The use of prophylactic antibiotics in head and neck oncological surgery

PURPOSE OF REVIEW: An overview of best evidence-based current practice in the use of prophylactic antibiotics in elective oncological head and neck surgery is presented. RECENT FINDINGS: Patients undergoing head and neck oncological surgery are at great risk of developing complications following surgery. The incidence of wound infection has been reported to be as high as 87%, often with devastating effects. Prophylactic antibiotics have helped to reduce significantly the risk of infection; however, clinicians managing these patients should also have a thorough understanding of the risk factors leading to postoperative infections and should apply the most basic surgical principles at all times, to minimize infection rates. SUMMARY: Prophylactic antibiotics usage in clean-contaminated major oncological head and neck surgery is mandatory to reduce the risk of infection. In clean major oncological head and neck surgery their use is also advisable but there is no evidence that in clean surgery for benign disease it offers any advantage. Short antibiotic regimes of four doses per 24 h are as effective as prolonged courses regardless of the complexity of the procedure. A combination of antibiotic agents covering aerobic, anaerobic and Gram-negative bacteria is superior to single agents. High-risk patients should be also given short regimes, as there is no evidence that prolonged courses are of more benefit in these patients. Methicillin-resistant Staphylococcus aureus infection can have devastating consequences for patients undergoing major head and neck surgery. Protocols of prevention and treatment should be in place in all institutions treating patients with head and neck cancer. Close collaboration between surgical, microbiology and infection-control teams is essential.     

Risk factors of postoperative infection in head and neck surgery

Objectives

Patients undergoing head and neck oncological surgery are at great risk of developing complications following surgery. It is important to clarify risk factors contributing to operative wound infections.

Methods

Two hundred and nine cases with head and neck tumor (87 female, and 122 male, averaged 58.6 years old) were studied at Mie University Hospital within a 24-month interval, during 2002 and 2003.

Results

Twenty-one (10.0%) surgical site infections (SSIs) were recorded. Univariate analysis revealed that the following factors were significantly related to SSI: blood loss, previous chemotherapy, clean-contaminated surgery, tracheotomy, malignant tumor, advanced T-stage, flap reconstruction, and long operative time. Multivariate analysis showed that blood loss, previous chemotherapy, and the type of surgery contributed to SSI. Otherwise, the following factors did not show any significant correlations: age, body mass index, smoking, alcohol intake, diabetes, sex, previous radiotherapy, N-stage or ASA score.

Conclusions

In order to minimize postoperative wound infection, clinicians managing the head and neck tumor patients should have a thorough understanding of the risk factors leading to postoperative infections such as blood loss, previous chemotherapy, and clean-contaminated surgery.     

Extended use of perioperative antibiotics in head and neck microvascular reconstruction

Purpose

Many head and neck surgical procedures are considered clean-contaminated wounds and antibiotic prophylaxis is recommended. Despite prophylaxis, the incidence of surgical site infections remains significant – especially in the setting of free tissue transfer. The antibiotic course is often of a longer duration after free tissue transfer than the recommended 24 hour post-operatively. Currently, there is no consensus on appropriate antibiotic regimen or duration at this time. This study investigates the outcomes of a 7-day perioperative antibiotic regimen after microvascular reconstruction of the head and neck at our institution.

