Hadi Seikaly

Gastroesophageal reflux prophylaxis decreases the incidence of pharyngocutaneous fistula after total laryngectomy

Pharyngocutaneous fistula is a serious complication after laryngectomy. Gastric fluid is known to cause severe laryngopharyngeal injury and poor mucosal healing. This study was designed to evaluate the effects of a gastroesophageal reflux prophylaxis regimen on the incidence of fistula after laryngectomy. Twenty‐one consecutive patients were entered in the study. Patients with positive resection margins were excluded from the overall analysis. All patients had a Connells two‐layer closure of the pharynx with absorbable suture, suction drainage of the neck, postoperative tube feeding, and prophylactic antibiotics. All patients were started on an antireflux regimen postoperatively composed of continuous tube feeds, intravenous ranitidine, and intravenous metoclopramide hydrochloride. Patients were followed postoperatively with Gastrografin swallows and clinically for 8 weeks. The control group consisted of retrospectively studied patients managed identically except for the antireflux prophylaxis. The two groups were well matched for factors reported to influence the rate of pharyngocutaneous fistula formation. The control group had six fistulae (26%) and an average of 16.5 days of hospital stay. The study group had no fistulae and an average of 11.5 days of hospital stay (P = .02). This study suggests that gastroesophageal reflux may predispose to fistula formation after laryngectomy and that mechanical and pharmacological prophylaxsis decreases postoperative morbidity and length of hospital stay.

Extended Use of Topical Nasal Decongestants

Use of sympathomimetic topical nasal decongestants to treat nasal obstruction is usually restricted to 3 to 5 days to avoid potential rebound swelling (rhinitis medicamentosa). In this study, 10 healthy volunteers used oxymetazoline (long‐acting topical nasal decongestant) nightly for 4 weeks. Subjects who used antihistamines, oral or topical decongestants, or systemic steroids or who had active sinusitis were excluded from the study. Weekly history, physical examination, and anterior rhinomanometry revealed no adverse effects. Eight (80%) subjects developed nightly nasal obstruction a few hours before the evening dose; the obstruction resolved within 48 hours if no more decongestant was used. All subjects remained responsive to oxymetazoline 4 weeks and 8 weeks after the study began. This finding suggests that long‐acting decongestants may be safely used for longer than the recommended 3 to 5 days without adverse effects if used once nightly.

Combined Epstein‐Barr Virus and Human Papillomavirus Infection in Nasopharyngeal Carcinoma

Epstein‐Barr virus (EBV) has been shown to be a likely etiologic agent in nasopharyngeal carcinogenesis. Human papillomaviruses (HPVs) have previously been identified in numerous upper aerodigestive tract carcinomas. This pilot study was undertaken to investigate the prevalence of combined EBV and HPV infection in 17 patients with nasopharyngeal carcinoma (NPCA) using polymerase chain reaction (PCR). The primary goal was to determine if the presence of HPV could be correlated with molecular, histologic, or clinical parameters. There were seven patients with undifferentiated NPCA (World Health Organization [WHO] type III) and 10 patients with squamous cell carcinoma (WHO type I). All 17 patients had stage IV disease at presentation. EBV was identified in 15 patients (88.2%), and HPV subtypes were identified in samples from nine patients (52.9%). All HPV‐positive cases were also EBV positive. Western blot analysis of six samples showed a high level of expression of c‐myc and cdc2 kinase and a low level of p53 protein in NPCAs that contained both HPV and EBV (n = 3). Increased expression of c‐myc and cdc2 kinase was seen in the cases that contained EBV only, but to a lesser extent (n = 2). These findings indicate an effect of the virus on cellular proliferation and differentiation. Similarly, an elevated level of Rb protein was found only in the HPV‐containing NPCAs. Moderate differentiation (keratinization) occurred in four of eight HPV‐negative and none of the nine HPV‐positive NPCAs. (All HPV‐positive cases were poorly differentiated or undifferentiated.) This difference is statistically significant for this sample size (P < 0.03). There was a trend for the group that was HPV positive to have WHO III histology and for the HPV‐negative group to have WHO I. The presence of HPV could not be correlated with any clinical parameters in this small group of patients with advanced disease; however, these data suggest that coexistence of EBV and HPV infection may be a factor in the pathogenesis of NPCA and may have an effect on regulation of cellular proliferation and differentiation.

An integrated theory of the no-reflow phenomenon and the beneficial effect of vascular washout on no-reflow.

Objectives: No‐reflow is failure of perfusion in free tissue transfer despite adequate arterial inflow. The objectives of this study were to construct a theory of interactive mechanisms of the no‐reflow phenomenon and to determine whether preischemic vascular washout could increase flap ischemia tolerance.

