Rony K. Aouad

Noncontact diffuse optical assessment of blood flow changes in head and neck free tissue transfer flaps

Abstract. Knowledge of tissue blood flow (BF) changes after free tissue transfer may enable surgeons to predict the failure of flap thrombosis at an early stage. This study used our recently developed noncontact diffuse correlation spectroscopy to monitor dynamic BF changes in free flaps without getting in contact with the targeted tissue. Eight free flaps were elevated in patients with head and neck cancer; one of the flaps failed. Multiple BF measurements probing the transferred tissue were performed during and post the surgical operation. Postoperative BF values were normalized to the intraoperative baselines (assigning “1”) for the calculation of relative BF change (rBF). The rBF changes over the seven successful flaps were 1.89±0.15, 2.26±0.13, and 2.43±0.13 (mean±standard error), respectively, on postoperative days 2, 4, and 7. These postoperative values were significantly higher than the intraoperative baseline values (p<0.001), indicating a gradual recovery of flap vascularity after the tissue transfer. By contrast, rBF changes observed from the unsuccessful flaps were 1.14 and 1.34, respectively, on postoperative days 2 and 4, indicating less flow recovery. Measurement of BF recovery after flap anastomosis holds the potential to act early to salvage ischemic flaps.

Awake vs Sedated Tracheostomies: A Review and Comparison at a Single Institution

Objective The literature surrounding awake tracheostomies is sparse, particularly comparing awake tracheostomy patients to that of the sedated tracheostomy population. This study sought to compare tracheostomy patient demographics, indications, and outcomes of the 2 populations. Study Design Case series with chart review. Setting Tertiary care center. Materials and Methods All tracheostomies performed at our tertiary academic medical institution between January 2013 through November 2015 were reviewed. The data collected included demographics, comorbidity, anticoagulation, and outcomes. Results A total of 978 tracheostomies performed during this period met inclusion criteria, with 78 (8.0%) on awake patients. Most awake procedures were performed by otolaryngology (97.4%). Male sex predominated (73.1% awake vs 57.8% sedated). Forty-four patients (56.4%) were smokers in the awake group vs 326 of 900 (36.2%) in the sedated group. Malignancy was the primary indication for awake tracheostomy (68/78, 87.1%). One patient (1.3%) had significant postoperative bleeding compared to 26 of 900 (2.9%) of the sedated tracheostomy patients (P = .406). Only 9 (11.4%) were ever decannulated. Thirty-one (39.2%) patients ultimately underwent total laryngectomy, 3 could not be decannulated secondary to anatomical causes (stenosis or vocal fold paralysis), and 19 were lost to follow-up after discharge. There were 12 of 78 (15.4%) overall deaths in the awake cohort, with 215 of 900 (23.9%) in the sedated cohort (P = .088). Conclusion Despite all the differences between the 2 patient populations, the urgent awake tracheostomy appears to be safe and its complications do not appear significantly different from the sedated population.

Correlation of Positron Emission Tomography/Computed Tomography Scan with Smoking, Tumor Size, Stage and Differentiation in Head and Neck Cancer Patients

The goal of this study was to identify associations between positron emission tomography/computed tomography (PET/CT) maximum standardized uptake value (SUVmax) in patients presenting with head and neck squamous cell carcinoma (SCC) with tumor site, size, histologic differentiation, smoking, and diabetes. Charts of patients with oropharyngeal and laryngeal SCC who underwent 18F-fluorodeoxyglucose PET/CT scans were reviewed between May 2007 and August 2013. Statistical analyses included modeling log-transformed SUVmax values by tumor site, size, histologic differentiation, smoking status, and diabetes using unadjusted linear regressions. Differences were considered statistically significant for P< 0.05. A total of 111 patients (54 with oropharynx and 57 with larynx cancers) were included, 83 men and 28 women with an average age of 57.5 years old. There was a significantly higher pack-year smoking history (P = 0.005) in the larynx cancer group. While tumor T-stage was found to be significantly different (P < 0.0001), there was no difference in tumor size between the two groups: 3.16 cm and 3.58 cm in the oropharynx and larynx, respectively (P = 0.55). In the oropharynx cohort, SUVmax was associated with both tumor size (P = 0.0001) and stage (P < 0.0002). Interestingly, SUVmax differed by tumor differentiation in the larynx (P = 0.04) but not the oropharynx (P = 0.71). Finally, there was no significant difference in SUVmax relative to diabetes and smoking status. PET/CT SUVmax correlated with both tumor size and stage in oropharyngeal cancer patients, and it correlated only with tumor differentiation but not the size or stage in the larynx. There were no significant differences in SUVmax by diabetes or smoking status.

Prognostic indicators and survival in salvage surgery for laryngeal cancer

Perineural invasion (PNI) and lymphovascular invasion (LVI) are known to be poor prognostic indicators in primary surgery. The purpose of this study was to determine their impact on survival in the setting of salvage laryngectomy.

A Mass on the Nasal Dorsum

An elderly manwith a history of multiple skin cancers of the face presented with a 4-month history of a mass on the nasal dorsum. Findings from a biopsy of the lesion performed at an outside facilitywereconsistentwithsquamouscell carcinoma(SCC).Threeyears prior, the patient underwent 2 excisional biopsies of a mass at the same location showing infiltratingmoderately differentiated squamous cell carcinoma with acantholytic and pseudoglandular features. The lesion extended into the papillary dermis at the base of the excision. Therewas no endolymphatic or perineural invasion. A third excision performed later failed to demonstrate any disease. The patient’s other medical problems included diabetesmellitus, coronaryarterydisease,andemphysema.Findings fromaphysical examination were significant for a 3 × 2-cm ulcerative, nodular massof thenasal dorsum(Figure, A). Therewasnopalpable lymphadenopathy in theneck.Computed tomographic imagesof thehead andneck revealeda2.6 × 1.7-cmenhancingmass infiltrating thenasal dorsumwith possible involvement of the anterior nasal septum (Figure, B). The patient underwent an en bloc excision with negativemargins. Multiple areas of necrosis and cutaneous ulcerationwere evident. The tumor consistedof nests, trabeculae, and infiltrating rays of mitotically active cells. Some cells showed foamy, clear cytoplasm,while otherswere basophilic to amphophilic (Figure, C). Extensiveangiolymphatic andperineural invasionwaspresent (Figure, D). Immunohistochemical staining was positive for P63 (nuclear) and EMA and focally positive for CAM 5.2 and CK-7. Staining for HMB-45,CD10, chromogranin-A, S100, andVimentinwasnegative. What is your diagnosis? A B

Salivary Duct Carcinoma of the Accessory Parotid Gland

Objective: 1) Present a rare case of salivary duct carcinoma of the accessory parotid gland (APG). 2) Understand the current prevalence, diagnosis, and management of benign and malignant tumors of the APG.Method: This study includes a case presentation and literature review. The literature review included articles from October 1966 to January 2010 and included all cases of accessory parotid gland tumors in adults.Results: One hundred and nineteen cases with 19 different tumor types were reported in the accessory parotid gland (APG). Pleomorphic adenoma and mucoepidermoid carcinoma represented 50% and 23%, respectively. There were no previously reported salivary duct carcinomas of the APG. Forty percent of APG neoplasms were malignant. This malignancy rate was comparable to previous studies reporting a higher rate of malignant tumors in the APG compared with 15% to 20% in parotid tumors. A standard parotidectomy remains the preferred approach with less risk to the facial nerve compared with direct cheek re...