Head and neck reconstruction using microsurgery: a 9-year retrospective study

A total of 137 patients diagnosed with head and neck cancer underwent ablative surgery and primary free flap reconstruction during a period of 9 years, 2001–2009 (men 73.7 %, women 26.3 %). Surgery included a multidisciplinary approach involving plastic, head and neck, and maxillofacial surgeons. Squamous cell carcinoma (SCC) represented the vast majority of the diagnosed tumors (91.2 %); other tumors represented in the study were malignant melanoma, sarcoma, adenocarcinoma and blastoma. The free flaps (n = 143) used for reconstructive surgery included radial forearm flap (n = 128), fibular flap (n = 13) and rectus abdominis muscular flap (n = 2). Twenty patients (15 %) needed reoperation within 48 h due to clinical signs of hematoma (n = 8) and free flap ischemia (n = 12). Furthermore, we report a total of 12 free flap failures, giving an overall free flap success rate of 92 %. Five patients were treated due to infections at donor site (4 %). The overall survival rate (OS) in male patients diagnosed with oral SCC stage II–IV after 2 and 5 years was 82 and 78 %, respectively. Female patients in the same group displayed a 2- and 5-year OS of 78 and 67 %, respectively. Furthermore, analysis of patients treated for recurrence of primary SCC displayed a 2- and 5-year OS of 70 and 55 %, respectively. We conclude that our multidisciplinary approach and treatment algorithm for head and neck cancer including primary free flap reconstruction reconstitutes a safe and reliable tool.     

Multivariate analysis as an advantageous approach for prediction of the adverse outcome in head and neck microvascular reconstructive surgery

Background

The use of a free flap has become a mainstay of reconstruction following the ablative surgery in head and neck. The success rates are about 90%, however, several factors have been described to have an adverse effect on free flap survival.

Post-operative MRSA infections in head and neck surgery

Purpose

Surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus (MRSA) is a serious post-operative complication, with head and neck cancer patients at greater risk due to the nature of their disease. Infection with MRSA has been shown to be costly and impart worse outcomes on patients who are affected. This study investigates incidence and risks for MRSA SSIs at a tertiary medical institution.

The role of colour duplex sonography in preoperative perforator mapping of the anterolateral thigh flap

The anterolateral thigh (ALT) flap was first described in 1984. It is now widely used in reconstructive surgery following extensive tumour resection in head and neck cancer. Routine preoperative perforator mapping is recommended due to variability of the vascular anatomy of the flap. A wide array of diagnostic tools is available for this purpose, including colour duplex sonography (CDS). In this study, we report our experience with CDS. The number, location, and course (myocutaneous or septocutaneous) of ALT perforators were assessed by CDS prior to reconstructive surgery in 22 patients with head and neck cancer. These data were compared with the intraoperative anatomical findings to assess agreement and reliability. The positive predictive value and sensitivity of CDS in detecting perforator location was 89.4 and 94.4 %, respectively, when compared to the surgical report. CDS also identified the perforator course with 100 % accuracy. Colour duplex sonography is an effective, non-invasive, and relatively inexpensive technique for assessing the location of skin perforators.     

Prophylactic antibiotics in head and neck free flap surgery: A novel protocol put to the test

ObjectiveRecent evidence supports the use of ampicillin-sulbactam as a favored choice for antibiotic prophylaxis following head and neck free flap reconstructive surgery. However, there is a paucity of evidence guiding the optimal duration of antibiotic prophylaxis. The aim of this study is to compare the infection rates of short courses of ampicillin-sulbactam versus extended courses of various antibiotics in head and neck free flap reconstructive surgery.MethodsThis is a retrospective cohort study conducted from 2012 to 2017 at a tertiary academic center on 266 consecutive patients undergoing head and neck surgery with free flap reconstruction. The primary outcome measure was the rate of any infection within 30 days of surgery.ResultsThere were 149 patients who received antibiotic prophylaxis for an extended duration of at least seven days. 117 patients received a short course of antibiotics defined as 24 h for non-radiated patients and 72 h for radiated patients. Postoperative infections occurred in 45.9% of patients, of which 92.6% occurred at surgical sites. There was no significant difference in terms of postoperative infection rate between patients receiving an extended duration of antibiotics versus a short duration (p = 0.80). This held true for subgroups of surgical site infections (p = 0.38) and distant infections (p = 0.59 for pneumonia and p = 0.76 for UTI). Risk factors for infections were identified as hypothyroidism (p = 0.047) and clean contaminated wound classification (p = 0.0002).ConclusionShorter duration of ampicillin-sulbactam prophylaxis in free flap reconstruction of head and neck defects does not negatively affect postoperative infection rates.Level of evidenceLevel 2b.     

