Intraparotid node metastases in adults with parotid mucoepidermoid cancer: an indicator of prognosis?

We have retrospectively analysed the predictive value of intraparotid nodal metastases in patients having neck dissection for parotid mucoepidermoid cancer. The main outcomes were intraparotid nodal metastases, a new system for staging metastatic parotid nodes, and recurrence-free survival. The overall rate of intraparotid metastasis was 30/122 (25%), and seven patients had deep parotid nodal metastases. This metastasis was significantly related to tumour stage, neck disease, perineural invasion, lymphovascular invasion, and pathological tumour grade. The sensitivity of intraparotid nodal metastases in predicting neck disease was 50%, and the specificity of them predicting neck disease was 89%. The stages of the intraparotid nodes were as follows: P0 (n = 92 patients), P1 (n = 10), P2 (n = 16), and P3 (n = 4). A Cox’s model analysis confirmed that the stage of the intraparotid nodes was an independent prognostic factor for recurrence, so the presence of intraparotid nodal metastases is associated with a higher risk for recurrence of disease.     

Using a patient prompt list to raise concerns in oncology clinics does not necessarily lead to longer consultations

Head and neck oncology post-treatment consultations form a critical component of care in terms of support and surveillance. They occur frequently in the first few years and can place substantial demands on healthcare resources. However, they provide useful opportunities for patients to raise issues and receive tailored information and support. The aim of this paper was to assess whether completion of a 56-item patient prompt list (PCI - the Patient Concerns Inventory) immediately prior to the consultation significantly increased its duration. This was a pragmatic cluster preference randomised controlled trial of 288 patients with 15 consultant clusters from two sites “using” (n = 8) or “not using” (n = 7) the PCI. Consultation times were known for 283 patients (136 PCI, 147 non-PCI) who attended their first post-treatment trial consultation a median (IQR) of 103 (70-160) days after the end of treatment. Consultations lasted a median (IQR) of 10 (7-13) minutes (mean 11) in non-PCI patients and a median (IQR) of 11 (8-15) minutes (mean 12) in PCI patients (p = 0.07). After adjustment for patient clustering and significant case mix, the 95% confidence interval for the mean difference was between 1.45 minutes shorter with the PCI and 2.98 minutes longer (p = 0.50). There was significant variation in duration by consultant, tumour stage, treatment mode, overall quality of life (QoL), and distress (all p < 0.001). In those who completed the PCI, duration increased with the total number of items selected (p < 0.001). In conclusion, the inclusion of a prompt list to help facilitate conversation with patients did not make a substantial difference to consultation times.     

Head and neck cancer surgery in an elderly patient population: a retrospective review

Should advanced age be a contraindication to the surgical management of head and neck cancer patients? A retrospective chart review was performed of patients aged ≥80 years treated surgically for a head and neck malignancy during the period 1996–2011 in a tertiary care cancer centre. The average follow-up was 32 months. Fifty-three patients were identified (mean age 85 years). Cardiovascular disease was the most prevalent co-morbidity (43%). Forty-five patients (85%) had oral cavity/oropharynx squamous cell carcinoma. Surgeries performed included 40 neck dissections and 12 microvascular free flaps. The average length of hospital stay (LOS) was 6.4 days. An increased LOS was significant in patients requiring free flap reconstruction (P < 0.01). There were no perioperative deaths or free flap failures. The most common postoperative complications were cardiovascular (n = 8), infection (n = 10), and delirium (n = 6). Thirty-four patients were discharged directly home. Free flap reconstruction did not adversely affect discharge disposition (P > 0.05). More than 75% of patients did not report any major limitations to their activities of daily living. Major head and neck surgical procedures can be tolerated by patients of advanced age using careful patient selection. Age alone should not be a primary factor in the management of head and neck cancer patients.     

