Richard M. Hirata

Prognostic significance of human papillomavirus in oropharyngeal squamous cell carcinomas

The human papillomavirus (HPV) has been identified as a causative factor in 20% to 25% of all head and neck squamous cell carcinomas (HNSCC). Ongoing research suggests that the presence of HPV DNA in HNSCC predicts a positive prognosis with respect to disease‐free and overall survival. However, most studies have been limited by the heterogeneity in treatment regimens and/or anatomic subsites of tumor origin. In this study, we correlate clinical outcomes with HPV status for patients with oropharyngeal carcinomas who were uniformly treated with a concurrent chemoradiation treatment protocol.

Considering the spinal accessory nerve in head and neck surgery.

Loss of trapezius muscle function represents the single most important source of long-term morbidity from a radical neck dissection. Its preservation has been one of the central features of the conservative or modified neck dissection. We recently undertook an evaluation of 100 consecutive patients who had undergone composite resection for head and neck cancer and examined them with particular emphasis on the function of the trapezius muscle. The mean interval from the time of radical neck dissection to the time of this evaluation was 6.2 years. The operations included radical neck dissection with sacrifice of the spinal accessory nerve, radical neck dissection with preservation of the spinal accessory nerve, and radical neck dissection with interpositioned cable graft reconstruction. The survey showed that 67 percent of the patients who underwent radical neck dissection with sacrifice of the spinal accessory nerve, although they showed profound atrophy of the trapezius muscle, had few symptoms related to this deficit. Similarly, 47 percent of patients who underwent radical neck dissection with preservation of the spinal accessory nerve showed some signs of muscle atrophy, and 20 percent showed little or no function of the muscle. Interpositioned nerve grafts appeared to function well in 66 percent of the patients. The survey showed that a surprising number of patients treated with a standard radical neck dissection and sacrifice of the spinal accessory nerve had few postoperative symptoms related to the loss of trapezius muscle function. Also unexpected was the number of patients with signs of muscle dysfunction despite nerve preservation.

Head and neck surgery in the aged

This study was carried out to determine the perioperative mortality rate of patients over the age of 65 years who are undergoing major head and neck resections under general anesthesia. The total number of patients was 810 and the perioperative mortality rate (death within 30 days of operation) was 3.5 percent (29 of 810). This rate is relatively low when compared with the rate for patients undergoing similar procedures during the same period in the 35 to 65 years age group. Since 1975 reports of other types of surgery in the elderly have given perioperative mortality rates of from 4.8 to 26 percent. Previous studies of head and neck surgery in the elderly have given perioperative mortality rates of from 1.3 to 13.6 percent. Head and neck surgery in the elderly continues to be a safe procedure when compared with other types of surgery. As the portion of patients in the population over the age of 65 continues to increase, advanced age alone should not be a deterrent to performing aggressive surgical therapy for head and neck cancer.

Definitive mandibular replacement using reconstruction plates.

Mandibular defects following radical cancer surgery continue to provide challenges to head and neck surgeons. Twenty-seven patients with advanced oral cancer underwent primary mandibular replacement with metal reconstruction plates without the use of bone. Twenty-one patients (78%) had successful reconstruction with primary soft tissue healing. Six patients required removal of the plate in the postoperative period. Two of these patients had their reconstruction plates replaced as a secondary procedure following soft tissue healing. Thus, 23 of 27 patients (85%) had final mandibular reconstruction and were followed for an average of 19 months. Functional and cosmetic results were satisfactory. For patients with advanced disease, this technique compares favorably with microvascular transfer in terms of operating time and donor defect. Despite problems with plate exposure, the initial and overall success rates of 78% and 85%, respectively, make the use of these plates a reasonable choice for immediate reconstructive needs in patients with difficult tumors.

Anaplastic carcinoma arising in a thyroglossal duct tract.