Pretreatment performance status and nutrition are associated with early mortality of locally advanced head and neck cancer patients undergoing concurrent chemoradiation

Unexpected fatal events in patients with head and neck cancers undergoing concurrent chemoradiation therapy are a clinical concern. Malnutrition, which is reported frequently in head and neck cancer patients, are associated with immunity derangement. The purpose of this study was to identify risk factors for early death of patients undergoing chemoradiation. We retrospectively analyzed the records of 194 stage III, IVA, and IVB head and neck cancer patients who were treated with chemoradiation between 2007 and 2009. We defined early death as death while receiving chemoradiation or within 60 days of treatment completion. Risk factors for early death were tested using univariate and multivariate analyses. Fourteen patients (7.2 %) experienced early death, 78.6 % of whom died of infection. Univariate analysis revealed significant correlations between early death and several pretreatment variables, including Eastern Cooperative Oncology Group performance status (PS) >1, hemoglobin <10 g/dL, albumin <3 g/dL, body mass index (BMI) <19 kg/m², and peripheral blood total lymphocyte count <700/μL. Multivariate analysis showed that PS >1, BMI <19 kg/m², and peripheral blood total lymphocyte count <700/μL were independent variables associated with early death. Poor performance status and malnutrition before chemoradiation independently predict early death in locally advanced head and neck cancer patients undergoing chemoradiation. Cautious management of head and neck cancer patients with these risk factors is required throughout chemoradiation period.     

Impact of patient comorbidities on head and neck microvascular reconstruction. A report on 423 cases

The aim of this study was to assess the impact of the different subtypes of patient comorbidities on the outcomes of head and neck microvascular reconstruction. A total of 423 patients who underwent head and neck free flap reconstruction in our institution between 2000 and 2010 were included in this retrospective study. The impact of the different subtypes of patient comorbidities (as defined by the Kaplan–Feinstein Index) and other global health status-related factors on free flap success, local and general complications, postoperative mortality and length of stay was assessed in univariate and multivariate analysis. We found no correlation between patient comorbidities and free flap failure. In multivariate analysis, we demonstrated a significant correlation between tobacco consumption (p = 0.04) and local complications. Gastro-intestinal comorbidity (p = 0.005) and malnutrition (p = 0.02) were associated with a higher risk of fistula formation. Diabetes mellitus (p = 0.003), gastro-intestinal (p = 0.02), systemic (p = 0.02) and cardiac comorbidities (p = 0.03) were significant predictors of medical complications. We concluded that the different subtypes of patient comorbidities were relevant predictors of complications in head and neck microvascular reconstruction.     

Predictive factors for prolonged operative time in head and neck patients undergoing free flap reconstruction

PurposeDefining the predictive factors associated with prolonged operative time may reduce post-operative complications, improve patient outcomes, and decrease cost of care. The aims of this study are to 1) analyze risk factors associated with prolonged operative time in head and neck free flap patients and 2) determine the impact of lengthier operative time on surgical outcomes.MethodsThis retrospective cohort study evaluated 282 head and neck free flap reconstruction patients between 2011 and 2013 at a tertiary care center. Perioperative factors investigated by multivariate analyses included gender, age, American Society of Anesthesiologists class, tumor subsite, stage, flap type, preoperative comorbidities, and perioperative hematocrit nadir. Association was explored between operative times and complications including flap take back, flap survival, transfusion requirement, flap site hematoma, and surgical site infection.ResultsMean operative time was 418.2 ± 88.4 (185–670) minutes. Multivariate analyses identified that ASA class III (beta coefficient + 24.5, p = .043), stage IV tumors (+34.8, p = .013), fibular free flaps (−44.8, p = .033 for RFFF vs. FFF and − 67.7, p = .023 for ALT vs FFF) and COPD (+36.0, p = .041) were associated with prolonged operative time. History of CAD (−43.5, p = .010) was associated with shorter operative time. There was no statistically significant association between longer operative time and adverse flap outcomes or complications.ConclusionAs expected, patients who were medically complex, had advanced cancer, or underwent complex flap reconstruction had longer operative times. Surgical planning should pay special attention to certain co-morbidities such as COPD, and explore innovative ways to minimize operative time. Future research is needed to evaluate how these factors can help guide planning algorithms for head and neck patients.     