Selective versus comprehensive neck dissection in the treatment of patients with a pathologically node-positive neck with or without microscopic extracapsular spread in oral squamous cell carcinoma

The objective of this study was to compare the prognosis and complications between selective neck dissection (SND) and comprehensive neck dissection (CND) for patients with a pathologically node-positive neck in squamous cell carcinoma of the tongue and the floor of the mouth. This was a retrospective cohort study. There was no significant difference between the SND group and the CND group in 3-year neck control rate (86.2% vs. 85.9%, P = 0.797) or disease-specific survival (DSS) rate (64.6% vs. 61.9%, P = 0.646). Further analyses of the respective 3-year DSS rates in the SND and CND subgroups were as follows: pN1 without extracapsular spread (ECS), 67.7% vs. 72.2%, P = 0.851; pN2b without ECS, 64.7% vs. 68.8%, P = 0.797; and pN+ with ECS, 57.1% vs. 60.0%, P = 0.939. Of note, there were significantly fewer complications in the SND group compared with the CND group (7.3% vs. 20.0%, P = 0.032). Multivariate analysis showed that the modality of neck treatment, pN+ status, and microscopic ECS did not serve as independent prognostic factors. SND plus adjuvant radiotherapy is a management strategy of high efficiency and minor morbidity for selected oral cancer patients with a pN+ neck with or without microscopic ECS.     

Changes of perfusion of microvascular free flaps in the head and neck: a prospective clinical study

Reconstruction with a free flap is routine in head and neck surgery. However, reliable assessment of perfusion can be difficult, so we prospectively evaluated it in 4 types of microvascular free flaps in the oral cavity (n = 196) and assessed differences in blood flow by non-invasive monitoring with a laser Doppler flowmetry unit. We measured oxygen saturation, haemoglobin concentration, and velocity on the surface of the flap preoperatively at the donor site, and on the flap on the first, second, and seventh postoperative days, and after 4 weeks in 186/196 patients, mean (SD) age of 60 (13) years. We studied the radial forearm (n = 76, 41%), fibular (n = 45, 24%), anterolateral thigh (n = 53, 28%), and soleus perforator (n = 12, 7%) flaps. The values for the radial forearm flap differed significantly from the others. There were significant differences in haemoglobin concentrations between the fibular and soleus perforator flaps, and between the anterolateral thigh and soleus perforator flaps (p = 0.002 each). Free flaps are unique in the way that perfusion develops after microvascular anastomoses. Knowledge of how each flap is perfused may indicate different patterns of healing that could potentially influence long term rehabilitation and detection of future deficits in perfusion.     

Factors contributing to delayed decannulation of temporary tracheostomies following free tissue reconstructive surgery for head and neck cancer

Temporary tracheostomies (TT) are performed to secure the airway perioperatively and postoperatively in head and neck cancer patients undergoing tumour resection and free tissue reconstructive surgery. Patients report that having a TT is unpleasant and they appreciate its removal at the earliest opportunity. Early removal not only improves patient satisfaction but should allow for a more rapid recovery. The aim of this prospective study was to assess factors that contribute to delays in decannulation following TT and hence to provide an insight into the factors that will support earlier decannulation when it is safe to do so. Consecutive patients who had TT over a six-month period were included. Delayed decannulation was defined as that after day seven postoperatively. There were 42 patients with a median (IQR) age of 70 (60-74) years, 26 of whom were men. The tracheostomy was surgical in 29 and percutaneous in 13. The median (IQR) time to decannulation was 4 (3-5) days (range 1-11 days). Seven patients had delayed removal (7-11 days), the reasons being hospital-acquired pneumonia (HAP) (n = 4), prolonged stay in the high dependency unit (HDU) following postoperative myocardial infarction and cardiac arrest (n = 1), failure to tolerate TT occlusion (n = 1), and not stated (n = 1). There were early postoperative complications in 14 patients but despite this seven decannulations were still performed within two and six days. Additional multiprofessional assessment over weekends is likely to facilitate earlier decannulation. As some TTs are removed after a few days there is a need for better selection to avoid their use in certain patients.     

