Dysphagia in Head and Neck Cancer Patients: Pretreatment Evaluation,Predictive Factors,and Assessment during Radio-Chemotherapy,Recommendations

Progress in head and neck cancer (HNC) therapies has improved tumor response, loco-regional control, and survival. However, treatment intensification also increases early and late toxicities. Dysphagia is an underestimated symptom in HNC patients. Impairment of swallowing process could cause malnutrition, dehydration, aspiration, and pneumonia. A comprehensive literature review finalized in May 2012 included searches of electronic databases (Medline, Embase, and CAB abstracts) and scientific societies meetings materials (American Society of Clinical Oncology, Associazione Italiana Radioterapia Oncologica, Associazione Italiana di Oncologia Cervico-Cefalica, American Head and Neck Society, and European Society for Medical Oncology). Hand-searches of HNC journals and reference lists were carried out. Approximately one-third of dysphagia patients developed pneumonia requiring treatment. Aspiration pneumonia associated mortality ranged from 20% to 65%. Unidentified dysphagia caused significant morbidity, increased mortality, and decreased the quality of life. In this review we underline definition, causes, predictive factors of dysphagia and report on pretreatment and on-treatment evaluation, suggesting some key points to avoid underestimation. A multi-parameter assessment of swallowing problems may allow an earlier diagnosis. An appropriate evaluation might lead to a better treatment of both symptoms and cancer.     

头颈肿瘤术后大范围缺损的重建与修复

目的 为解决头颈部晚期恶性肿瘤术后大范围缺损造成的器官功能障碍和容貌毁损。方法 采用各种修复方法对７例患者进行了一期重建与修复,应用胃造瘘术防治术后咽瘘。结果 ６例患者获得成功（８５．７％）,获功能、容貌及心理三重功效。结论 根据组织缺损部位、范围及特点和功能的不同来选择不同的修复方法,胃造瘘术是一种有效的咽瘘防治手段。     

Results of Free Flap Reconstruction After Ablative Surgery in the Head and Neck

Objectives

Due to the complex anatomy and function of the head and neck region, the reconstruction of ablative defects in this area is challenging. In addition, an increasing interest in improving the quality of life of patients and achieving good functional results has highlighted the importance of free flaps. The aim of this study was to summarize the results of free flap reconstruction and salvage of free flaps in a single institute, and to analyze differences in the results by the flap donor site, recipient site, and learning curve.

Methods

The medical records of patients who underwent free flap reconstruction from 2004-2012 were reviewed retrospectively. One hundred and fifty free flaps were used in 134 patients, who had an average age of 57.7 years. The types of flaps applied, primary defect sites, success rates, results of salvage operations for compromised flap, and the learning curve were analyzed.

Results

The anterolateral thigh flap was preferred for the reconstruction of head and neck defects. The overall success rate was 90.7%, with 14 cases of failure. A total of 19 salvage operations (12.7%) for compromised flap were performed, and 12 flaps (63.2%) were salvaged successfully. Dependency on the facial vessels as recipient vessels was statistically different when oral and oropharyngeal defects were compared to hypopharyngeal and laryngeal defects. The learning curve for microvascular surgery showed decrease in the failure rate after 50 cases.

Conclusion

The free flap technique is safe but involves a significant learning period and requires careful postoperative monitoring of the patient. Early intervention is important for the salvage of free flaps and for lowering the failure rate.     

Length of Stay After Free Flap Reconstruction of the Head and Neck

Objectives: To analyze the incidence and timing of postoperative complications after free tissue transfer (FTT) and relate that to length of stay (LOS.) Study Design: We reviewed one surgeon's experience with 97 patients undergoing 100 head and neck reconstructions via FTT for a variety of traumatic and ablative defects. Methods: Charts were reviewed for demographic data, type of defect and flap, complications, LOS, length of intensive care unit (ICU) stay, date of decannulation, and first oral intake, any readmission to the hospital, and preoperative radiation status. Results: Using strict guidelines, 31% of patients had some form of complication, including a 9% flap failure rate. Average postoperative LOS for all patients was 11 days. Average LOS for uncomplicated cases was 9 and for complicated cases was 16 days. For cases with flap‐related complications the average LOS rose to 20 days. All reconstructive failures (defined as patients requiring subsequent surgical procedures after a flap‐related complication, regardless of outcome) occurred within the first 7 postoperative days. Three patients were readmitted for various reasons: a partial flap dehiscence (postoperative day [POD] 9), meningitis (POD 24), and orocutaneous fistula (POD 22), for a 3.2% readmission rate. Fourteen percent of patients were on a regimen of oral intake, and 13% had decannulation by the time of discharge. Resumption of oral intake and tracheostomy decannulation were accomplished on an outpatient basis in the remainder of patients. Conclusions: There were no preventable complications associated with early hospital discharge, nor was there evidence of adverse patient outcome. We conclude that early hospital discharge is feasible after FTT reconstruction and is consistent with quality care.     

Wound Complications in Head and Neck Squamous Cell Carcinomas After Anti–PD‐1 Therapy

Immune checkpoint inhibitors have demonstrated activity in recurrent/metastatic head and neck squamous cell cancer, but less is known regarding their long‐term sequelae. We describe four patients who, after complete responses to anti–PD‐1 therapy, developed complications requiring surgical intervention. Patient 1 is a 57‐year‐old female whose marked tumor regression exposed some mandibular hardware. Patient 2 is a 39‐year‐old male who developed an ulcerated buccal lesion with exposed mandible. Patient 3 is a 66‐year‐old male with craniofacial osteoradionecrosis. Patient 4 is a 71‐year‐old male who developed an exposed and fractured mandible. All patients successfully underwent surgical intervention and remain disease free. Laryngoscope, 129:E428–E433, 2019     

Assessment of Carotid Artery Invasion in Patients With Head and Neck Cancer

Purpose Define radiological and histological features in which patients with head and neck cancer would benefit from a carotid artery resection. Resection of the carotid artery has been advocated for local control of advanced squamous cell carcinoma of the head and neck. To provide appropriate preoperative counseling and optimize the utilization of resources, the criteria for patient selection has to be defined. Methods Thirty‐four patients underwent carotid artery resection based on the clinical impression of tumor fixation. Eighteen and 28 patients were evaluated using computed tomography (CT) and histological analysis, respectively. The distance between the tumor cells and external elastic lamina was measured. CT scans were examined to determine the circumference of tumor attachment around the carotid artery. Results Clinical assessment predicted tumor within 1.8 mm of the carotid artery in 68% of cases. The overall survival for patients with tumor greater than 1.8 mm (N = 9) was better than that of patients with less (N = 19) than 1.8 mm (33.3% vs. 5.3%; median 24 versus 9 mo, P = .0899). Three of six patients (50%) with less than 180° circumference tumor attachment had tumor within 1.8 mm from the external elastic lamina. Eight of twelve patients (67%) with tumors encompassing more than 180° of the artery wall had tumor within 1.8 mm from the external elastic lamina. The overall survival rates for patients with tumor attachment greater and less than 180° were 8.3% and 33%, respectively. Discussion Tumor invasion into the carotid artery was the strongest predictor of outcome. Clinical assessment was as predictive as CT for tumor invasion. If tumor involvement of the carotid artery is less than 180°, peeling the tumor is an alternative to carotid artery resection.