Hung-Tao Hsiao

Primary closure versus radial forearm flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech.

The authors compared the postoperative speech and swallowing function of six patients who underwent free radial forearm flap reconstruction after hemiglossectomy with that of six control patients who underwent primary closure of the defect. Clinical speech pathologic evaluations included the Fletcher time-to-time maximum repetition rate of syllables, multiple rhyme test, and overall quality and intelligibility of the patients’ speech. Evaluation of swallowing included the duration of deglutition, bolus volume, and ingestion rate. Speech quality, including intelligibility and articulation, was better in patients with primary closure. However, the bolus volume and ingestion rate in deglutition were better in those with flap reconstruction. These results suggest that the flap adds bulk, thus improving pharyngeal clearance by maintaining the tongue-to-mouth roof contact that is necessary in the swallowing process. The nonfunctional flap, however, hinders articulation by restricting the mobility of the remaining portion of the normal tongue.

Swallowing function in patients who underwent hemiglossectomy: comparison of primary closure and free radial forearm flap reconstruction with videofluoroscopy.

The swallowing function of patients who had undergone hemiglossectomy with either primary closure of the defect or radial forearm flap reconstruction was studied with videofluoroscopy. Patients with primary closure were unable to lift the tongue tip, had poor tongue-to-palate contact on initiating swallowing, had premature spilling of the bolus into the pharynx, had a large amount of barium stasis on the floor of the mouth, and had prolonged oral transit time. With flap reconstruction, patients easily could lift the tongue and make good contact with the entire palate. They were able to seal the posterior pharyngeal sphincter by elevation of the reconstructed tongue, approximating it to the soft palate, so that premature spilling of the bolus rarely happened. Their swallowing pattern was nearly normal. Although the reconstructed flap is nonfunctional, it provides bulk and helps the remaining tongue to complete the swallow. Compared with primary closure of the tongue defect, the authors suggest it is better to reconstruct it with a free radial forearm flap when more than 50% of the tongue is resected.

Ileocolic free flap reconstruction, concomitant chemotherapy and radiotherapy and assessment of speech and swallowing function during management of advanced cancer of the larynx and hypopharynx: preliminary report.

Conclusion The new technique of ileocolic free flap reconstruction provides a better quality of life in terms of swallowing and speech for patients who have undergone laryngopharyngectomy with concomitant chemotherapy and radiotherapy (CCRT). Objectives To compare and contrast the swallowing and speech outcomes of patients who underwent total laryngopharyngectomy with ileocolic free flap reconstruction and to analyze the survival rate after surgery and CCRT. Material and methods This was a follow-up study of 12 patients with advanced (stages III, IVA and IVB) laryngeal and hypopharyngeal cancer who underwent major surgery, CCRT (with one exception) and ileocolic free flap reconstruction. Results All patients were able to tolerate single-stage combined management comprising total laryngopharyngectomy with or without radical neck dissection plus ileocolic free flap reconstruction and postoperative CCRT (with one exception), without immediate morbidity or mortality. Eleven patients were diagnosed with hypopharyngeal cancer and one with laryngeal cancer. The mean interval between surgery and CCRT was 34.1 days. The mean follow-up period was 16.5 months. Four patients died during the follow-up period as a result of local recurrence (n=2), distant metastasis (n=1) and suicide (n=1). One patient was alive with disease despite neck recurrence.

Comparison of radiotherapy strategies for locally advanced hypopharyngeal cancer after resection and ileocolic flap reconstruction

Conclusion. IMRT provided better conformity, less toxicity and better function restoration for advanced hypopharyngeal carcinoma after major surgery with ileocolic flap reconstruction. Objectives. To compare the results of adjuvant conventional radiotherapy (2DRT) with intensity modulated radiation therapy (IMRT) for locally advanced hypopharyngeal cancer after resection and ileocolic free flap reconstruction and to design treatment plans for those two modalities plus 3D conformal radiotherapy (3DCRT) for dose distribution comparison. Methods. 13 locally advanced hypopharyngeal cancer patients were enrolled, 8 treated with 2DRT and 5 with IMRT. Different plans were planned for 3 IMRT-treated patients for comparing dose distribution. Results. After major surgery, patients treated with IMRT had less toxicity and better functional restoration than those with 2DRT. IMRT and 3DCRT both showed lower dose to the spinal cord than did 2DRT. Only IMRT showed reduced dose to ileocolic flap.

Modified tenodesis method for treatment of mallet fractures.

IntroductionMallet fractures are avulsions of the terminal extensor tendon from the base of the distal phalangeal bone with a bony fragment. Surgical treatment, which provides accurate anatomical reduction and rigid fixation, is recommended for mallet fractures with involvement of more than one third of the base of the distal phalangeal bone. Various surgical methods have been reported, but there is still no standard treatment modality. The purpose of this investigation was to assess the results of our modified tenodesis method for mallet fractures. Materials and MethodsUsing our method, the dorsal fracture fragment was reduced and fixed to the main part of the distal phalangeal bone by 2 stitches of “figure-of-eight” 4-0 Prolene sutures. We reviewed 12 consecutive patients with 13 mallet fractures treated with our modified tenodesis method between January 2009 and March 2012. This retrospective study was composed of 7 male and 5 female patients, with a mean age of 35.7 years (range, 25–56 years). All patients underwent surgical treatment and sequent 3-week finger splinting. Patient follow-up lasted 3 to 6 months, with a mean period of 5.2 months. ResultsThe modified tenodesis method allowed accurate anatomical reconstruction of the injured extensor mechanism. Grading by Crawford criteria showed that the outcome was “excellent” in 8 of 13 digits and “good” in 5 of 13 digits. The follow-up hand x-rays also revealed congruent joint surfaces of distal interphalangeal joints with no evidence of joint space narrowing. No wound complications were encountered, and all the patients returned to normal activities without any disability. ConclusionsThe modified tenodesis method is simple and effective to provide accurate anatomical reduction and fixation for treatment of type I mallet fractures. No device penetration of the small bony fragment or pinning through the distal interphalangeal joint is required, and the surgical complication rate is low. We recommend this treatment modality for all but chronic cases.