The use of negative pressure wound therapy in the primary setting for high-risk head and neck surgery

BackgroundIn head and neck surgery, dead space is typically managed by transferring a secondary pedicled flap or harvesting a larger composite flap with a muscular component. We demonstrate the novel use of prophylactic negative pressure wound therapy (NPWT) to obliterate dead space and reduce possible communication between the upper aerodigestive tract and the contents of the neck.MethodsWe present a single-institutional case series of five patients with high-risk head and neck cancer treated with NPWT after ablative and reconstructive surgery to eliminate dead space following surgical resection.ResultsAll patients achieved successful wound closure following NPWT, which was applied in the secondary setting to combat infection in one patient and the primary setting to prophylactically eliminate dead space in four patients.ConclusionNPWT can be used to treat unfilled dead space in the primary setting of head and neck ablative and reconstructive surgery and help to avoid wound healing problems as well as the need for secondary flap transfers.     

The prognostic value of cyclin D1 expression in head and neck squamous cell carcinoma

The correlation between cyclin D1 overexpression and the clinical outcome of head and neck cancer is not defined. The aim of this meta-analysis was to evaluate the prognostic value of cyclin D1 in patients with head and neck cancer. A search thorough Ovid MEDLINE was performed to enroll all eligible articles. Twenty-two studies comprising a total of 1,929 patients with different head and neck cancers were included. Cyclin D1 overexpression was significantly associated with lymph node metastasis [OR 2.25; 95 % confidence interval (CI) 1.76–2.87] and worse disease-free survival (OR 3.06; 95 % CI 2.42–3.87]. Subgroup analysis revealed that cyclin D1 overexpression correlated significantly with nodal metastasis for laryngeal cancer (OR 2.26; 95 % CI 1.61–3.16) and was a significant poor predictor for nasopharyngeal cancer (OR 4.44; 95 % CI 1.89–10.42). Our meta-analysis suggests that cyclin D1 overexpression could represent an important prognostic indicator for patients with head and neck cancer.     

Surgical versus non-surgical management of early stage oropharyngeal squamous cell carcinoma

National guidelines state that early-stage oropharyngeal carcinoma can be treated by either primary surgery or radiotherapy. There is a paucity of evidence comparing surgery versus non-surgical therapy within the same population. With the shift in head and neck cancer treatment towards primary chemoradiation, the aim of this observational cohort study was to help define whether surgery still has a role for early-stage oropharyngeal disease, using a national prospective audit of all new head and neck cancers recruited between 1999 and 2001 in Scotland. Patients with T1-2 N0 M0 tumours were identified. Patients were divided into those treated surgically (±adjuvant radiotherapy) or non-surgically. Five-year outcome data were calculated. Forty-two patients were treated surgically (13 received adjuvant radiotherapy) and 32 patients treated non-surgically. Disease-specific 5-year survival was 69 and 60%, respectively (p?=?0.22). Locoregional failure occurred in seven of the surgical group and five of the non-surgical group. The success of chemoradiotherapy and the evidence for its use as adjuvant therapy may dissuade clinicians from considering surgical intervention. This study demonstrates the outcomes of surgical and non-surgical therapy within the same population. Where clear margins can be achieved, and in the absence of negative prognostic neck pathology, surgery remains a good option; allowing radiotherapy to be preserved for locoregional failures or second primary tumours. Although there are limitations to this study, it does demonstrate the benefit of prospective population data collection.     

