Heinz T. Luebbers

Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review.

Microvascular free tissue transfer is a reliable technique for head and neck reconstruction with success rates of 90–99%. Currently, there is no consensus concerning antithrombotic agents, antibiotics, or monitoring techniques. Therefore, the aim of this study was to review current literature dealing with microvascular free‐tissue transfer and factors influencing the outcome. In addition to excellent microsurgical techniques, coupling devices are a promising new technique, but are not useful in all arteries. Antibiotics should be given in three doses, as a more lengthy dosage time seems to have no advantage. The risk for elderly patients can be best assessed by the American Society of Anesthesiologists (ASA) score, but early mobilization, including intense chest physiotherapy, is important. Anticoagulation can be considered in cases of small vessels, significant size mismatch, vein graft, or vessels of poor quality. Monitoring should be done hourly during the first 24 hours and then every 4 hours for the next 2 postoperative days.

Head and Neck Cancer in the Elderly: A Retrospective Study over 10 Years (1999 - 2008)

IntroductionTreatment of elderly patients is in many ways different from that for younger ones. The aim of the present study was to identify the particular characteristics and needs of elderly patients suffering from head and neck cancer. From these patterns, considerations for this special group can be deduced.Patients and MaterialThe subjects for this study consisted of 376 patients suffering from head and neck cancer that were treated between 1999 and 2008, 99 (26.3.%) of whom were older than 70 years and were evaluated retrospectively concerning smoking/alcohol abuse, ASA status, kind of malignant neoplasm, localization and treatment.ResultsThe male-female ratio was 53:46, and mean age, 79 years (71 - 98). Out of 95 patients with a squamous cell carcinoma, 4 patients had a verrucous form. Out of 99 patients, 26 had a maxillary carcinoma and 12 patients had experienced previous non-head-and-neck cancer. An ASA score of 2 or 3 was found in 86 of the patients.ConclusionThe group of patients with head and neck cancer who were older than 70 years was characterized by a higher portion of female patients, a higher number of maxillary carcinomas, and a higher prevalence of previous second cancer.Making decisions in cancer therapy for elderly patients is challenging. Patients suffering from operable head and neck cancer should be treated with curative intent and with regard to quality of life if a careful assessment of comorbidities is performed preoperatively.

C-reactive protein levels: a prognostic marker for patients with head and neck cancer?

BackgroundRecent advances in understanding complex tumor interactions have led to the discovery of an association between inflammation and cancer, in particular for colon and lung cancer, but only a very few have dealt with oral cancer. Therefore, the aim of the current study was to investigate the significance of preoperative C-reactive protein (CRP) levels as a parameter for development of lymph node metastases or recurrence.Materials and methodsIn 278 patients with oral cancer, preoperative CRP levels were compared with development of recurrence and metastasis.ResultsIn 27 patients from the normal CRP group, and in 21 patients from the elevated CRP group, local recurrence was observed. Concerning lymph node metastases, 37 patients were in the normal group and 9 patients in the elevated CRP group. No significant correlation could be found between elevated CRP levels and metastasis (p = 0.468) or recurrence (p = 0.137).ConclusionOur findings do not appear to support a correlation between preoperative CRP levels and development of recurrence or metastases. In further studies, CRP levels in precancerous lesions and in Human Papilloma Virus (HPV) positive patients with oral squamous cell carcinoma (SCC) should be studied.

Evaluation of the pectoralis major flap for reconstructive head and neck surgery

PurposeThe pectoralis major myocutaneous flap (PMMF) is a commonly used flap in reconstructive head and neck surgery, but in literature, the flap is also associated with a high incidence of complications in addition to its large bulk. The purpose of the study is the evaluation of the reliability and indication of this flap in reconstructive head and neck surgery.Patients and methodsThe records of all patients treated with a PMMF between 1998 and 2009 were systematically reviewed. Data of recipient localization, main indication, and postoperative complications were analyzed.ResultsThe male to female ratio was 17:3, with a mean age of 60 years (45-85). Indications in 7 patients were recurrence of a squamous cell carcinoma, in one case an osteoradionecrosis and in 12 cases an untreated squamous cell carcinoma. In 6 male patients (30%), a complication appeared leading to another surgery.ConclusionThe PMMF is a flap for huge defects in head and neck reconstructive surgery, in particular when a bulky flap is needed in order to cover the carotid artery or reconstructive surgery, but the complication rate should not be underestimated in particular after radiotherapy.