Prognostic value of elective neck dissection in adenoid cystic carcinoma of head and neck: a meta-analysis: A call for randomized trials and international consensus

Adenoid cystic carcinoma of head and neck (AdCCHN) is an uncommon salivary gland cancer characterized for infrequent neck metastases, and high rate of local and distant recurrence. The aim of this meta-analysis was to analyse the significance of elective neck dissection (END) in terms of overall survival (OS) in patients with AdCCHN. A systematic literature search and meta-analysis was performed. Endpoint assessed by this meta-analysis included 5-year OS (death from any cause). Statistical heterogeneity was assessed using the Cochrane Q test and I² statistic. A pooled odds ratio (OR) was reported with 95% confidence interval (CI). There were 1934 patients in the END arm and 3083 in the observation group. The pooled OR, calculated for END vs. observation, was 0.94. Patients receiving END had similar risk for death compared to observation cohort (P = 0.76). No significant difference in final outcome after patient stratification based on T stage was identified (OR for T1/T2 1.27, P = 0.39; OR for T3/T4 0.95, P = 0.90). Observation for cN0 neck is a reasonable option in AdCCHN. These findings suggest the need for prospective trials on indications and extent of END in AdCCHN.     

Survival of oral mucosal melanoma according to treatment,tumour resection margin,and metastases

Because of the poor prognosis and of oral mucosal melanoma, and patients’ short survival, large, randomised, clinical studies are difficult. We have investigated its demographic characteristics and analysed the effect of treatment, resection margins, and metastases on survival. We recorded age, sex, site of primary tumour, and types of treatment, survival, and metastases in 74 patients treated at the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital. Survival was analysed based on bony invasion, depth of invasion, and resection margins, and we found that it varied depending on the primary site (p = 0.002), and declined with liver (p = 0.001) or brain (p = 0.033) metastases. The two-year survival according to the primary site was as follows: palate 85% (n = 32), anterior maxillary gingiva 53% (n = 13), mandible 58% (n = 13), and posterior maxillary gingival 74% (n = 10) and buccal mucosa 50% (n = 4). The two-year survival was 34% (n = 8) in patients with liver metastases and 23% (n = 7) in patients with brain metastases. In cases of bony invasion (p = 0.005), depth of invasion (p = 0.042), unclear resection margin (p = 0.023), or higher T stages (p = 0.009), the survival declined considerably. Neck dissection did not affect survival (p = 0.343). Survival of the patients given chemotherapy was significantly lower (p = 0.013) and the two-year survival was 54.0%. The patients given radiotherapy showed no significant difference in survival compared with those not given radiotherapy (p = 0.107). In conclusion, primary site, bony invasion, resection margins, depth of invasion and systemic metastases were critical to predict prognosis and selection of treatment of oral mucosal melanoma.     

Condylectomy as the treatment for active unilateral condylar hyperplasia of the mandible and severe facial asymmetry: retrospective review over 18 years

Unilateral condylar hyperplasia (UCH) of the mandible is a disorder affecting the condyle size, resulting in facial asymmetry. This study was a retrospective review of 27 patients with UCH who underwent condylectomy between 2000 and 2017 at Yonsei University Dental Hospital. Patient demographic characteristics were summarized. UCH was divided into three subtypes: hemimandibular elongation (HE, n = 15), hemimandibular hyperplasia (HH, n = 4), and osteochondroma (OC, n = 8). Of the 27 patients, only one with the HE type and five (18.5%) with the OC type complained of joint pain. Bone scans of all patients showed higher uptake on the UCH side. Lip and maxillary canting was prominent in the HH and HE types. Five patients (18.5%) underwent condylectomy alone, 13 (48.1%) underwent condylectomy with orthodontic treatment, and nine (33.3%) underwent adjunctive jaw surgery with orthodontic treatment. The treatment modalities varied according to the subtype. In all OC type patients, removal of the hyperplastic condyle treated the facial asymmetry. Additional post-surgical orthodontic treatment was necessary in only three cases (37.5%). All HH type patients required mandibuloplasty. All patients showed a stable occlusal outcome without relapse and an improvement in subjective symptoms, despite a decrease in mouth opening of 2.2 mm. These findings might be useful in treatment planning for UCH patients.     