Comparison of HPV prevalence in HNSCC patients with regard to regional and socioeconomic factors

HPV infection is considered as an independent risk factor for head and neck squamous cell carcinomas (HNSCC). Due to highly variable prevalence results in numerous studies, it is, however, difficult to estimate the relevance of HPV infection as risk factor for a specific patient collective. This study aimed to elucidate the disparities of HPV prevalence by analyzing socioeconomically and regionally different patient collectives. Two age, gender, stage and tumor location matched cohorts of 18 private health insured (PHIP) and 16 statutory health insured patients (SIP) suffering from an oropharyngeal squamous cell carcinoma (OSCC) and treated at a university hospital were screened for p16 overexpression and HPV infection by immunohistochemistry and PCR. In addition 85 HNSCC patients of an otolaryngology private practice (PPP) in a rural area were screened for p16 overexpression and positive cases were tested for HPV infection. HPV prevalence was 72.2 % in the PHIP collective in comparison to 25.0 % (p = 0.015) in the SIP collective with a significantly improved 5-year overall survival (p = 0.003) of the PHIP collective. The total HPV prevalence of PPP group was 7.1 % with the highest infection rate in tonsillar carcinomas (33.3 %) and a larger percentage of female patients in the HPV positive group (p = 0.037). This study shows that variable HPV infection rates in HNSCC can be caused by the selection of particular patient collectives, which suggest taking socioeconomic and regional factors into account for a decision on HPV testing, if it is not performed on a routine basis.     

Complications of sclerotherapy for 75 head and neck venous malformations

Sclerotherapy is one treatment option for head and neck venous malformations (VMs). Evaluation of complication risks is, however, essential to improve its safety. We aimed to systematically report sclerotherapy complications by means of the Clavien-Dindo classification and to distinguish factors predisposing to complications. We identified our institution’s head and neck VM patients who received sclerotherapy between 1 January 2007 and 31 August 2013, analyzed patient reports retrospectively, and applied to them the Clavien-Dindo classification. Our 75 VM patients underwent a total of 150 sclerotherapy sessions. The most common sclerosants were 3 % sodium tetradecyl sulfate and polidocanol. Complications occurred in 13 patients (17.3 %) and in 15 sessions (10.0 %); 3 complications required extensive postprocedural treatment and caused permanent morbidity, whereas 12 received conservative treatment. Patients with sclerotherapy complications underwent more treatments (p = 0.009) and more often needed further surgery (p = 0.007). We thus consider sclerotherapy a relatively safe treatment modality for head and neck VMs. To avoid complications, evaluation of VM characteristics and optimal treatment technique in a multidisciplinary team is vital.     

Are second primary head and neck cancers with previous hematological malignancy more aggressive than de novo head and neck cancers?

ObjectivesSecondary solid tumors can occur after the treatment of hematological malignancies and are associated with a poor prognosis. We evaluated the survival outcomes of patients with second primary head and neck cancers according to the site of cancer origin, type of hematological malignancy, and age.Materials and methodsWe enrolled all patients who underwent surgery for second primary head and neck cancer and were previously treated for hematological malignancy between 1997 and 2020. We analyzed the survival outcomes of patients with second primary head and neck cancer, and compared them with 3126 de novo head and neck cancer patients diagnosed during the same period at our hospital.ResultsThe 5-year overall survival (OS) rate was significantly worse for second primary head and neck cancer patients than de novo cancer patients (52.0 % and 77.9 %, respectively; p = 0.04) and those results were similarly observed in second primary oral cavity cancer (33.3 % and 75.7 %, respectively; p < 0.01). Patients with myelodysplastic syndrome and acute myeloid leukemia showed significantly worse 5-year OS rate than those with other types of hematological malignancies (p = 0.036). Multivariate analysis showed that bone marrow transplantation (BMT) was a risk factor for the recurrence of head and neck cancers (odds ratio = 6.635, p = 0.042).ConclusionPatients with second primary head and neck cancer, particularly of the oral cavity, had a worse prognosis than patients with de novo head and neck cancer. BMT predicts recurrence in second primary head and neck cancer patients.     