Preservation of the superior laryngeal nerve in supraglottic and supracricoid partial laryngectomy.

Conservation laryngeal surgery effectively controls laryngeal carcinoma. The success of conservation laryn- geal surgery is judged by the patient’s ability to achieve physiologic respiration, phonation, and deglutition. Some patients cannot tolerate supraglottic and supracricoid partial laryngectomy and develop sequelae such as aspi- ration pneumonia. The extent of resection in conservation laryngeal pro- cedures varies. After classic vertical partial laryngectomy, rapid resumption of deglutition is usually achieved. After supraglottic laryngectomy, swallowing therapy is initiated and feeding tube removal is usually achieved

THE CLAVIPECTORAL OSTEOMYOCUTANEOUS FREE FLAP

Microvascular free tissue transfer has revolutionized head and neck reconstruction and currently is considered the most successful and reliable method of primary oromandibular reconstruction. This study was designed to assess the feasibility of full thickness free vascularized transfer of the clavicle based on the clavicular branch of the thoracoacromial artery and the soft tissue component associated with the thoracoacromial axis. Forty dissections of the pectoral region were performed on 26 cadavers. The anatomic relations of the region and the thoracoacromial arterial and venous systems were documented in detail. Selective ink injections of the thoracoacromial arterial branches were also performed on fresh cadavers. The clavicle was supplied mainly by the clavicular artery (medial three quarters), with minor contribution from the deltoid artery (lateral quarter). An average of 16.1 cm (range of 12 to 20 cm) was obtained with total clavicular harvest and the clavicle had sufficient width and height to support dental implants. Two soft tissue donor sites were associated with the thoracoacromial artery: the sternocostal head of the pectoralis major muscle, with the overlying skin supplied by the pectoral artery, and the clavicular head of the pectoralis major muscle, with the overlying skin supplied by the deltoid and clavicular arteries. Sensory innervation of the upper chest was supplied through the supraclavicular nerves, whereas the lateral pectoral nerve supplied motor innervation to both heads of the pectoralis major muscle. The anatomy of the clavipectoral donor site and the first case of full thickness free clavicular transfer for mandibular reconstruction in the English literature are presented. The donor site is an excellent source of well vascularized, thin, pliable, hairless, potentially innervated (motor and sensory) soft tissue, along with up to 20 cm of clavicular bone. The surgical anatomy is familiar to the head and neck surgeon. The harvesting does not require repositioning of the patient and is amenable to a two-team, simultaneous approach. The functional and cosmetic donor site morbidity is minimal even with clavicular harvest. The major disadvantage of this flap is the relatively short pedicle. The authors conclude that the thoracoacromial system provides a free flap with osseous and soft tissue components that are well suited for oromandibular reconstruction.

Clavipectoral osteomyocutaneous free flap in oromandibular reconstruction.

INTRODUCTION Mandibular reconstruction continues to challenge most head and neck reconstructive surgeons despite the tremendous advances in surgical and fixation techniques. We recently described the clavipectoral osteocutaneous flap for mandibular reconstruction. This flap encompasses the clavicle and the clavicular head of the pectoralis major with overlying skin. OBJECTIVES The purpose of this article is to report our prospective clinical experience with the use of clavipectoral osteocutaneous flap in the reconstruction of oromandibular defects. STUDY DESIGN Prospective case series. METHODS Five patients with significant mandibular defects underwent reconstruction using the newly described clavipectoral flap. All patients had shoulder range of motion testing preoperatively and at 3 and 6 months postoperatively. Panorex and bone scans were obtained on the seventh postoperative day. RESULTS All five flaps survived. The transferred clavicles demonstrated good vascularity on the postoperative bone scans. The shoulder morbidity was minimal, with all patients resuming their preoperative level of activity. CONCLUSIONS The clavipectoral flap has bone and soft tissue components that are especially suited for composite mandibular defects, but it should be used as a second-line flap owing to the short pedicle and the regular need for vein grafts.

Easier technique for venous end-to-side anastomoses

other anastomosis involving vessels of mismatched size. In the most commonly described technique for end-to-side anastomosis, a diamond-shaped piece of vein wall is re- moved. The two end (anchoring) sutures are performed first, followed first by all the back wall sutures and then by the front wall sutures (Fig.

Tissue expander insertion through a mini incision

Tissue expanders are usually placed deep to the subcutaneous layer through large incisions.1-3 Expansion is started 2 weeks after insertion in order to allow the wound to develop sufficient integrity to withstand the expansive forces.13 This method, although effective, has some limitations. The large incision delays expansion, may interfere with the final flap design, and may dehisce to expose the expander or cause its extrusion.