Robert L. Eisenberg

Orbital Exenteration to Manage Infiltrative Sinonasal, Orbital Adnexal, and Cutaneous Malignancies Provides Acceptable Survival Outcomes: An Institutional Review, Literature Review, and Meta-Analysis

PURPOSE Orbital exenteration (OE) is an aggressive operative undertaking that results in a disfiguring and dysfunctional outcome for patients. The purpose of our study was to determine the survival outcome for patients who underwent OE for malignant disease that had invaded the orbit. MATERIALS AND METHODS We conducted an ambispective cohort study based on a review of the records of 31 consecutive patients who had undergone OE within John Hunter Hospital. The study period was 2006 to 2013. The predictor variables were the demographic, tumor site, and clinicopathologic characteristics that might influence survival. The secondary outcome variable was survival. Descriptive statistics were calculated for the categorical and continuous variables. Kaplan-Meier estimates of the survival distribution were plotted. We also performed a review of published studies and a meta-analysis to investigate the nature of OE performed by various surgical disciplines. RESULTS Of the 31 patients included in the present study, 24 were men and 7 were women. The mean age was 65 years. Of the 31 cases, 15 were squamous cell carcinoma, 8 were basal cell carcinoma, and 8 were a mixture of other pathologic types. The time to median (50%) survival for all patients was 78.4 months. The 1-year survival rate was 93.4% and the 5-year survival rate was 54.1%. Although not statistically significant, notable differences were found in the interval to death with respect to the identification of perineural invasion, lymphovascular invasion, and histopathologic features. The review of published studies suggested a difference in the histologic features and location of the disorder treated, the extent of OE undertaken, and the method of reconstruction between the ophthalmology and nonophthalmology surgical disciplines. CONCLUSIONS Although OE results in significant disfigurement and dysfunction, it does provide good survival outcomes, given the extent of disease at presentation, evident in our group of patients. Continuation of the study, with greater numbers of patients, will serve to increase the statistical power of our observations.

Auditory-Perceptual Voice Characteristics in Pre-Operative Patients Undergoing Thyroid or Parathyroid Surgery

Objectives: To systematically evaluate auditory perceptual voice characteristics in people with thyroid disease prior to undergoing thyroid surgery. Patients and Methods: This study examined the auditory perceptual voice characteristics of 96 individuals with thyroid disease. Participants were categorised by type of thyroid disease (i.e. multinodular goitre, thyroid cancer, thyroid nodule, toxicity or parathyroidism) and by status of compression (i.e. compression versus no compression). Auditory perceptual voice ratings were made on samples of connected speech by using the Perceptual Voice Profile. Results: A high prevalence of participants had deviant auditory perceptual voice features; however, the majority of these abnormalities were slight to mild in severity and only 8% of participants had a clinically significant auditory perceptual abnormality. There was no significant difference in features between diagnostic categories, and only high pitch was rated as more significantly deviant in patients without compression versus those with compression. Conclusions: This study supports the need for auditory-perceptual ratings to be included as part of pre-operative multidimensional assessment of voice in patients with thyroid disease.

Microvascular reconstruction of the mouth, jaws, and face: experience of an Australian oral and maxillofacial surgery unit.

PURPOSE Microvascular reconstruction of oncologic surgical and traumatic defects has been globally practiced by plastic and orthopedic surgical disciplines since the early 1970s. During the past 20 years, reconstructive techniques have been progressively incorporated into the purview of oral and maxillofacial and otolaryngology-head and neck surgeons, particularly those practicing in Europe, the United Kingdom, and China. There has also been a steady increase in the adoption of these techniques in North America, South America, and Japan. MATERIALS AND METHODS We reviewed our experience (during a 5-year period) with microvascular reconstruction of postablative defects in the oral and maxillofacial region. To our knowledge, resection and neck dissection (or neck exploration in benign free tissue transfer); undertaken by an oral and maxillofacial surgeon), and free tissue transfer reconstruction (undertaken by otolaryngology head and neck and oral and maxillofacial surgeons) of ablative defects of the mouth, jaws, and face (managed within an Australian head and neck cancer multidisciplinary care team) have not been previously reported. RESULTS The study cohort comprised 107 patients who underwent 109 microvascularly anastomosed free tissue transfers. Of the 107 patients, 79 were males and 38 were females. The median age was 62 years (range 15 to 87). The clinicodemographic analyses and the range of complications observed in this patient cohort are reported. The overall flap success rate in our study was 97%. CONCLUSIONS The surgical outcomes of our study compare favorably with those previously reported.

Surgical management of transitional cell carcinoma of the lacrimal sac: Is it time for a new treatment algorithm?

Transitional cell carcinoma (TCC) arising in the lacrimal sac is a rare neoplasm. Despite radical surgery and radiotherapy, these tumors generally have a poor prognosis due to an often late diagnosis, high rate of loco-regional recurrence and mortality. There are only a relatively small number of documented cases of TCC when compared to other epithelial malignancies of the lacrimal drainage system. As would be anticipated, there are currently no evidence-based clinical practice guidelines for the treatment of these lesions. We present an illustrative case and consider the literature in relation to current surgical management of these tumors. We propose an alternate management consideration for these tumors.

