Sternocleidomastoid myofascial flap for reconstruction after composite resection of invasive squamous cell carcinoma of the tonsillar region: technique and outcome.

OBJECTIVE: To present the surgical technique and determine the efficacy of sternocleidomastoid myofascial (SCMF) flap reconstruction after composite resection with intent to cure. STUDY DESIGN: Retrospective review of 73 consecutive patients with a previously isolated and untreated moderately to well-differentiated invasive squamous cell carcinoma of the tonsillar region and a minimum of 3 years follow-up, managed at a tertiary referral care center during the years 1970 to 2002, with an ipsilateral superiorly based SCMF flap after composite resection. METHODS: The surgical procedure is presented in detail. Potential technical pitfalls are highlighted. Survival, mortality, and morbidity are documented. Univariate analysis for potential correlation between the incidence for postoperative flap complications and various variables is also performed. RESULTS: The 1, 3, and 5 year Kaplan-Meier actuarial survival estimates were 82.2%, 64.4%, and 49.3%, respectively. Death never appeared to be related to the completion of the SCMF flap. Thirty-three (45.2%) patients had some kind of significant postoperative surgical complication, and nine (12.3%) patients had some kind of significant postoperative medical complication. The most common significant postoperative complication was partial SCMF flap necrosis and pharyngocutaneous fistula noted in 30.1% and 10.9% of patients, respectively. Complete SCMF flap necrosis was never encountered. No patient developed carotid artery rupture or died as a result of the SCMF flap, and none required additional surgery. In univariate analysis, no significant statistical relation was noted between the significant postoperative surgical complications related to the use of the SCMF flap and the variables under analysis. CONCLUSIONS: The superiorly based SCMF flap appears to be simple to perform and useful for reconstruction of defects after composite resection.

Post-intubation laryngeal injuries and extubation failure: a fiberoptic endoscopic study.

PURPOSE: To describe laryngeal injuries after intubation in an intensive care unit and assess their risk factors and their association with post-extubation stridor (PES) and extubation failure. METHODS: Prospective study including 136 patients extubated after more than 24 h of mechanical ventilation. Fiberoptic endoscopic examination of the larynx was systemically performed within 6 h after extubation in order to record four types of laryngeal anomalies: edema, ulceration, granulation, and abnormal vocal cord (VC) mobility. RESULTS: Median duration of intubation was 3 days (min 24 h, max 56 days). Laryngeal injuries were frequent (73% of patients) and were associated with duration of intubation [odds ratios (OR) 1.11, 95% confidence interval (CI) 1.02-1.21, P = 0.02] and absence of use of myorelaxant drugs at intubation (OR 0.13, 95% CI 0.01-0.99, P = 0.05). Eighteen patients presented a PES. Lesions associated with PES were edema (67%, P < 0.01) and abnormal VC mobility (67%, P < 0.01). These injuries were associated with duration of intubation (OR 1.05, 95% CI 1.01-1.09, P = 0.04), emergency intubation (OR 2.7, 95% CI 1.2-6.4, P = 0.02), and height/endotracheal tube size ratio (OR 0.97, 95% CI 0.95-0.99, P = 0.01). Seventeen patients were reintubated within 48 h following extubation. Laryngeal examination of these patients more frequently showed granulation (29.4%, P = 0.02) and abnormal VC mobility (58.8%, P < 0.01). CONCLUSION: This study found a high frequency of laryngeal injuries after extubation in ICU, which were associated with intubation duration and patient's height/ETT size ratio. Edema was not the only injury responsible for PES, and although edema is frequent it is not the only injury associated with reintubation.