A 68-year-old woman had a 2-year history of a slowly enlarging midline submental neck mass. During the course of an admission for a severe aortic graft infection, the mass rapidly enlarged. Examination revealed an 8 x 8 cm firm mass, filling the entire submental and right submandibular spaces, down to the level of the thyroid cartilage and extending laterally to the right sternocleidomastoid muscle, with involvement of the overlying skin. There was no cervical adenopathy and the thyroid was palpably normal. A CT scan demonstrated infiltration of the right submandibular gland and sternocleidomastoid muscle. The mass was overlying the thyroid cartilage and hyoid bone, but no evidence of invasion was seen. The thyroid gland was normal in appearance and clearly separate from the mass. There was no adenopathy noted (Fig. 1). A fine-needle aspiration of the mass was performed, consistent with a diagnosis of carcinoma. Metastatic evaluation, which included a chest radiograph, direct laryngoscopy, fiberoptic bronchoscopy, and esophagoscopy, was normal. Resection of the tumor mass included the overlying involved skin, hyoid bone, suprahyoid and strap musculature, right hypoglossal nerve, and a wedge of the base of tongue. A right radical neck dissection and a left suprao-

Value of contralateral supraomohyoid neck dissections

This study was carried out to determine the merit of contralateral supraomohyoid neck dissection in the clinically negative neck. When performed in conjunction with a standard radical neck dissection on the ipsilateral side, a yield of 2.8 percent pathologically positive nodes (5 of 177) was obtained in the contralateral neck. Little difference was noted in the yield of midline lesions versus unilateral lesions which approached the midline (3 and 2.6 percent, respectively). Similarly, the yield with preoperative radiation was close to that of the nonradiated group (3 and 2.7 percent, respectively). Additionally, in 1.7 percent of patients (3 of 177) with both clinically and pathologically negative nodes, metastases later developed in the contralateral neck, which indicates that the dissection is not necessarily effective in preventing future disease. The contralateral supraomohyoid neck dissection in the treatment of malignancies of the oral cavity, pharynx, and larynx does not appear to be of significant therapeutic value.

Pharyngocutaneous fistula after total laryngectomy: A single-institution experience, 2001–2012

PURPOSE The purpose of this study was to determine the incidence of and risk factors for pharyngocutaneous fistula in patients undergoing total laryngectomy at a single institution. MATERIALS AND METHODS The records of 59 patients undergoing primary or salvage total laryngectomy at our institution from 2001 to 2012 were retrospectively reviewed. Data collected included patient, tumor and treatment characteristics, and surgical technique. Risk factors were analyzed for association with pharyngocutaneous fistula formation. RESULTS Twenty patients (34%) developed fistulas. Preoperative tracheostomy (OR 4.1; 95% CI 1.3-13 [p=0.02]) and low postoperative hemoglobin (OR 9.1; 95% CI 1.1-78 [p=0.04]) were associated with fistula development. Regarding surgical technique, primary sutured closure of the total laryngectomy defect had the lowest fistula rate (11%). In comparison, primary stapled closure and pectoralis onlay flap over primary closure had nonsignificantly increased fistula rates (43%, OR 6.0; 95% CI 1.0-37.3 [p=0.06] and 25%, OR 2.7; 95% CI 0.4-23.9 [p=0.38], respectively). Pectoralis flap incorporated into the suture line had a significantly increased fistula rate (50%, OR 7.1; 95% CI 1.4-46 [p=0.02]). After stratification for salvage status, patient comorbidities were associated with fistula in non-salvage cases whereas disease-related characteristics were associated with fistula in salvage cases. Fistula development was associated with increased length of hospital stay (p<0.001) and increased time before oral diet initiation (p<0.001). CONCLUSIONS Pharyngocutaneous fistula is a common complication of total laryngectomy. Preoperative tracheostomy, postoperative hemoglobin, and surgical technique are important in determining the risk of fistula.

Evaluation of prophylaxis treatment of Candida in alaryngeal patients with tracheoesophageal voice prostheses.

The objective of this study was to evaluate the effectiveness of nystatin and Biotène® mouthwash Oral Rinse for controlling Candida in total laryngectomy (TL) patients with a tracheosophageal voice prosthesis (TEP) because Biotène® mouthwash Oral Rinse is a less costly alternative to nystatin and requires less adherence time.