Brittany E. Howard

Oncologic safety of the submental flap for reconstruction in oral cavity malignancies

Objectives To evaluate the oncologic safety of the submental flap regarding potential transposition of involved nodes to the reconstruction site and recognize the submental flap as an excellent option for oral cavity reconstruction. Study Design Case series with chart review. Setting Tertiary academic referral center. Subjects and Methods All patients undergoing reconstruction with submental flaps following the resection of primary and recurrent malignancies of the oral cavity between 2002 and 2012 were reviewed. Analysis included tumor location, staging, reconstructive details, postoperative course, and outcomes. Results Fifty patients were identified having undergone submental flap reconstruction of defects following resection for oral cavity malignancies. No patient had identifiable clinical or radiographic level I nodal involvement preoperatively. Patients’ ages ranged from 35 to 88 years (mean, 70 years). American Joint Committee on Cancer staging of patients included stage II (n = 16, 32%), stage III (n = 10, 20%), and stage IVa disease (n = 28, 48%). All patients underwent a level 1A and 1B dissection with removal of the nodal basin and submandibular gland. The prevalence of occult lymph node metastasis involving level 1 was 10%. On follow-up, there were no local recurrences associated with submental flap transposition to the oral cavity. One patient with multifocal oral disease had a tongue recurrence geographically separate from the submental flap reconstruction. There was 100% flap survival. Conclusions The submental flap provides a rapid and reliable option for oral cavity defect reconstruction. With appropriate management of the level 1 nodal compartment, oncologic outcomes are not compromised.

Oropharyngeal cancer treatment: The role of transoral surgery

Purpose of reviewThis article reviews literature pertaining to squamous cell carcinoma (SCC) of the oropharynx and the evolution of transoral surgical (TOS) techniques for its management. Oncologists are recognizing a changing pattern in the cause of oropharyngeal cancer, namely the increasing incidence of HPV-associated tumors. An effort is underway to reduce the morbidity of treatment without jeopardizing survival. This is a timely discussion for reassessment of current standards of care and opening dialogue on treatment de-escalation. Transoral approaches including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) have revolutionized the surgical approach to SCC. Recent findingsThe incidence of HPV-related oropharyngeal SCC is increasing at epidemic rates. Although there are no studies comparing nonsurgical treatment to TOS in a randomized controlled fashion, there is an abundance of retrospective and prospective reports of TORS and TLM. Both early and advanced-stage oropharyngeal tumors can be managed successfully with surgery, with or without adjuvant therapy. SummaryAlthough there are no hard scientific differences in oncologic outcomes between primary chemoradiation protocols and primary TOS-based approaches, retrospective comparisons support an advantage of primary surgery. In addition, functional outcomes may be superior following TOS treatment. Management of oropharyngeal SCC will most likely continue to be multidisciplinary with an ongoing effort to de-escalate treatment to reduce morbidity.

Oral steroid therapy in chronic rhinosinusitis with and without nasal polyposis.

Chronic rhinosinusitis (CRS) is a heterogeneous group of disorders characterized by inflammation of the sinonasal mucosa. CRS can be divided into two subtypes: CRS without polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). Corticosteroids are frequently employed to treat CRS due to their potent anti-inflammatory effects. Treatment of CRS with oral steroids must be carefully balanced against potential adverse effects. This article reviews the current literature on management of CRS with systemic corticosteroids. We discuss the available evidence in CRSsNP, CRSwNP, and allergic fungal sinusitis (AFS). Studies are evaluated for level of evidence and graded to provide evidence-based recommendations. Our review finds a lack of high-quality evidence supporting oral corticosteroid therapy in CRSsNP. In comparison, randomized controlled trails support the use of oral corticosteroids for CRSwNP. Similarly, systemic steroids for AFS treatment are supported by quality studies demonstrating efficacy. Utilization of steroids is also recommended in the perioperative setting for CRSwNP.

Reconstruction of Lateral Skull Base Defects A Comparison of the Submental Flap to Free and Regional Flaps