Microvascular reconstruction of the mouth, face and jaws. Oromandibular reconstruction - free fibula flap.

Dental surgeons may encounter in their clinical practice patients who present with aggressive pathologies that require early diagnosis and prompt treatment. This action may limit the extent of tissue damage and, where relevant, improve survival outcome. Clinicians should therefore be aware of the range of resective, reconstructive and rehabilitative options that are available in the management of these patients. We present our experience with the free fibula flap used for oromandibular reconstruction; this was undertaken in 21 patients following resective surgery for malignant pathology, cytologically benign but biologically aggressive odontogenic pathology and radiation induced osteonecrosis. We also review the history, surgical anatomy, surgical assessment and potential complications that are relevant to the free fibula flap.

An Overview and Comparative Evaluation of Head and Neck Cancer Risk Factors in India and Australia

Aim: An overview and comparative evaluation of head and neck cancer risk factors in India and Australia. Method: In this review we included articles with information on head and neck cancer risk factors and its association based on: smoking tobacco, alcohol, smokeless tobacco, betel nut and areca nut chewing, viral infection like HPV, dental hygiene, diet, family history, socioeconomic status, other heavy metals and systemic conditions. Articles with clinical features, diagnosis, treatment and prognosis were excluded. Results: Head and neck cancer in India has different demographic, risk factors, dietary habits, personal and family history. Oral cancer is more common amongst all head and neck squamous cell cancers in males. This is mainly attributed with consumption of a variety of smokeless tobacco, smoking, alcohol, poverty, illiteracy, cultural, advanced stage at presentation; lack of good treatment infrastructure creates main challenge to India as compared to Australia. Conclusion: The knowledge about risk factors for HNC in public health education for general population supports health promotion and tobacco prevention, which is the main aim of the programs started by the government, as head and neck cancers are potentially preventable.

Combined Transfacial and Endoscopic Approach to Resect a Posterior Pharyngeal wall Tumour in the Setting of Absolute Trismus

Gary R Hoffman1*, Nigel G Maher2 and Robert L Eisenberg3 1Department of Maxillofacial Surgery, John Hunter Hospital, University of Newcastle Medical School, Australia 2Melanoma Institute Australia, John Hunter Hospital, Australia 3Department of Otorhinolaryngology, John Hunter Hospital, Australia *Corresponding author: Gary R Hoffman, Department of Maxillofacial Surgery, John Hunter Hospital, Lookout Road, New Lambton Heights 2305 NSW, Australia, Tel: 0061-2-4921-3000; E-mail: garyhoffman_au@hotmail.com

Surgical management of a tumour involving both peri-mandibular spaces and skull base.

Three-dimensional cross-sectional imaging has aided the accurate anatomico–spatial assessment of pathology arising within the deep recesses of the sub-skull base and upper neck. In spite of these developments, direct surgical access to this region is impeded by the maxillofacial skeleton and the presence of major neurovascular structures. The cervical fascial laminae and the disposition of resident muscles combine to divide the supra hyoid region into as many as ten well defined spaces. The perimandibular spaces include the parapharyngeal (PPS) (and its pre-styloid and post-styloid subdivisions), the masticator (MS) and the buccal (BS). Tumours of the PPS account for 0.5% of those occurring in the head and neck. The majority are benign (sialogenic 45% and neurogenic 42%). Malignant neoplasms account for the remaining 13%. We present the case of a 26-year-old male who was referred by his general dental practitioner for assessment of a 6-month history of persistent right side cheek swelling. This was in association with variable third division trigeminal nerve parasthesia. He was constitutionally well with the absence of any significant medical history. Magnetic resonance imaging revealed a 6.5 cm diameter mass arising within the MS and extending beyond into the pre-PPS and BS (Figs 1,2). Multiple attempts at biopsy (FNA, CT guided FNA, open) were non-diagnostic. Review by a surgical-radiology MDT proffered a differential diagnosis including schwannoma and rhabdomyosarcoma. Under general anaesthesia, an ‘L’ mandibular ramus – coronoid process ostectomy was employed via a transcervical approach to provide direct access to the MS to facilitate excision of the tumour. A staging selective regional lymphadenectomy was undertaken to complete the procedure (Fig. 3). The histopathological findings (patternless pattern), combined with the immunohistochemistry and imaging, supported a diagnosis of solitary fibrous tumour. The surgical management of tumours arising within the masticator space remains a challenging problem. The choice of surgical approach is dictated by several factors. This includes the size and nature of the tumour, its relationship to important anatomical structures, and the desire to preserve both form and function. Traditionally, techniques have been either surgically conservative (hampered by access) or radical (hampered by morbidity). Conservative approaches that are used include trans-parotid (with facial nerve preservation) or trans-oral (via a curved incision in the palatopharyngeal arch). Radical approaches have included either mastoidectomy, styloidectomy or total excision of the vertical part of the mandible. In an attempt to obviate the necessity to remove the ascending ramus to facilitate access, three surgical options have been proposed: