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BACKGROUND: The objective of this study was to examine the utility of postoperative radiation for low and intermediate grade cancers of the parotid and submandibular glands. METHODS: The authors conducted a retrospective, Canadian-led, international, multi-institutional analysis of a patient cohort with low or intermediate grade salivary gland cancer of the parotid or submandibular gland who were treated from 2010 until 2020 with or without postoperative radiation therapy. A multivariable, marginal Cox proportional hazards regression analysis was performed to quantify the association between locoregional recurrence (LRR) and receipt of postoperative radiation therapy while accounting for patient-level factors and the clustering of patients by institution. RESULTS: In total, 621 patients across 14 tertiary care centers were included in the study; of these, 309 patients (49.8%) received postoperative radiation therapy. Tumor histologies included 182 (29.3%) acinic cell carcinomas, 312 (50.2%) mucoepidermoid carcinomas, and 137 (20.5%) other low or intermediate grade primary salivary gland carcinomas. Kaplan-Meier LRR-free survival at 10 years was 89.0% (95% confidence interval [CI], 84.9%-93.3%). In multivariable Cox regression analysis, postoperative radiation therapy was independently associated with a lower hazard of LRR (adjusted hazard ratio, 0.53; 95% CI, 0.29-0.97). The multivariable model estimated that the marginal probability of LRR within 10 years was 15.4% without radiation and 8.8% with radiation. The number needed to treat was 16 patients (95% CI, 14-18 patients). Radiation therapy had no benefit in patients who had early stage, low-grade salivary gland cancer without evidence of nodal disease and negative margins. CONCLUSIONS: Postoperative radiation therapy may reduce LLR in some low and intermediate grade salivary gland cancers with adverse features, but it had no benefit in patients who had early stage, low-grade salivary gland cancer with negative margins.
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Recidiva Local de Neoplasia , Neoplasias das Glândulas Salivares , Humanos , Estudos Retrospectivos , Radioterapia Adjuvante , Recidiva Local de Neoplasia/prevenção & controle , Recidiva Local de Neoplasia/patologia , Canadá/epidemiologia , Neoplasias das Glândulas Salivares/radioterapia , Neoplasias das Glândulas Salivares/cirurgia , Glândulas Salivares/patologia , Estadiamento de NeoplasiasRESUMO
Three-dimensional imaging can be used to obtain objective assessments of facial morphology that is useful in a variety of clinical settings. The VECTRA H1 is unique in that it is relatively inexpensive, handheld, and does not require standardized environmental conditions for image capture. Although it provides accurate measurements when imaging relaxed facial expressions, the clinical evaluation of many disorders involves the assessment of facial morphology when performing facial movements. The aim of this study was to assess the accuracy and reliability of the VECTRA H1, specifically when imaging facial movement. Methods: The accuracy, intrarater, and interrater reliability of the VECTRA H1 were assessed when imaging four facial expressions: eyebrow lift, smile, snarl, and lip pucker. Fourteen healthy adult subjects had the distances between 13 fiducial facial landmarks measured at rest and the terminal point of each of the four movements by digital caliper and by the VECTRA H1. Intraclass correlation and Bland-Altman limits of agreement were used to determine agreement between measures. The agreement between measurements obtained by five different reviewers was evaluated by intraclass correlation to determine interrater reliability. Results: Median correlation between digital caliper and VECTRA H1 measurements ranged from 0.907 (snarl) to 0.921 (smile). Median correlation was very good for both intrarater (0.960-0.975) and interrater reliability (0.997-0.999). The mean absolute error between modalities, and both within and between raters was less than 2 mm for all movements tested. Conclusion: The VECTRA H1 met acceptable standards for the assessment of facial morphology when imaging facial movements.
