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.     

锌,铁预防豚鼠钻井井场噪声性听力损失的实验观察

为观察给予饲料中添加锌,铁喂养豚鼠,采用听性脑干反应(ABR)和耳蜗电图(EcochG)及扫描和透射电镜技术观察,在钻井井场柴油机旁噪声[102 dB(A)]暴露下豚鼠听功能和耳蜗毛细胞的变化.结果表明,当脱离噪声后听力逐渐恢复,于第7d组可见明显恢复.耳蜗毛细胞改变明显减轻,并逐渐恢复正常.而喂普通饲料组未见恢复.证明锌、铁能有效地防治钻井井场噪声所致的听力损伤.     

Carcinoma of the oropharynx: factors affecting outcome

OBJECTIVES/HYPOTHESIS: To assess the value of both patient- and tumor-related factors of oropharyngeal squamous cell carcinoma in predicting patient outcome, with respect to the three primary subsites of the disease. It was hypothesized that the subsite has a significant impact on outcome. STUDY DESIGN: Historical cohort study. METHODS: A chart review was conducted of 126 patients diagnosed with squamous cell carcinoma of the oropharynx over a 10-year period. The oropharynx was divided into the following subsites: 1) base of tongue, 2) tonsil and pillars, and 3) uvula, soft palate, and posterior pharyngeal wall. Patient-related factors included age and gender. Tumor-related factors included American Joint Committee on Cancer stage, T stage, N stage, and grade. These factors were compared using the end points of disease-free survival and treatment response (complete response or partial response/no response). RESULTS: Tumor-related factors such as American Joint Committee on Cancer stage (P = .016) and T stage (P = .008) had a significant impact on treatment response. The American Joint Committee on Cancer stage (P = .030) and the T stage (P = .005) were also significant predictors of disease-free survival. Base-of-tongue lesions responded significantly worse to treatment than did tonsil and pillar or uvula, soft palate, and posterior pharyngeal wall lesions (P = .014). The disease-free survival for base-of-tongue cancer was significantly worse than for tonsil and pillar or for uvula, soft palate, and posterior pharyngeal wall cancer (P = .010). CONCLUSION: Patient-related factors such as age and gender were not significant in predicting disease-specific outcome. Important tumor-related factors were the American Joint Committee on Cancer stage and the T stage. Among the oropharyngeal subsites, squamous cell carcinoma of the base of tongue was associated with the worst outcome.     

An anionic charge barrier in the guinea pig cochlea

Summary A charge barrier has been found in the the glomerular basement membrane of the kidney and plays an important role in the filtration of solutes. In the present study, we used electron microscopy to localize anionic sites of a similar charge barrier in the guinea pig cochlea. Polyethyleneimine (PEI) was used as a cationic marker to detect anionic sites. Our results showed a localization of PEI with regular interspaces, indicating the anionic sites to the charge in the capillary basement membrane of the stria vascularis and the spiral ligament, and in the basal lamina of Reissner's membrane and the spiral prominence. This charge barrier, as well as structural size barrier, may play an important role in the maintenance of normal inner ear functions.     

Does evaluation of tumor volume or/both origination site better guide to optimal surgery for inverted papilloma?

IntroductionSinonasal inverted papilloma is noted for its high rate of recurrence. Staging systems aid to reduce recurrence and avoid excessive surgeries by guiding the selection of the optimal surgical approach.ObjectiveTo evaluate the effectiveness of different endoscopic approaches in inverted papilloma by assessing tumor origin site and tumor volume.MethodsKrouse classification system that is based on tumor volume was used for staging; furthermore, tumor origin sites were grouped as lateral nasal wall, medial wall and other walls of maxillary sinus. The main treatment method for all patients was endoscopic sinus surgery. Endoscopic extended middle meatal antrostomy, endoscopic Caldwell-Luc and endoscopic medial maxillectomy were the additional surgery types performed in different combinations.ResultsFifty-five patients (42 male) with a mean 54.9 ± 14.4 years of age were included. 37 patients were diagnosed with advanced stage inverted papilloma (67.2 %). Recurrence was observed in 12 patients (21.8 %). In early stage lateral nasal wall origination, no recurrence was observed in the simple tumor resection group (0/10). In early stage medial wall origination, no recurrence was observed in the extended middle meatal antrostomy group (0/8). In advanced stage medial wall origination, the recurrence rates of extended middle meatal antrostomy, extended middle meatal antrostomy + endoscopic Caldwell- Luc and endoscopic medial maxillectomy were 100.0 %, 53.8 % and 13.6 %, respectively (p  = 0.002). In advanced stage other walls of maxillary sinus origination, recurrence rates of extended middle meatal antrostomy + endoscopic Caldwell-Luc and endoscopic medial maxillectomy were 20 % and 16.6 %, respectively (p  = 0.887).ConclusionTumor origin site, tumor stage and surgery types show an impact on recurrence. Despite the fact that tumor origin site singly could lead to appropriate selection of the surgery type in most cases, tumor stage carries substantial importance in selection of surgery type for sinonasal-inverted papilloma. An operation plan regarding both tumor volume and tumor origin site may aid surgeons in selecting optimal endoscopic surgical method to avoid recurrence or excessive surgeries.     

