: There were 11 patients in the observed arm and 2 patients in the END arm who developed nodal recurrence alone without associated local or distant recurrence. All 13 patients were salvaged, and no patient died of nodal recurrence. The 5-year disease-specific survival rate was 87% for the observation arm and was 89% for the END arm; the 2% difference was not significant. CONCLUSION: Observation may be an acceptable alternative to END if strict adherence to a cancer surveillance protocol is followed.

Mature miR-184 and squamous cell carcinoma of the tongue.

Human microRNA 184 (miR-184) is overexpressed in squamous cell carcinoma (SCC) of the tongue. In vitro inhibition of miR-184 levels could induce apoptosis and hinder proliferation of tongue SCC cells. Patients with tongue SCC have high plasma miR-184 levels. Plasma miR-184 is likely associated with the tumor load. Surgical removal of the primary tumor reduced plasma miR-184 levels significantly. The data suggested that miR-184 is linked to the pathogenesis of tongue SCC. Further studies are warranted to evaluate the use of microRNA-based serological markers in monitoring tongue SCC.

Lateral thoracic flap for donor site repair of pectoralis major myocutaneous flap.

OBJECTIVE: To study the use of the lateral thoracic flap to repair a pectoralis major flap donor site defect when primary closure is not possible. STUDY DESIGN: Prospective study. SUBJECTS AND METHODS: All patients requiring pectoralis major flap reconstruction after tumour extirpation in the head and neck region, whose chest wall donor defects could not be closed primarily, were recruited to the study; lateral thoracic flaps were performed to close the wounds. RESULTS: Ten patients were recruited between July 2005 and November 2007. The patients were between 48 and 76 years of age. The lateral thoracic flap size ranged from 5 x 8 cm to 9 x 12 cm. All secondary donor sites in the lateral chest wall were closed primarily. There was no flap necrosis and the secondary donor sites healed without complications. CONCLUSION: The lateral thoracic flap is safe and reliable technique for reconstructing the chest wall donor defect from the pectoralis major flap when primary closure is not possible.

Management of head and neck tumours during pregnancy: case report and literature review.

Ethical dilemmas arise in managing head and neck cancers during pregnancy. The timing of treatment is an important determinant on foetal wellbeing. Diagnostic and treatment modalities may harm the foetus, while delaying or choosing suboptimal treatment in order to preserve foetal health may worsen maternal outcome. A multidisciplinary approach should be adopted to enable parents and clinicians to make the best clinical decision. We report on two cases. Case 1 is a 34-year-old female who presented with squamous cell carcinoma of the tongue at 29 weeks' gestation. Partial glossectomy, selective neck dissection and posterior tibial flap reconstruction was performed at 31 weeks. She underwent induction and early delivery at 38 weeks prior to receiving radiotherapy. Case 2 is a 36-year-old female who presented with carcinoma of the cervical oesophagus complicated by tracheal invasion, thyroid and cervical lymph node metastasis at 13 weeks' gestation. Pregnancy was terminated at 16 weeks. She received a course of neoadjuvant chemoirradiation.

Mature miR-184 as Potential Oncogenic microRNA of Squamous Cell Carcinoma of Tongue.

PURPOSE: The aim of this study was to evaluate the microRNA expression patterns in squamous cell carcinoma (SCC) of the tongue. EXPERIMENTAL DESIGN: Expression levels of 156 human mature microRNAs were examined using real-time quantitative PCR (Taq Man MicroRNA Assays; Human Panel) on laser microdissected cells of 4 tongue carcinomas and paired normal tissues. Expression of mature miR-184 was further validated in 20 paired tongue SCC and the normal tissues. Potential oncogenic functions of miR-184 were evaluated in tongue SCC cell lines (Cal27, HN21B, and HN96) with miR-184 inhibitor. Plasma miR-184 levels were evaluated using real-time quantitative PCR. RESULTS: Using 3-fold expression difference as a cutoff level, we identified 24 up-regulated mature miRNAs including miR-184, miR-34c, miR-137, miR-372, miR-124a, miR-21, miR-124b, miR-31, miR-128a, miR-34b, miR-154, miR-197, miR-132, miR-147, miR-325, miR-181c, miR-198, miR-155, miR-30a-3p, miR-338, miR-17-5p, miR-104, miR-134, and miR-213; and 13 down-regulated mature miRNAs including miR-133a, miR-99a, miR-194, miR-133b, miR-219, miR-100, miR-125b, miR-26b, miR-138, miR-149, miR-195, miR-107, and miR-139. Overexpression of miR-184 was further validated in 20 paired tongue SCC and normal tissues (P = 0.002). Inhibition of miR-184 in tongue SCC cell lines could reduce cell proliferation rate. Down-regulation of c-Myc was observed in two cell lines in response to miR-184 inhibitor. Suppressing miR-184 could induce apoptosis in all three cell lines. Plasma miR-184 levels were significantly higher in tongue SCC patients in comparison with normal individuals, and the levels were significantly reduced after surgical removal of the primary tumors. CONCLUSIONS: Overexpression of miR-184 might play an oncogenic role in the antiapoptotic and proliferative processes of tongue SCC. In addition, plasma miR-184 levels were associated with the presence of primary tumor. Further studies on the aberrantly expressed miRNAs in tongue SCC as well as using plasma miRNAs as novel tumor markers are warranted.

Preoperative measurement of tumor thickness of oral tongue carcinoma with intraoral ultrasonography.