Objectives To compare reconstructive techniques, operative times, duration of hospitalization, and need for subsequent flap revisions between reconstructive approaches to lateral skull base defects. Study Design Case series with chart review. Setting Tertiary academic referral center. Subjects Patients (n = 31) undergoing reconstruction of composite lateral skull base defects from 2002 to 2014. Methods Data were analyzed for demographics, tumor characteristics, reconstructive technique, operative time, duration of hospitalization, complications, and outcomes. Results Thirty-one patients were identified for inclusion. Lateral temporal bone defects resulted from resection of malignant lesions, including squamous cell carcinoma (n = 25), basal cell carcinoma (n = 2), and other carcinoma (n = 4). Defects were reconstructed with submental flaps (n = 16), pedicled latissimus dorsi flaps (n = 6), and free anterolateral thigh flaps (n = 9). All cases involved neurosurgery, neurotology, and head and neck surgery services. Although time of surgical resection was similar, time saving was noticed with submental reconstruction. Compared with free flaps, submental flap reconstruction was associated with significantly reduced total operative time (mean, 544 vs 683 min; P = .00817) and duration of hospitalization (4.9 vs 9.8 days; P = .02067). Submental flaps were significantly less likely to require revision debulking procedures (mean = 0.6) compared with latissimus dorsi flaps (mean, 1.3; P < .00001) and free flaps (mean, 1.6; P < .00001). There was 100% flap survival. Conclusion The musculocutaneous submental flap provides an excellent option for reconstruction of lateral skull base defects given its proximity, reliability, ease of harvest, and exceptional color match. Submental flap reconstruction was associated with reduced operative time, hospitalization duration, and flap revisions.

Submandibular Gland Preservation during Concurrent Neck Dissection and Transoral Surgery for Oropharyngeal Squamous Cell Carcinoma

Objectives Analyze the effect of ipsilateral submandibular gland preservation on patients undergoing concurrent neck dissection and transoral surgery for oropharyngeal squamous cell carcinoma. Evaluate for (1) intraoperative and postoperative communications between the oropharynx and neck and (2) oncologic outcomes. Study Design Retrospective chart review of prospectively collected data. Setting Tertiary academic referral center. Methods and Subjects Retrospective chart review of patients undergoing transoral laser resection of oropharyngeal squamous cell carcinoma with simultaneous neck dissection(s) for primary, persistent, recurrent, and second primary disease between January 1999 and February 2013. Data analyzed for operative technique, pathologic diagnosis, postoperative course, complications, and oncologic outcomes. Results Overall 253 patients were identified. Of these, 96 patients underwent ipsilateral submandibular gland preservation and 157 underwent ipsilateral submandibular gland removal at the time of neck dissection. The prevalence of intraoperative communication between the neck and oropharynx was significantly lower in cases with submandibular gland preservation (2/96, 2.08%) compared to those with submandibular gland removal (22/157, 14.13%). No postoperative leaks occurred in the gland preservation group (0/96, 0%) compared to a leak prevalence of 8.92% (14/157) when the gland was removed (P = .0041). There was no difference in local, regional, or distant disease recurrence between submandibular gland preservation and gland removal. Similarly, Kaplan-Meier analysis showed no difference in disease free survival, disease specific survival, or overall survival. Conclusions Submandibular gland preservation during neck dissection in patients undergoing transoral surgery for oropharyngeal squamous cell carcinoma significantly reduces the risk of intraoperative and postoperative salivary leaks without compromising oncologic outcomes.

Idiopathic Subglottic and Tracheal Stenosis A Survey of the Patient Experience

Objectives: To report and compare patients’ experiences with acquired subglottic stenosis (AS) versus idiopathic subglottic and tracheal stenosis (ISTS). Methods: A survey was made available to patients with AS and ISTS. Results were analyzed for inter- and intragroup differences using a 2-tailed t test. Results: The study included 160 survey participants (AS n = 28; ISTS n = 132), with a predominance of female participants (82% AS, 98% ISTS). Acid reflux was the most prevalent comorbidity across groups (42%-43%). A significant difference in time to diagnosis was found between groups, with 32% of AS patients diagnosed within 3 months of symptom onset, compared to 2% with ISTS. A diagnosis delay greater than 18 months occurred for 58% of ISTS patients. There was no difference in treatment approach, with the most common treatment being balloon dilation, followed by laser dilation. Tracheal resection was performed in 36% of patients in both groups. Patient satisfaction with surgical outcomes was significantly higher after tracheal resection (76%) compared to other treatment modalities (39%). Conclusions: ISTS remains a diagnostic challenge as highlighted by the delay in diagnosis compared to AS. There appears to be no historical or symptomatic factors specific to ISTS. Additionally, patients report increased satisfaction and symptom resolution after tracheal resection.