Lymphepithelioma-like carcinoma of the lacrimal gland

In this report a patient with a lymphoepithelioma (LE)-like carcinoma of the lacrimal gland is described for the first time in the literature. LE-like carcinomas outside the nasopharynx rarely occur in the major and minor lacrimal glands of natives of Greenland, Inuit or natives of southern China. The patient’s tumor was extirpated using a Krönlein approach followed by total parotidectomy and modified radical neck dissection on the ipsilateral side after the detection of suspicious lymph nodes by ultrasound transmission. Adjuvant radiochemotherapy with cisplatin and 5-fluorouracil was then carried out. Three years later there is no sign of recurrence. As a result of this case we recommend careful examination of the orbit and lacrimal gland in cases of LE-like cancer with an unidentified primary tumor.     

Observational study of the long-term impact of donor-site sequelae after head and neck reconstruction by free anterolateral thigh flap

ObjectiveFree anterolateral thigh flap has many applications in head and neck reconstruction surgery. The aims of the present study were: (1) to assess functional and esthetic sequelae of harvesting for oncologic purposes; and (2) to assess long-term impact of harvesting on quality of life according to patient and to physician.Materials and methodsForty-one patients undergoing reconstruction by free anterolateral thigh flap following oncologic head and neck surgery were assessed by questionnaire at > 6 months postoperatively. Donor site sequelae were assessed in consultation. Harvesting impact was assessed on 5-point Likert scales by patient and by surgeon.ResultsThirty nine percent of patients showed ≥ 1 sequelae. Donor site sequela impact on sport, daily living and work was assessed by patients as none or mild in 94%, 98% and 100% of cases, respectively. Sixty-one percent of patients and 58.5% of surgeons considered scar esthetics to be discreet or very discreet.ConclusionMorbidity related to anterolateral thigh flap harvesting was low, and functional sequelae at the donor site were well tolerated. The scar was only moderately satisfactory, but could easily be hidden.     

Short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest

OBJECTIVES/HYPOTHESIS: The existing literature on postoperative donor extremity function describes a spectrum of morbidity in the long term (>3 mo after surgery). However, the consensus is that there is minimal to no impact of flap harvest on patients' activities of daily living. No previous reports have examined functional donor site morbidity in the early postoperative period; such may affect patients' overall perioperative progress, especially with respect to donor extremity dominance. The authors' objective was to quantify functional morbidity of the donor site in radial forearm fasciocutaneous free flaps during the early postoperative period. STUDY DESIGN: Retrospective case series review. METHODS: Patient data were obtained from hospital records of 12 consecutive patients who underwent head and neck reconstruction with radial forearm fasciocutaneous free tissue transfer over a 6-month period at a tertiary academic medical center. Functional results of each patient's donor extremity obtained preoperatively and at 5 to 8 days after surgery were determined by quantifying forearm supination and pronation, wrist flexion and extension, and sharp and dull hand sensations in radial, median, and ulnar nerve distributions. RESULTS: Mean patient age was 57 years (age range, 42-71 y). The nondominant extremity was the donor site in 9 of 12 patients. Using the paired two-tailed t test, statistically significant differences were demonstrated in preoperative versus postoperative forearm supination (P <.032), pronation (P <.006), wrist flexion (P <.000), and wrist extension (P <.000). Three of 12 patients demonstrated diminished sharp sensation in the "anatomical snuffbox" distribution. CONCLUSION: The authors describe statistically significant functional forearm and wrist range-of-motion morbidity associated with the harvest of a radial forearm fasciocutaneous free flap in the early postoperative period.     