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Transoral robotic surgery (TORS) approach for the treatment of oropharyngeal cancer allows for reduced patient morbidity, amongst other advantages over the traditional lip-splitting mandibulotomy method. Free-flap reconstruction is commonly utilized in head and neck cancer surgeries; however, safety and outcomes of this technique in TORS procedures have not been well studied. The objective of this study was to perform a systematic review to evaluate the efficacy and safety of TORS with free-flap reconstruction (TORS-FFR) for oropharyngeal cancer. A systematic search of Scopus, EMBASE, CINAHL and PubMed databases was completed. Following PRISMA guidelines, case series/reports, retrospective and prospective cohort studies were included. Primary outcomes measured were deaths and complication rates associated with TORS-FFR for oropharyngeal cancers. Secondary outcomes included functional swallowing and airway outcomes, operative time and length of hospital stay. Twenty-one studies met the inclusion criteria comprising a total of 132 patients. The mean patient age was 58.4 years. The most frequent complication was infection (8.9%) followed by flap wound dehiscence (4.2%). The average total operative time was 710 min (n = 48), while average length of hospital stay was 13.5 days (n = 48). Reconstructions were most commonly fashioned from radial forearm free flaps (RFFF), with anterolateral thigh flaps (ALT) representing the second most common free-flap subtype. TORS-FFR procedures for oropharyngeal cancer are safe, with low serious complication rates. This surgical approach may be associated with decreased length of hospital stay; however, further studies are required to better characterize post-operative outcomes.Level of evidence 1a.
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Retalhos de Tecido Biológico , Neoplasias Orofaríngeas , Procedimentos Cirúrgicos Robóticos , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Estudos Prospectivos , Neoplasias Orofaríngeas/cirurgiaRESUMO
INTRODUCTION: Resection of the mandible and temporomandibular joint (TMJ) without formal reconstruction is a devastating condition that negatively affects all aspects of the patient's life. We have approached the reconstruction of mandibular defects that include the condyle with simultaneous reconstruction with a vascularized free fibular flap (FFF) using Surgical Design and Simulation (SDS) and alloplastic TMJ prosthesis. The objective of this study is to report the functional and quality of life (QOL) outcomes in a cohort of patients that had undergone our reconstructive protocol. METHODS: This was a prospective case series of adult patients that underwent mandibular reconstruction with FFF and alloplastic TMJ prosthesis at the our center. Pre-operative and post-operative maximum inter-incisal opening (MIO) measurements were collected, and patients completed a QOL questionnaire (EORTC QLQ-H&N35) during those perioperative visits. RESULTS: Six patients were included in the study. The median patient age was 53 years. Heat map analysis of the QOL questionnaire revealed that patients reported a positive clinically significant change in the domains of pain, teeth, mouth opening, dry mouth, sticky saliva, and senses (relative change of 2.0, 3.3, 3.3, 2.0, 2.0, and 1.0 respectively). There were no negative clinically significant changes. There was a median perioperative MIO increase of 15.0 mm, and this was statistically significant (p = 0.027). CONCLUSIONS: This study highlights the complexities involved in mandibular reconstruction with involvement of the TMJ. Based on our findings, patients can obtain an acceptable QOL and good function following simultaneous reconstruction with FFF employing SDS and an alloplastic TMJ prosthesis.
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Retalhos de Tecido Biológico , Prótese Articular , Reconstrução Mandibular , Adulto , Humanos , Pessoa de Meia-Idade , Reconstrução Mandibular/métodos , Qualidade de Vida , Articulação Temporomandibular/cirurgia , Resultado do TratamentoRESUMO
Background: To help ensure adequate hemostasis immediately following potassium titanyl phosphate (KTP) laser treatment, many centres treating hereditary hemorrhagic telangiectasia (HHT) routinely use nasal packing post-operatively. The purpose of this study was to compare hemostatic thrombin matrix with standard packing for postoperative bleeding, patient pain, and comfort. Methods: A prospective, randomized, double-blinded, non-inferiority study was conducted with participants at an HHT centre of excellence (COE) and randomized to the treatment group with reconstituted thrombin gelatin matrix (Surgiflo®) or control group with a biodegradable synthetic polyurethane foam (NasoPore®). Adult subjects with confirmed HHT and moderate to severe epistaxis (a minimum calculated epistaxis severity score [ESS] of 4.0) warranting KTP laser treatment were recruited. Data was collected 2 weeks post operatively by a blinded reviewer completing a visual outcomes evaluation and each patient completing a subjective symptoms questionnaire. Non-parametric statistical analysis was employed. Results: Twenty-eight adult patients were randomized to the treatment and control arms with comparable preoperative epistaxis severity scores. Postoperative nasal bleeding was equivalent. Significantly less pain was found in the treatment arm (p = .005). While there were trends towards less obstruction and increased satisfaction in the treatment group as well as less crusting in the control group, these findings were not statistically significant. Allocation to the treatment group was associated with an approximately $75 higher cost. Conclusions: When compared to NasoPore® for hemostasis, Surgiflo® hemostatic matrix performed equivalently while causing less discomfort in HHT patients following nasal KTP treatment. Level of evidence: 1b.
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INTRODUCTION: Jaw defect reconstructions have been transformed by the development of free tissue transfer using vascularized bone incorporating osseointegrated dental implants. We recently developed a modification our method this procedure and termed it the Modified Alberta Reconstruction Technique (MART). The objective of this study aimed to assess the soft tissue component and outcomes of the MART as compared to the Alberta Reconstructive Technique (ART) or conventional (BDD) reconstructions. PATIENTS AND METHODS: This was a prospective cohort study of adult patients who underwent jaw reconstruction with dental implant rehabilitation between 2000 and 2019 in Edmonton, Alberta. Patients were aged-matched and placed into a cohort based on the type of reconstruction they received. Outcomes were compared between the groups. Expert and aesthetic analyses were performed. Statistical analysis was conducted to determine significance. RESULTS: A total of 46 patients (15 BDD, 15 ART and 16 MART) were included. Demographics were similar between groups. There was no difference in complications. The soft tissue component of the MART cohort was more favourable to work with as judged by the occlusal reconstructive experts. The MART was rated as more aesthetically appealing in comparison to the BDD and ART (p = 0.049). CONCLUSIONS: The MART is a safe, effective, and aesthetically appealing procedure. It yields a good functional result and a clinically better soft tissue component for occlusal reconstructions. For a select group of patients requiring jaw reconstruction, the MART is an ideal reconstructive option as the modification provides good control of the soft tissue around the implants.
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Prótese Ancorada no Osso , Implantes Dentários , Procedimentos de Cirurgia Plástica , Adulto , Idoso , Alberta , Fíbula/cirurgia , Humanos , Estudos Prospectivos , Procedimentos de Cirurgia Plástica/métodosRESUMO
BACKGROUND: The tongue is an essential organ for human interaction, communication and survival. To date, there is a paucity of objective functional, patient reported, or quality of life outcomes of patients undergoing a total glossectomy with preservation of the larynx (TGLP). OBJECTIVE: To examine prospectively collected objective, self-reported functional and quality of life (QOL) data in patients undergoing TGLP and free flap reconstruction. METHODS: Sixteen TGLP patients were identified in the prospective head and neck cancer and functional outcomes database between January of 2009 and December 2017. Data collection included patient age, sex, performance status, TNM staging, diagnosis and adjuvant treatment. Swallowing and speech functions were measured and prospectively recorded pre- and postoperatively. Patient reported outcomes were measured with the Speech Handicap Index (SHI) and the M.D. Anderson Dysphagia Inventory (MDADI). RESULTS: All patients had a significant reduction in their objective swallowing (P = 0.035), sentence (P = 0.001) and word intelligibility (P < .001) scores. There was no significant reduction in SHI or total MDADI scores. All patients maintained their QOL in the post-treatment time frame. There was no relationship between free-flap type and outcome. CONCLUSION: Total glossectomy with laryngeal sparing and free flap reconstruction results in significant reduction in objective functional measurements, but patients report stable functional and quality of life outcomes after treatment.