Lingual Thyroidectomy The Mayo Clinic Experience With Transoral Laser Microsurgery and Transoral Robotic Surgery

Objectives: We report the clinical findings, surgical management, and outcomes for lingual thyroidectomy. Methods: We performed a retrospective case review of lingual thyroidectomy performed at 3 tertiary-care academic referral centers between 1994 and 2012. Results: Nine patients underwent lingual thyroidectomy for symptoms including globus sensation (6 patients), dysphagia (5 patients), and airway obstruction (5 patients). Before surgery, 3 patients had attempted medical suppressive therapy. Lingual thyroidectomy was performed by transoral laser microsurgery in 4 patients, transoral robotic surgery in 3 patients, transoral surgery without microscopic assistance in 1 patient, and an open approach with a modified Sistrunk procedure in 1 patient. Total thyroidectomy was attained in 7 patients, and subtotal resection in 2. The follow-up averaged 8 months, and all patients reported significant improvement in their symptoms. One patient had a recurrence. Complications included postoperative bleeding and epiglottic perforation in 1 patient and airway obstruction secondary to angioedema in another patient. There was no significant difference in operative times between transoral laser microsurgery (91 ± 16 minutes) and transoral robotic surgery (109 ± 35 minutes). Transoral surgery without microscopic assistance and open resection had longer operative times (206 and 246 minutes, respectively). Conclusions: Surgical resection of lingual thyroid glands achieves significant improvement in patient symptoms, with low rates of recurrence. We favor a total lingual thyroidectomy approach with use of either a microscope or a robotic endoscope for optical assistance.

Hyalinizing Trabecular Tumor Masquerading as Papillary Thyroid Carcinoma on Fine-Needle Aspiration

Background/Aims: Hyalinizing trabecular tumors are rare neoplasms of the thyroid gland often mistaken for thyroid carcinoma on fine-needle aspiration. We review the distinguishing characteristics of hyalinizing trabecular tumors and their management. Methods: We present the case of a patient diagnosed with papillary thyroid carcinoma on fine-needle aspiration as well as a review of the literature. Results: Intraoperative findings were felt to be inconsistent with papillary thyroid carcinoma and only a thyroid lobectomy was performed pending the results from pathologic evaluation, which confirmed a benign process and a diagnosis of hyalinizing trabecular tumor. Due to the diagnostic difficulty in distinguishing hyalinizing trabecular tumors from thyroid carcinomas on fine-needle aspiration, many patients receive overtreatment for what is primarily a benign disease. Conclusions: Recognition of hyalinizing trabecular tumors as a possible benign etiology of a thyroid mass can facilitate appropriate management.

Measurement of cochlear length using the ‘A' value for cochlea basal diameter: A feasibility study†

Objectives: To determine whether the cochlea basal diameter (A value) measurement can be consistently and precisely obtained from high-resolution temporal bone imaging for use in cochlear length estimation. Methods: A feasibility study at a tertiary referral center was performed using the temporal bone CTs of 40 consecutive patients. The distance from the round window to the lateral wall was measured for each cochlea by two independent reviewers, a neuroradiologist and an otolaryngologist. The interrater reliability was calculated using the intraclass correlation coefficient (ICC) and the Bland–Altman plot. Results: Forty patients (19 males, 21 females) for a total of 80 cochleae were included. Interrater reliability on the same ear had a high level of agreement by both the ICC and the Bland–Altman plot. ICCs were 0.90 (95% CI: 0.82, 0.94) for the left ear and 0.96 (95% CI: 0.92, 0.98) for the right ear. Bland–Altman plot confirmed interrater reliability with all 96% of measurements falling within the 95% limits of agreement. Conclusions: Measurement between the round window and lateral cochlear wall can be consistently and reliably obtained from high-resolution temporal bone CT scans. Thus, it is feasible to utilize this method to estimate the cochlear length of patients undergoing cochlear implantation.

Positive and Negative Predictive Value of PET-CT in Skull Base Lesions: Case Series and Systematic Literature Review.

Objectives To study positive (PPV) and negative predictive value (NPV) of positron emission tomography with computed tomography (PET-CT) scans in determining malignancy in skull base lesions and perform a systematic literature review for optimal PET-CT interpretation. Design Retrospective case series and systematic literature review of the current English literature. Setting Tertiary referral academic medical center. Participants All patients with skull base lesions that underwent PET-CT and tissue biopsy from 2010 to 2013. Main Outcome Measures PPV and NPV of radiologists report and standardized uptake value (SUV) cutoff of 2.5 and 3, biopsy with pathologic interpretation, clinical follow-up. Results A total of 31 PET-CT scans of 16 patients were studied; 10 PET-CT were performed upfront for diagnostic purposes and 21 were post-treatment surveillance scans. The PPV of radiologists interpretation, SUV cutoff of 2.5, and SUV cutoff of 3.0 was 80%, 60%, and 68.4%, with a NPV of 100%, 83.3%, and 75%, respectively. Literature search yielded 500 abstracts; 7 studies met inclusion criteria for detailed review. No consensus or guidelines for optimal SUV cutoff value was found. Conclusions PET-CT based on SUV cutoff criteria alone has high NPV but low PPV in determining malignancy in skull base lesions. Interpretation by a radiologist experienced in nuclear medicine and neuroradiology, synthesizing clinical, SUV, and radiologic data are of superior value.