Voice and swallowing after laryngopharyngectomy and free ileocolic flap reconstruction for hypopharyngeal cancer.

Sixteen patients with hypopharyngeal carcinoma who underwent laryngopharyngectomy had immediate reconstruction with a free ileocolic flap to restore voice and swallowing. All patients had satisfactory voice production and swallowing in the early postoperative stage. Maintaining adequate tension and decreasing redundancy of the transferred colon prevented food pooling and provided smooth, rapid swallowing. A wedge resection of the subserosa of the ileocecal valve to increase the intraluminal pressure helped prevent food reflux and provide good phonation. Although this modified technique yielded good initial results, both voice and swallowing deteriorated after concurrent chemoradiotherapy, possibly because of radiation injury to the transferred bowel.

Functional outcome following free ileocolic flap in total pharyngolaryngectomy

Conclusion. Reconstruction after radical resection for advanced laryngeal and hypopharyngeal cancer can be carried out with low mortality, acceptable morbidity, and a promising functional outcome. Objectives. To evaluate the functional outcome of reconstruction by a free vascularized ileocolic flap after concurrent chemoradiotherapy (CCRT) and surgery for advanced laryngeal and hypopharyngeal cancer. Patients and methods. Fifteen patients (all male, mean age 49.8 years) with squamous cell carcinoma of larynx (n=1) or hypopharynx (n=14) received a circumferential pharyngolaryngectomy and resection of the proximal esophagus followed by postoperative CCRT (60–65 Gy, cisplatin and 5-fluorouracil). A single-stage reconstruction was performed with a free vascularized ileocolic flap using a microsurgical technique. Results. The course of all operations was uneventful. Eight patients were alive at a follow-up of 24 months after operation, while seven patients died from local recurrence, distant metastasis, and suicide. Relief of dysphagia was achieved in 14 cases. Speech intelligibility was recorded in five patients.

Squamous Cell Carcinoma of the Oral Cavity in the Elderly

SUMMARY Background: As the population of older patients continues to grow and impact society, especially in developed countries, these individuals will require more medical attention. As such, it is important to compare the survival rates of patients suffering from oral squamous cell carcinoma beyond 65 years of age with younger patients. Methods: A retrospective review of 418 patients diagnosed and treated between 2004 and 2006 for squamous cell carcinoma of the oral cavity at Mackay Memorial Hospital was carried out. Patients were divided two groups with a cut-off age of 65. Staging, overall survival and disease-free survival were determined for both populations. Results: There were no significant differences between the two groups in stage I (p = 0.901 in overall survival [OS], p = 0.889 in disease-free survival [DFS]), stage II (p = 0.345 in OS, p = 0.169 in DFS), stage III (p = 0.348 in OS, p = 0.119 in DFS), stage IVB (p = 0.234 in OS, p = 0.236 in DFS) or stage IVC (p = 0.086 in OS). The survival after treatment was better in the younger group than the older group for stage IVA (p = 0.009 in OS, p = 0.005 in DFS). Conclusion: Squamous cell carcinoma of the oral cavity did not have a significantly different outcome for elderly patients when compared with younger patients. Elderly patients with stage IVA squamous cell carcinoma of the oral cavity had poorer survival rates. When properly evaluated and monitored, conservative and conventional therapies seemed efficacious in the elderly. [International Journal of Gerontology 2009; 3(1): 75–80]

Prognostic Factors of Local Necrosis Due to Poisonous Snakebite-A Clinical Review in Mackay Memorial Hospital

Purpose: To evaluate the prognostic factors of wound necrosis due to snakebite in northern Taiwan and determine the proper treatment for snakebites. Methods: The medical records of 117 venomous snakebite patients admitted to a medical center in northern Taiwan from 1989 to 2000 were retrospectively reviewed. The patients were separated into wound necrosis patients and normal wound healing patients. Clinical envenomation was graded on a 5-point scale. The relationship of wound necrosis, clinical grades, and associating factors was analyzed using the Chi-square method. Results: Most (74%) patients were attacked by the green habu (41 patients) and the Taiwan habu (44 patients), and most (84%) had minimal or no envenomation. The peak months of accidents were August and October. The prognostic factors related to wound necrosis were: species of snakes, local incision, local injection of antivenom, days of antibiotics given, grade of envenomation, and duration of hospital stay. Conclusion: Systemic infusion of early adequate antivenom is the effective method in preventing wound necrosis due to venomous snakebites. Local incision or local injection of antivenom is not recommended in the treatment program. Prolonged use of antibiotics is not necessary in patients with wound necrosis.

Epiglottis reconstruction with free radial forearm flap after supraglottic laryngectomy.

A bilobed free radial forearm flap was designed to reconstruct a defect in the epiglottis and tongue base in 2 patients who underwent supraglottic laryngectomy. The flap was initially sutured in the shape of the epiglottis to prevent aspiration during deglutition. Six months after surgery, after a full course of radiation therapy, the flap had flattened and underwent atrophy, but the patients still had good voice production and were able to swallow well without any aspiration. Regardless of the final shape of the reconstructed epiglottis, it will suffice to prevent aspiration if the flap is large enough to occlude the tracheal outlet.