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BACKGROUND: The accurate diagnosis of Eustachian tube (ET) dysfunction can be very difficult. Our aim is to determine whether a 678 Hz probe tone is a more accurate indicator of Patulous ET (PET) than the 226 Hz probe tone when used in compliance over time (COT) testing. METHODS: Twenty subjects (11 normal ET ears and 7 PET ears) were individually seated in an examination room and connected to a GSI TympStar Middle Ear Analyzer. The order of probe tone frequency (678 or 226 Hz) was randomized. Baseline "testing" COT recordings for each ear undergoing testing were completed. Subjects were instructed to occlude their contralateral nostril and to breathe forcefully in and out through their ipsilateral nostril until the test had run to completion. This process was repeated with the probe tone that had not been previously run. For the control group, each subject had one random ear tested. For the experimental group, only the affected ear(s) was tested. Wilcoxon rank rum tests were performed to determine statistical significance. RESULTS: The baseline COT measurements for the control group and PET group were similar, 0.86 mL (SD = 0.34) and 0.74 (SD = 0.33) respectively. Comparing the 226 Hz tone between groups revealed that PET patients had a median COT difference 0.19 mL higher than healthy ET patients, and for the 678 Hz tone, PET patients had a median COT difference of 0.57 mL higher than healthy ET patients. Both were deemed to be statistically significant (p = 0.002, p = 0.004 respectively). The was a statistically significant median COT difference between the 678 Hz and 226 Hz of 0.61 mL (p = 0.034) for the PET group, while the same comparison for the control group of 0.05 mL was not significant (p = 0.262), suggesting that the 678 Hz tone yields a larger response for PET than the 226 Hz tone, and no difference for the control group, thus making it less prone to artifact noise interference. CONCLUSION: The 678 Hz probe tone is a more reliable indicator of ET patency, and should be preferably used over the 226 Hz tone for future COT testing.
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Audiometria de Tons Puros , Otopatias/diagnóstico , Tuba Auditiva , Adulto , Tuba Auditiva/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Eustachian tube (ET) dysfunction can be very difficult to diagnose accurately. Our aim is to determine whether a newly developed sonotubometric test using clicks can reliably detect ET opening during swallowing in normal ET subjects, and patulous ET (PET) in subjects with ET dysfunction. METHODS: Sixteen subjects (19 normal ET ears and 6 PET ears) were individually placed in a sound-isolated audiometry booth and subjected to a 1000Hz click train stimulus, played through the nose. PET subjects were identified through the ET clinic at our institution, while healthy subjects were recruited. Transmission through the ET was recorded by a microphone in the ear ipsilateral to the presenting nostril, during no swallow and swallow states, and this was used to compute a power ratio (power in the frequency range of interest to the whole frequency range). The power transmission ratio both before and after the swallow was averaged, and represented the baseline (BaseR). The power transmission ratio during swallow represented the peak (PeakR). The same process was repeated in the absence of a stimulus to account for swallowing noise. Wilcoxon rank rum tests were performed to determine statistical significance. RESULTS: It was found that for healthy ET patients, the median difference between the PeakR and BaseR was 0.51 (p = 0.004). For the PET patients in this study, the median difference between the PeakR and the BaseR was 3.30 (p = 0.041). Comparing the baseline between groups revealed that PET patients had a median BaseR 1.05 higher than healthy ET patients. PET patients had a median PeakR of 3.84 higher than healthy ET patients. Both were deemed to be statistically significant (p = 0.003, p = 0.003 respectively). A significant difference was found between median PeakR for the stimulus and no-stimulus condition for the healthy ET group (0.59, p < 0.001) and for the PET group (4.39, p = 0.031), indicating that it was unlikely that swallowing noise caused false positive results. CONCLUSION: The results of this study suggest that a novel click stimulus is capable of detecting ET opening during swallowing in healthy patients as well as highlighting PET in diseased subjects.