Screening recurrence and lymph node metastases in head and neck cancer: the role of computer tomography in follow-up

IntroductionFollow-up of patients with oral cancer is being questioned with regard to financial costs and effectiveness. Therefore, the aim of the present study was to evaluate whether local recurrence and cervical lymph node metastases were first discovered clinically or by routine computer tomography.Materials and methodsThe records of all 317 patients that were treated for an oral cancer between 1998 and 2008 were systematically reviewed. Criteria for inclusion were tumor histology with a squamous cell carcinoma of the head and neck, and regular follow-up examinations with a minimum follow-up time of 12 months, including clinical and radiological (CT) controls. All patients had the first CT after 6 months, followed by yearly CT controls.ResultsOut of 315 patients with an oral squamous cell carcinoma, 294 were evaluated. Those experiencing neither recurrence of the tumor nor lymph node metastases constituted 62%. Local recurrence was seen in 36 (12%), lymph node metastases in 32 (11%), and both in 16 (6%). Of the 32 patients with lymph node metastases, 25 were recognized first clinically, and 7 were detected by routine CT scans; concerning local recurrence, 32 appeared clinically, and 4 were detected by routine CT scans.ConclusionRoutine CT for follow-up is still indicated for detecting lymph node metastases as well as local recurrence.

Microvascular tissue transfer in cleft palate patients: advocacy of the prelaminated radial free forearm flap.

AbstractThe closure of wide palatal clefts and recurrent oronasal fistulae may be challenging. After repeated failure of conventional techniques, microvascular tissue transfer may be indicated in the closure of such fistulae. Depending on the location and the size of the palatal fistula, different tissues are required to sufficiently close the palatal gaps. A subdivision of common flaps into mucosa, muscular, bony, skin, and fascia flaps was carried out to analyze their suitability for alveolar, hard, and soft palate reconstruction. Furthermore, the bulk of flaps and the length of the vascular pedicle were analyzed to rate the suitability of different flaps for palatal closure. Based on a new classification of oronasal fistulae, all these factors were taken into consideration to introduce a decision guidance of what microvascular flap fits a particular clinical situation. The radial free forearm flap was found to be sufficient in the closure of all classes of oronasal fistulae.

Free flap monitoring protocol.

In microsurgery, the successful salvage of free tissue transfer is dependent on the rapid decision to return to the operating room. Therefore, a free flap monitoring protocol is presented, including checking color, temperature, capillary return, and signal from a handheld Doppler ultrasonograph in an intraoperatively marked skin area directly over the pedicle.

Neurological deficit of the facial nerve after root canal treatment

Here we report the unusual case of a patient who suffered neurological deficit of the facial nerve as a complication of a root canal treatment. During the canal treatment, 3% hydrogen peroxide and 90% ethanol rinses were performed. The present case demonstrated rinse toxicity to vital tissue as evidenced by severe clinical damage. Chlorhexidine can be used instead of potentially toxic rinses with good antimicrobiological results. Furthermore, special attention should be paid to determination of the root canal length and the integrity of the canal system before rinsing. Also irrigation should be applied at a low pressure.

Evaluation of white blood cell count as a possible prognostic marker for oral cancer

IntroductionThere seems to be increasing evidence that inflammation leads to cancer. For several cancers, an association with white blood cell (WBC) count has been reported. So far, no studies have been performed for cancer of the oral cavity and WBC. Therefore, the aim of the present study was to look at whether WBC count can be used as a prognostic marker for recurrence or metastases for oral cancer.Material and methodsFor 278 patients with oral cancer, the preoperative WBC count was compared with the clinicopathological information: age, gender, T-status, N-status, recurrence, metastases, follow-up time, and time till recurrence or metastases appeared.ResultsOut of 278 patients, 48 developed recurrence, 24 second tumors, 46 cervical metastases, and 14 distant metastases. The mean follow-up time was 35.97 months (range: 12-107 months). Significant Pearson correlation at the 0.05 level could be found for the T-status (0.046), but not for the N status (0.121). No significant correlation could be found between WBC count and the development of recurrence or metastases.ConclusionIn conclusion, our findings demonstrate that elevated WBC count does not seem to be a predictor for recurrence or for further metastases. Further research is recommended to investigate the WBC count in precancerous lesions and in HPV positive patients with oral SCC.

A new method for closure of large donor side defects after raising the pectoralis major flap

BackgroundAlthough free flaps are reliable for head and neck reconstructions, the pectoralis major flap (PMF) is still often used. In cases of a large PMF, the closure of the donor side can be a challenge.Case reportA technique, originally developed for the treatment and prevention of abdominal ruptures after laparotomy, is presented as an alternative for closure of large donor side defects.ConclusionThe use of Ventrofil® is an additional option for large donor side defects and especially to bridge the period of postoperative swelling. If utilized special attention must be paid to possible pressure necrosis of the underlying skin.