Outcomes of free flap reconstructive surgery in head and neck cancer patients over 80-years old

An increasing elderly population in the United Kingdom has led to an increasing number of older patients with head and neck cancer, resulting in a greater demand for complex head and neck reconstructive surgery in this potentially high-risk age group. A possible perceived poorer tolerance to such major treatment risks under-treating some of these patients. The purpose of this study was to assess the outcomes in the elderly population (older than 80 years) who had undergone free flap reconstruction following head and neck cancer resection. A retrospective review of 127 patients was performed. Eighteen patients were 80 or older (14.2%) and 109 under 80 (85.8%). The elderly group experienced increased number of postoperative medical complications (p = 0.01), but the surgical complications were not significantly different in the two groups (p = 0.4). The average length of hospital stay was significantly longer in the older group (p = 0.01). There was one flap failure during the study period, which belonged to the younger group of patients. Elderly patients undergoing free flap reconstruction experience an increased rate of postoperative medical complications resulting in an increased length of hospital stay. However, good surgical outcomes can still be achieved in this age group, and therefore age alone should not be considered as a primary factor in head and neck cancer management.     

The prognostic significance of the lymph node ratio in oral cancer differs for anatomical subsites

The aim of this study was to validate the prognostic significance of the lymph node ratio (LNR) in patients suffering from oral squamous cell carcinoma in regard to different anatomical subsites. A cohort of 430 patients was investigated to determine the rates of primary metastasis and local and regional disease recurrence. Correlation analysis of the LNR with relevant clinical and pathological parameters was performed. Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the prognostic impact for different subsites. Significantly differing rates of primary metastasis and loco-regional disease recurrence were found for cancer of different anatomical subsites of the head and neck. Furthermore, ROC curve analysis suggested that LNR has prognostic relevance in subsets of cancer (tongue, P <  0.001; alveolar process, P =  0.04; maxilla, P =  0.03; buccal mucosa, P =  0.02). The LNR of cancer located in the soft palate (P =  0.6) and floor of the mouth (P =  0.11) showed little or no association with the clinical outcome. There is the need for a more sensitive consideration of the LNR as a factor in the assessment of risk and the treatment decision, as the anatomical subsite plays a crucial role in its impact on the clinical outcome.     

Comparison of Hogan pharyngeal flap and sphincter pharyngoplasty in postoperative velopharyngeal function

The purpose of this study was to compare speech and breathing after sphincter pharyngoplasty and the Hogan pharyngeal flap in the management of cleft-related velopharyngeal insufficiency (VPI). We reviewed 78 patients with VPI who had either the Hogan flap (n = 30) or sphincter pharyngoplasty (n = 48) between 2009 and 2011. Velopharyngeal function, nasal patency, and speech were compared. In the Hogan flap group, 25 patients had achieved velopharyngeal competence and nine had normal speech. In the sphincter pharyngoplasty group, 29 patients achieved velopharyngeal competence and 20 normal speech. The Hogan flap group had a higher rate of velopharyngeal competence (n = 25) than the sphincter pharyngoplasty group (p = 0.033), but there was no significant difference in intelligibility of speech. Eighteen patients in the Hogan flap group and 33 in the sphincter pharyngoplasty group reported symptoms of snoring, with no significant difference in nasal ventilation. Our results suggest that a posterior pharyngeal flap is a more effective technique for managing VPI after repair of cleft palate than sphincter pharyngoplasty, and causes no more postoperative complications in nasal breathing.     

Perioperative evaluation of glycaemic status in neck dissection: a retrospective analysis at a single hospital centre

Diabetes mellitus is generally considered a risk factor for impaired wound healing. This study aimed to evaluate the glycaemic status of patients undergoing neck dissection and describe its impact on postoperative outcomes, especially wound healing. A retrospective analysis was performed of the preoperative, intraoperative, and postoperative glycaemic data obtained from the medical charts of 60 adult patients who had undergone 64 neck dissections. Nine of the 64 procedures were performed in diabetic patients (14.1%). The average glucose values were: preoperative 5.99 ± 1.25 mmol/l, intraoperative 8.90 ± 2.62 mmol/l, and postoperative 10.01 ± 2.49 mmol/l. All registered preoperative hyperglycaemia cases (eight cases) were diabetic. Postoperative insulin therapy was done in 14 procedures (21.9%). Wound healing complications were found in five patients (7.8%); there was no wound infection. There was no association of wound healing complications with preoperative diabetic status (P = 1.000), preoperative glucose control (P = 1.000), preoperative (P = 0.469), intraoperative (P = 0.248), and postoperative (P = 0.158) glucose values, or with postoperative glucose control (P = 0.577). These data do not support the association of stress-induced hyperglycaemia or diabetes mellitus with postoperative wound healing problems in neck dissection.     

The impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap: a systematic review and meta-analysis

Reconstructive surgery with a free vascularised tissue flap is indicated in large defects in the head and neck region, which arise mostly because of head and neck cancer. Tobacco smoking is a major risk factor for head and neck cancer, and many patients undergoing reconstructive surgery in the head and neck have a history of smoking. The objective of this meta-analysis was to determine the impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap. A systematic review was undertaken for articles reporting and comparing the incidence of overall surgical complications after reconstructive surgery with a free vascularised tissue flap between smokers and nonsmokers. Relevant articles were searched using PubMed, Cochrane, and Embase databases, and screened for eligibility according to the PRISMA guidelines. The risk of bias analysis was conducted using the Newcastle-Ottawa quality assessment scale. A meta-analysis was performed to quantitatively compare the incidence rate of overall surgical complications, flap failure, surgical site infection, fistula, and haematoma between smokers and nonsmokers using OpenMetaAnalyst (open source) software. Only qualitative analysis was performed for wound dehiscence, bleeding, nerve injury, and impaired wound healing. Forty-six articles were screened for eligibility; 30 full texts were reviewed, and 19 studies were included in the quantitative meta-analysis. From the 19 studies, 18 were retrospective and 1 was a prospective study. In total, 2155 smokers and 3124 nonsmokers were included in the meta-analysis. Smoking was associated with a significantly increased risk of 19.12% for haematoma (95% Confidence Interval (CI): 4.75–33.49; p < 0.01), and of 4.57% for overall surgical complications (95% CI: 1.97–7.15; p < 0.01). No significant difference in risk was found for flap failure (95% CI: ?4.33–9.90; p = 0.44), surgical site infection (95% CI: ?0.88–2.60; p = 0.33) and fistula formation (95% CI: ?3.81–3.71; p = 0.98) between smokers and nonsmokers. Only for flap failure was a significant heterogeneity found (I² = 63.02%; p = 0.03). Smoking tobacco was significantly associated with an increased risk of overall surgical complications and haematoma, but did not seem to affect other postoperative complications. Encouraging smoking cessation in patients who need reconstructive head and neck surgery remains important, but delaying surgery to create a non-smoking interval is not needed to prevent the investigated complications. More high-quality retrospective or prospective studies with a standardised protocol are needed to allow for definitive conclusions.     

Role of computed tomography angiography in the diagnosis of vascular stenosis in head and neck microvascular free flap reconstruction

The aim of this study was to evaluate the role of computed tomography angiography (CTA) in the diagnosis of vascular stenosis at the vascular pedicle of head and neck microvascular free flaps. A prospective study was done of 65 consecutive patients (49 male, 16 female; mean age 55 years) who had undergone head and neck microvascular free flap reconstruction. All patients underwent 64-slice CTA of the carotid artery. Post-processing with volume rendering reconstruction of CTA images was done. There was excellent inter-observer agreement (weighted kappa = 0.82, 95% confidence interval (CI) 0.74–0.93) in grading of the degree of vascular stenosis. The true sensitivity of CTA for diagnosis of stenosis of the vascular pedicle to the flap was 63% (95% CI 63–100%). Patients with failed flaps showed complete occlusion (n = 2) on CTA and underwent a replacement flap procedure. Patients with failing flaps showed severe stenosis (n = 6) of the vascular pedicle on CTA and underwent revision surgery. There was no change in the degree of stenosis on follow-up CTA for patients with moderate stenosis (n = 9). CTA is a reliable, non-invasive, high-quality imaging tool for the diagnosis and grading of vascular stenosis of the vascular pedicle of head and neck microvascular free flaps.     