Obstructive site localization using multisensor manometry versus the Friedman staging system in obstructive sleep apnea

The aim of this study was to find the correlation between an anatomy-based staging system and pressure manometry performed during sleep. A retrospective study of 45 patients with obstructive sleep apnea (OSA) was carried out. All patients were evaluated by polysomnography, and obstruction sites were localized using a multisensor manometer during the full night. Obstruction sites were classified into retropalatal and retroglossal. The patients were also staged by anatomic findings of tonsil size and palate position. The % retroglossal obstruction was 29.4, 33.5 and 48.6% in stages I, II and III, respectively. There was no significant difference between stages. In contrast, when compared according to the Friedman tongue position (FTP), the mean % retroglossal obstruction of FTP grade 3 was significantly higher than that of FTP grade 1 (P = 0.009) although apnea hypopnea index, body mass index and lowest SpO₂ were not different among FTP grades. It seems that FTP correlates with retroglossal obstruction and may be used to select patients in need of retroglossal modification of the airway. C. H. Lee and T.-B. Won contributed equally to the content of this article.     

Treatment of the donor site of free radial flaps: vacuum sealing versus conventional wound care

Introduction: Radial forearm flap donor side defects can be treated by vacuum therapy and conventional wound dressing. The aim of this study was to compare different wound management considering wound healing, including risk factors and cost effectiveness.

Materials and methods: Retrospective study including patients treated with radial flaps in the Department of Head and Neck Surgery in Erlangen from January 2005 to August 2013. Wound healing was assessed regarding complications considering several risk factors and comorbidities. Data were analyzed comparing conventional dressing and vacuum therapy, including a calculation of costs.

Results: The study included 138 patients (n?=?55 conventional dressing; n?=?83 vacuum dressing). The incidence of wound complications in the vacuum group was 50.6 and 32.7% in the conventional dressing group (p?=?.058). The presence of risk factors and comorbidities did not have significant impact on the occurrence of complications. Costs for vacuum therapy turned out to be at least five times higher.

Conclusion: In view of the current state of research, these results show that using vacuum dressings has no significant benefit in the wound management of forearm donor side defect covered with full-thickness skin grafts. If the costs and economical aspects are also considered, conventional wound dressing may be preferred.     

Diagnostic utility of positron emission tomography-computed tomography for predicting malignancy in cystic neck masses in adults

OBJECTIVES: Combined positron emission tomography and computed tomography (PET-CT) is used for the diagnostic evaluation and staging of squamous cell carcinoma of the head and neck (SCCHN). By superimposing anatomic localization of CT with the physiologic data of PET, occult primary and metastatic neoplasms might be identified. Because the diagnostic algorithm for cystic neck masses in adults often overlaps with the work-up of cancer of unknown primary site, we evaluated the utility of PET-CT scans to identify the presence of malignancy and the location of primary tumor. STUDY DESIGN: Single-institution retrospective case review series. METHODS: We reviewed the PET-CT imaging of cystic neck masses occurring in five patients over 40 years of age with significant risk factors for SCCHN and correlated this information with histopathology. RESULTS: In each patient in our series, the PET portion of a combined PET-CT was misleading, whereas the CT examination was more suggestive of the correct pathology. Ultimately, clinical judgment and endoscopic evaluation, guided by CT findings, were most valuable for distinguishing malignant versus benign processes and identifying the primary tumor sites. CONCLUSIONS: PET-CT may not be a reliable modality for identifying malignancy in adults with suspicious cystic neck masses. A thorough clinical evaluation by an experienced head and neck surgeon, in conjunction with contrast-enhanced CT, may be sufficient to facilitate the optimal management of such patients.     

Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio as predictors of wound healing failure in head and neck reconstruction

Conclusions: In microsurgical head and neck reconstruction, a higher rate of post-operative wound complication could be predicted by a lower pre-operative neutrophil ratio (Objectives: To evaluate the predictor of post-operative wound complications in microsurgical head and neck reconstruction.

