Jeffrey R. Harris

Prevention of radiation induced xerostomia by surgical transfer of submandibular salivary gland into the submental space.

BACKGROUND AND PURPOSE Xerostomia is a significant morbidity of radiation treatment in the management of head and neck cancers. We hypothesized that the surgical transfer of one submandibular salivary gland to the submental space, where it can be shielded from radiation treatment (XRT), would prevent xerostomia. MATERIALS AND METHODS We conducted a prospective Phase II clinical trial and the patients were followed clinically with salivary flow studies and the University of Washington Quality of Life questionnaire. RESULTS We report the results on 76 evaluable patients. The salivary gland transfer was done in 60 patients. Nine patients (of 60) did not have postoperative XRT and in eight patients (of 60) the transferred gland was not shielded from XRT due to proximity of disease. The median follow up is 14 months. Of the 43 patients with the salivary gland transfer and post-operative XRT with protection of the transferred gland, 81% have none or minimal xerostomia, and 19% developed moderate to severe xerostomia. Three patients (6.9%) developed local recurrence, five patients (11.6%) developed distant metastases and five patients (11.6%) have died. There were no complications attributed to the surgical procedure. CONCLUSION Surgical transfer of a submandibular salivary gland to the submental space preserves its function and prevents the development of radiation induced xerostomia.

The Implantable Cook-Swartz Doppler Probe for Postoperative Monitoring in Head and Neck Free Flap Reconstruction

OBJECTIVE To determine if the implantable Cook-Swartz Doppler Flow Monitoring System (Cook Vascular Inc, Vandergrift, Pennsylvania) improves surgical salvage rates for compromised free flaps. DESIGN Retrospective medical record review spanning 2002 to 2006 for a large head and neck oncology program. SETTING A tertiary care hospital. PATIENTS A consecutive series of 351 patients (244 men and 107 women; mean age, 58.63 years) who underwent free flap reconstruction of head and neck defects that were monitored using the implantable Doppler probe were included. RESULTS The most common indication for surgery was squamous cell carcinoma (81.0%), followed by functional reconstruction (4.3%). The most common free flap used was radial forearm (68.0%), followed by the fibular free flap (19.0%). With operative exploration used as the gold standard, the Cook-Swartz Doppler Flow Monitoring System had a sensitivity of 65.8% and specificity of 98.2% for the detection of flap compromise. For the detection of vascular compromise of the monitored vessel (excluding flap compromise cases whereby flow in the monitored vessel was not compromised on operative exploration, ie, venous obstruction, hematoma formation, and necrotizing fasciitis), the sensitivity increased to 100%. CONCLUSIONS This is the largest reported series, to our knowledge, of implantable Cook-Swartz Doppler use, and our experience would suggest that this is a reliable technique for postoperative monitoring in head and neck reconstruction. Our use of the implantable Doppler probe allowed us to recognize vascular compromise early, resulting in an overall flap success rate of 98.1%, with a 92.0% salvage rate of flaps that experienced vascular compromise of the monitored vessel.

Objective and Subjective Scar Aesthetics in Minimal Access vs Conventional Access Parathyroidectomy and Thyroidectomy Surgical Procedures: A Paired Cohort Study

OBJECTIVE To determine if performing parathyroidectomy surgery through minimal access (MA) incisions has any notable aesthetic or quality-of-life impact on patients compared with conventional access (CON) techniques. DESIGN Paired cohort with (1) a prospective MA incision and scar cohort and (2) a sex- and age-matched (within 3 years) retrospective CON incision and scar cohort. SETTING Tertiary care center. PATIENTS Fifteen patients enrolled in prospective study protocol over a 2-year period; 11 patients met inclusion criteria. A sex- and age-matched retrospective cohort of patients was selected from a patient population undergoing surgical treatment of thyroid neoplastic diseases using a CON approach. Inclusion criteria were use of MA incision for parathyroidectomy and return for long-term follow-up scar assessment. INTERVENTIONS Minimal access parathyroidectomy surgery vs CON thyroidectomy surgical procedures, postoperative follow-up assessment of scar aesthetics by patient and naive viewers, and digital photography and analysis of the surgical incision site. All patients were followed for at least 8 months after surgery. MAIN OUTCOME MEASURES The Patient and Observer Scar Assessment Scale (POSAS), Vancouver Scar Scale, and photographic scar analysis by naive viewers. RESULTS There was no significant difference in scar assessment scale scores between the MA and CON cohorts and no clinically significant difference in overall patient satisfaction with scars between cohorts (POSAS: Patient Scar Assessment Scale, P = .14, and Observer Scar Assessment Scale, P = .79; Vancouver Scar Scale, P = .76). There was increased visibility of scars in the CON cohort to naive viewers. CONCLUSIONS Although they were more readily visible to naive viewers, CON (larger) cervical scars created in parathyroidectomy or thyroidectomy surgery do not translate into decreased patient satisfaction with their scar result. This may indicate a limited quality-of-life benefit in using MA approaches in transcervical surgical procedures.