The influence of 2020 coronavirus lockdown on presentation of oral and maxillofacial trauma to a central London hospital

The novel coronavirus COVID-19 was first identified in China in December 2019. Its spread resulted in a pandemic, with the United Kingdom entering a period of national lockdown on 23 March 2020 to reduce disease burden on the National Health Service (NHS). King’s College Hospital is a Major Trauma Centre serving an inner-city population of 700,000 with 120,000 patients attending the emergency department (ED) annually. We aimed to determine the effect of lockdown on OMFS trauma presentations and lessons learned from emergency service provision during a pandemic. All referrals to the oral and maxillofacial surgical (OMFS) team from ED during the first six weeks of the lockdown period – 23 March 2020 - 3 May 2020 – were compared with the same six-week period in 2019. A total of 111 referrals were made to OMFS during the first six weeks of the lockdown period in 2020 compared with 380 referrals in 2019. Of these, 50.5%, (n = 192) were related to facial trauma in 2019 vs (63.1%, n = 70) in 2020. Fewer patients were admitted under OMFS: 17.4% (n = 35) in 2019 vs 2.9% (n = 2) in 2020, and a greater number of patients were discharged from OMFS care directly from the ED: 63.2% (n = 127) in 2019 vs 82.9% (n = 58) in 2020. There was profound effect of the lockdown on referrals to OMFS from the ED, in number and type of diagnosis. This is potentially reflective of the increased availability of acute/emergency dental services in South-East London during the lockdown period. This gives us valuable insight for service planning in the event of further restrictions.     

Malignant peripheral nerve sheath tumours in the head and neck region: retrospective analysis of clinicopathological features and treatment outcomes

Malignant peripheral nerve sheath tumours (MPNST) are rare soft tissue sarcomas. The aim of this study was to assess clinicopathological characteristics and prognostic factors in order to improve the treatment of such tumours in the head and neck region. We performed a retrospective analysis of head and neck MPNST patients in our hospital between 1996 and 2012. Clinical features and pathological findings of these cases (n = 43) were summarized. In addition, prognostic variables were evaluated by univariate and multivariate analyses. The median age of the patients at presentation was 41 years. Surgery was the main treatment approach. Pertinent information regarding the presence of neurofibromatosis type 1 was found in 13 patients (30.2%). Two-thirds of these patients were admitted for a primary tumour (n = 27, 62.8%), while one-third (n = 16, 37.2%) were treated for recurrent neoplasms. The overall survival rate was 46.5%. Multivariable analysis identified tumour size, surgical margins, and postoperative radiotherapy to be independent prognostic factors. MPNST of the head and neck is extremely difficult to manage. Surgery with postoperative radiation may be the optimum choice of treatment for primary head and neck MPNST.     

Results of monitoring fasciocutaneous,myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases

Four free-flap types were compared regarding perioperative blood perfusion parameters and to define critical values for success. 166 cases were investigated: radial forearm flap (fasciocutaneous, n = 89); fibula flap (osteocutaneous, n = 32); ALT flap (myocutaneous, n = 25); soleus perforator flap (n = 20). All flaps were monitored with simultaneous laser-Doppler flowmetry and tissue spectrophotometry intra- and postoperatively up to 14 days. In 24 (15%) of 166 cases perfusion irregularity occurred. Operative exploration was performed in 12 cases (9 successful). 11 flaps (5 radial forearm, 3 fibula, 2 ALT, 1 perforator) were lost due to vascular compromise, which led to an overall success rate of 93%. Rapid increase in haemoglobin concentration of > 30% identified venous congestion. Abrupt decline of blood flow and haemoglobin oxygenation indicated arterial occlusion. For radial forearm flaps haemoglobin oxygenation of 15% and a deep flow of 20 AU were identified as minimum values for flap viability. For fibula, ALT, and perforator flaps haemoglobin oxygenation of 10% and a deep flow of 15 AU were determined as the minimum values. This non-invasive technique was an accurate method for evaluating viability of free-flaps.