Methods: Patients who were undergoing tumor ablation and microsurgical reconstruction from April 2011 to March 2014 were analyzed retrospectively. The pre-operative hematological data, age, sex, co-morbidities, body mass index (BMI), adjuvant therapies, smoking, operation time, blood loss, total protein, T-stage, and Anesthesiologists Performance Status (ASA-PS) score were collected. Cases of post-operative wound healing failure were reviewed.

Results: One hundred and three consecutive patients were enrolled. Among these, the results of 77 patients who were younger than 70 years of age were analyzed. The distributions of the neutrophil ratio (p?=?.0005), lymphocyte ratio (p?=?.0166), monocyte ratio (p?=?.0341), NLR (p?=?.005), and PLR (p?=?.008) differed significantly between the patients with and without post-operative wound healing failure. Neutrophil ratio, NLR, and PLR cut-off values of 64.9, 3.5, and 160 were significantly associated with the rate of wound healing failure rate (p?=?.0002, .00021, .0042, respectively).     

Sugar-binding sites with specificity for glucosamine in the guinea pig middle ear mucosa

Summary Glucosamine-binding sites were detected in Lowicryl K4M-embedded guinea pig middle ear mucosa by electron microscopy, using glucosaminyl bovine serum albumin. Incubation of ultrathin tissue sections with gold-labeled glucosaminyl bovine serum albumin (GlcN/BSA/gold) resulted in binding mainly on cilia, microvilli, rough endoplasmic reticulum and nuclei. The sugar binding was not inhibited after ultrathin sections had been digested with trypsin or neuraminidase. Various carbohydrates and glycoconjugates were tested as competitive inhibitors of G1cN/BSA/gold labeling on the tissue sections. The sugar specificity range detected by the glucosamine-binding sites included glucosamine, N-acetylglucosamine, mannose and fucose, whereas N-acetylgalactosamine, galactose and glucose were not detectable. A series of endotoxic substances such as Salmonella minnesota Re595 lipid A complex with BSA and lipopolysaccharides (LPS) derived from Escherichia coli 055: B5 or S. minnesota Re595 also competed with GlcN/BSA/gold binding. This indicates that the lipid A backbone glucosamine or other carbohydrate portions of LPS is a part of the structure recognized by glucosamine binding sites.     

Second osteocutaneous fibular free flaps for head and neck defects

OBJECTIVE: To analyze the morbidity of a second fibular free tissue transfer when necessary in rare instances when the initial fibular flap fails. CASE DESIGN: Retrospective analysis of a case series. METHODS: A database of patients who underwent resection of head and neck malignancies with resultant free flap reconstruction was analyzed retrospectively. All patients undergoing fibular free flaps were studied, and those needing a second fibular osteocutaneous flap were identified. The morbidity from the second flap was evaluated by a standard questionnaire. RESULTS: Seven patients underwent a second fibular osteocutaneous flaps for reconstruction; data were available from six. The indications for the second flap were perioperative flap loss (5 patients), osteoradionecrosis (1), and recurrent tumor (1). Follow-up began at 3 months; mean follow-up was 44 (range 9-67) months. The morbidity of harvesting a second fibular flap was similar to that of a unilateral harvest. Four of six patients rated their overall morbidity as low; one patient indicated an intermediate morbidity, and one patient rated their morbidity from the procedure as major. The only donor site morbidities were episodes of mild cellulitis that resolved with outpatient antibiotics. CONCLUSION: Harvest of a second fibular osteocutaneous is a reasonable option for reconstruction when a second flap becomes needed. The morbidities are comparable with those encountered with a unilateral fibular flap harvest.     

Basic study of nasal provocative test first report: Side,site of the nose,size of site and allergen amount

Summary The methodology of the provocative nasal test has varied according to the investigators. In order to establish a standard method of this test quantification of the nasal challenge, including the amount of the allergen, nasal site, side and size of allergen deposition, was studied. From the results obtained it is preferable to use the end point test and to apply allergen to the anterior part of the inferior turbinate in a 7mm² size of surface area, bilaterally. An alternative test is to use a fixed amount of allergen (500 g house dust in house dust allergy).