BACKGROUND: Tumor thickness of oral tongue carcinoma is an important independent prognostic factor for local recurrence, subclinical nodal metastasis, and survival. An accurate preoperative assessment of tumor thickness is therefore essential in optimizing treatment algorithm. The present study aims at evaluating the accuracy of intraoral ultrasonography in preoperative measurement of tumor thickness. METHODS: Forty-five patients with oral tongue carcinoma had intraoral ultrasonography to document tumor thickness using a 7.5 MHz right angle probe. The ultrasonic tumor thickness was correlated with the fresh unpreserved surgical specimen pathologic tumor thickness. RESULTS: Ultrasonic tumor thickness had significant correlation with pathologic tumor thickness. The accuracies of ultrasonic measurement of tumor thickness in staging of tumor thickness at cutoff values between 3 and 15 mm were above 91%. CONCLUSION: Intraoral ultrasonography had satisfactory accuracy in the measurement of tumor thickness and is a useful adjunct in assisting pretreatment staging and prognosis evaluation of oral tongue carcinoma.

Surgical techniques and results of lateral thoracic cutaneous, myocutaneous, and conjoint flaps for head and neck reconstruction.

BACKGROUND: This paper aims at presentation of our surgical techniques and results of the lateral thoracic (LT) flaps for head and neck reconstructions. METHOD: There were seven LT cutaneous, seven LT myocutaneous, and two LT conjoint myocutaneous flaps for reconstruction of head and neck mucosal or cutaneous defects. RESULTS: The largest flap size was 22 cm x 13 cm. All donor sites were closed primarily. The highest point of reconstruction was in the nasopharynx internally and zygoma externally. All flaps survived without major complication. CONCLUSIONS: The LT flap has the versatility of cutaneous, myocutaneous, and conjoint flaps with pectoralis major or latissimus dorsi myocutaneous flaps to reconstruct large surgical defects. It has a large, reliable surface area, a long pedicle to reach nasopharynx and zygoma, and has less bulky muscle to facilitate tubular reconstruction of circumferential pharyngeal defect, one-stage operation, esthetic hidden donor site scar in axillary region, and minimal donor site morbidity. It is an additional reliable pedicle flap in our armamentarium for reconstruction of both cutaneous and mucosal defects in the head and neck region.

Calcium alginate dressing-related hypercalcemia.

To date, no adverse effects or contraindications have been observed in association with the use of calcium alginate dressing on an exuding wound. This is the first case in the literature in which it is suggested that using a large quantity of calcium alginate dressing could be harmful. The scenario leading to the complication and suggestions to prevent similar conditions in the future are described.

Long-term performance of indwelling tracheoesophageal speaking valves in Chinese patients undergoing laryngectomy.

OBJECTIVES: To assess the use of indwelling tracheoesophageal speaking valves in Chinese patients undergoing laryngectomy, to identify the clinicopathologic factors for favorable outcome, and to evaluate the factors that determine prosthesis lifetime. DESIGN: Retrospective review. SETTING: Tertiary care institution. PATIENTS: Sixty consecutive patients with total laryngectomy were included. All had indwelling tracheoesophageal speaking valves for voice restoration. INTERVENTION: Anterograde replacement of voice prosthesis in case of failure of functional speech production or leakage of saliva. MAIN OUTCOME MEASURES: Incidence of successful tracheoesophageal speech rehabilitation for daily communication, influence of different clinicopathologic factors on the outcome, and prosthesis lifetime and its relationship to different clinicopathologic factors. RESULTS: The success rate of speech rehabilitation was 78%. Age younger than 60 years was the only clinicopathologic factor associated with successful speech rehabilitation (P = .04, Fisher exact test). The median device lifetime was 8.2 months. Both age of 60 years or older and the use of subsequent prosthetic valves were identified as risk factors for valve failure on univariate analysis (n = 192; log-rank test; P = .02 and P = .03, respectively), with age of 60 years or older as the only risk factor that reduced the device lifetime in the Cox proportional hazards model (P = .03; relative hazard ratio, 1.5; 95% confidence interval, 1.1-2.4). CONCLUSIONS: Our success rate in using indwelling tracheoesophageal speaking valves was comparable to that reported in the Western literature. The median device lifetime of 8.2 months was satisfactory. Patient age was found to be a significant predictor of successful tracheoesophageal speech rehabilitation, with age of 60 years or more adversely affecting device lifetime.

Microvascular reconstruction of the hepatic artery in live donor liver transplantation: experience across a decade.

HYPOTHESIS: Hepatic arterial anastomosis by means of a microvascular technique can be performed with a high success rate in live donor liver transplantation in adult recipients. DESIGN: Retrospective analysis of data collected prospectively. SETTING: Tertiary referral center. PATIENTS: From September 28, 1993, through December 23, 2002, 28 children received left lateral segment grafts (n = 23) or left lobe grafts (n = 5), and 124 adults received left lobe (n = 6) or right lobe (n = 118) grafts. Microvascular technique was used for hepatic arterial anastomosis. Attention was paid to exposure, orientation of the axis of arterial ends, and matching of size. Long microinstruments were used for arterial ends deeply located inside an adult's abdominal cavity. An average of 16 stitches was used for a vessel anastomosis 3 mm in diameter. INTERVENTIONS: Intraoperative and postoperative Doppler ultrasonography were performed. MAIN OUTCOME MEASURES: Hepatic artery thrombosis rate. RESULTS: All hepatic arterial anastomoses were patent after reconstruction. Complications occurred in 3 patients. They had hepatic arterial thrombosis at 19 days, 25 days, and 3 months after liver transplantation. The overall complication rate was 2%. CONCLUSION: With attention to exposure, appropriate instruments, and experience, a low complication rate of 2% can be achieved in hepatic arterial anastomosis by using a microvascular technique, even in adult patients with the liver graft situated deeply in the abdominal cavity.