Two-year results of a prospective preventive swallowing rehabilitation trial in patients treated with chemoradiation for advanced head and neck cancer

The objective of the study was the assessment of the results of a prospective clinical trial with two preventive swallowing rehabilitation programs on the long-term side effects of chemoradiotherapy (CCRT) in advanced head and neck cancer patients. The study cohort consisted of 29 patients, randomized in two exercise groups: a standard (S) group receiving routine swallowing exercises (N = 14), and an experimental (E) group receiving swallowing exercises based on the TheraBite® Jaw Motion Rehabilitation System? (N = 15). Assessment of functional changes was carried out with multidimensional outcome measures (e.g., videofluoroscopy, study-specific questionnaires) at four time points (pre-treatment, at 10 weeks, 1 year, and 2 years post-treatment). Overall, in the first year post-treatment many initial tumor- and treatment-related problems diminished significantly, except xerostomia (59 %). The only additional improvement at 2 years was that the overall weight significantly further increased (p = 0.000), however, without regaining baseline value. In the subgroup analysis according to exercise group, this difference was significant in the E-group only (p = 0.002). The same was the case for the subgroup analysis according to site of disease, with a significant weight gain in the ‘below the hyoid bone’ group only. This study shows that the overall functional problems at 1 and 2 years post-CCRT are limited. Both rehabilitation programs produce similar results, with a slight but significant benefit for the E-group in weight gain at 2 years, as also seen in the ‘below the hyoid bone’ group. Both rehabilitation programs applied are feasible and show good compliance despite the burdensome CCRT.     

Factors involved in free flap thrombosis after reconstructive surgery for head and neck cancer

Objective

Reconstructive surgery in which a free flap is used following extended resection for head and neck cancer has been popular for more than a quarter of a century. However, postoperative total flap necrosis has not been completely resolved, and few studies have analyzed the specific risk factors for this complication.

Methods

Over a three-year period from 2005 to 2007, 388 flaps were used for reconstructive surgery on 384 patients at Department of Head and Neck of the Cancer Institute Hospital of Japanese Foundation for Cancer Research, and the results for 22 flaps with thrombosis were analyzed.

Results

The only statistically significant risk factor for free flap thrombosis was the history of radical concurrent chemoradiotherapy.

Conclusions

It will be necessary to keep this observation in mind when performing salvage surgery following chemoradiotherapy, which is expected to be performed more often in the future.     

Hypotensive anaesthesia and bleeding during endoscopic sinus surgery: an observational study

Significant bleeding during functional endoscopic naso-sinusal surgery (FESS) impairs recognition of anatomical references and may negatively affect surgical outcome. Through their hypotensive effect, adjuvant anaesthetic agents may influence intraoperative bleeding. The present study compared intraoperative bleeding in patients undergoing FESS administered a clonidine-based anaesthetic regimen and in patients receiving other an anaesthetic combination with higher acquisition costs. Prospective observational study included 37 subjects undergoing FESS in 2011. Assessment of intraoperative bleeding was according to type of anaesthesia (clonidine vs. opioid derivatives). Patients receiving clonidine (N = 11; 29.7 %) presented significantly lower surgical field bleeding scores than those receiving opioid derivatives (N = 26; 70.3 %) [mean (SD) Boezaart scores 1.91 (0.53) vs. 2.92 (0.79), p < 0.0001]. The multivariate analysis including baseline characteristics and risk factors related to bleeding intensity showed that the type of drug used for controlled hypotensive anaesthesia was the best predictor of bleeding during FESS, with an OR of 0.03 for clonidine based vs. opioid based anaesthesia (p = 0.014). The anaesthetic combination including clonidine for controlled hypotensive anaesthesia produces lower levels of surgical field bleeding during FESS. Compared with other hypotensive anaesthetics, clonidine is inexpensive and associated with better surgical conditions during FESS. If confirmed through randomized clinical trials, the use of clonidine during FESS can reduce surgical time and improve surgical results through a less bloody field, resulting in lower patient morbidity and improvement of operating room resources.