Phase III randomized study: Oral pilocarpine versus submandibular salivary gland transfer protocol for the management of radiation-induced xerostomia

Xerostomia is a serious morbidity of radiation treatment in head and neck cancer.

Functional outcomes after surgical reconstruction of the base of tongue using the radial forearm free flap in patients with oropharyngeal carcinoma.

Historically, the prevention of functional morbidity after multimodal treatment for squamous cell carcinoma in patients with large base of tongue lesions has been challenging. The purpose of the present research is to report prospectively collected speech and swallowing outcomes for patients with disease that encompassed half or more of the base of tongue.

Total glossectomy with laryngeal preservation and free flap reconstruction: objective functional outcomes and systematic review of the literature.

Advanced tongue cancer is a devastating diagnosis with potential for significant morbidity after treatment. This is especially true for patients undergoing total glossectomy with laryngeal preservation (TGLP), free flap reconstruction and adjuvant radiotherapy. The goals of this study were to: 1) determine long‐term objective functional and quality of life outcomes, 2) investigate the influence of rehabilitation on functional recovery and 3) determine swallowing ability in patients with TGLP.

Early operative intervention versus conventional treatment in epistaxis: randomized prospective trial.

OBJECTIVE This prospective randomized trial was designed to compare intranasal endoscopic sphenopalatine artery ligation (ESAL) with conventional nasal packing in the treatment of recurrent epistaxis. METHODS Patients were registered in the study databank following referral for epistaxis control to the otolaryngology service at the University of Alberta. All patients were initially packed using Merocel (Xomed Surgical Products, Jacksonville, FL) nasal dressings bilaterally. Patients were enrolled in the study following failure of Merocel packings. Informed consent was obtained in accordance with the Health Research Ethics Board. The patients were then managed with Vaseline nasal packs or ESAL. Patient demographics, treatment characteristics, number of hospitalization days, and rates of recurrence were recorded prospectively. The total cost of treatment for each patient was calculated. RESULTS Nineteen patients were enrolled in the study. There was a significant reduction in cost and length of hospitalization of the patients undergoing ESAL compared with the conventional nasal packings. ESAL was also 89% effective in controlling the bleeding and had minimal sequelae or complications. The overall calculated cost of patients undergoing ESAL was dollars 5133 compared with dollars 12213 in the conservative group, resulting in an average saving of dollars 7080 per patient. There was overwhelming patient satisfaction with ESAL compared with nasal packings. CONCLUSION ESAL is an excellent, well-tolerated, and cost-effective method of treating recurrent epistaxis.

A Longitudinal Study of Functional Outcomes After Surgical Resection and Microvascular Reconstruction for Oral Cancer: Tongue Mobility and Swallowing Function

PURPOSE Controversy exists regarding physiologic outcomes related to the tongue after radial forearm free flap (RFFF) reconstruction of hemiglossectomy defects. The purpose of this study is to report swallowing and tongue mobility outcomes for patients with RFFF reconstruction of the anterior two thirds of the tongue. MATERIALS AND METHODS Swallowing and tongue mobility were assessed at 4 different time points over the course of 1 year of treatment for 15 patients who underwent RFFF reconstruction of the anterior two thirds of the tongue. Preoperative swallowing function in the treatment group was compared with a patient group that had no involvement of the tongue. A comparison group of 14 patients with nasopharyngeal cancer was used to compare preintervention function in patients with and without lesions of the tongue. RESULTS No differences existed between the experimental and comparison groups before intervention. Two significant differences were found for swallowing ability and tongue mobility in the experimental group. Some of the measures at 1 month postoperatively were significantly different from some of the preoperative measures for liquid swallows and posterior-tongue mobility. All measures returned to baseline by the studys end. CONCLUSION Although some minor deficits exist in swallowing and tongue mobility after RFFF reconstruction, it appears that these problems are no longer evident 12 months postoperatively.

FUNCTIONAL SOFT PALATE RECONSTRUCTION : A COMPREHENSIVE SURGICAL APPROACH

Dysfunction of the soft palate is devastating to the patients quality of life, resulting in unintelligible speech and poor swallowing. Reconstruction of the soft palate is complex because the dynamic fibromuscular structure cannot be duplicated. The efficacy of soft palate reconstruction has therefore been called into question. The purpose of this article is: (1) to describe our comprehensive surgical paradigm for soft palate reconstruction, (2) to provide details of the surgical techniques used, and (3) to report on patient functional outcomes.

Oral sensation and function: A comparison of patients with innervated radial forearm free flap reconstruction to healthy matched controls†

Limited evidence exists for the use of innervated radial forearm free flap (RFFF) reconstruction of hemiglossectomy defects. This study reports on sensation, mastication, and speech outcomes for patients with innervated RFFF reconstruction of the anterior two‐thirds of the tongue.