Faculty Bibliography

PURPOSE OF REVIEW: Sentinel node biopsy (SNB) is emerging as a potential tool to evaluate neck node metastasis in head and neck cancer. The purpose of this article is to undertake a systemic review of published literature and to outline future directions for further studies. RECENT FINDINGS: Existing data suggest that the status of the sentinel lymph node (SLN) predicts the pathologic stage of the nodal basin. It has been demonstrated that radiolabeled lymphoscintigraphy is superior to blue dye to localize the SLN in head and neck cancer. SLN biopsy should be recommended only in patients with previously untreated early stage (T1/2) oral cavity and orophparynx cancer with clinical N0 stage. The procedure is technique sensitive. The isolated SLN should be subjected to serial step sectioning at 150 microm and staining by hematoxylin and eosin and immunohistochemistry. Intraoperative frozen section and imprint cytology are not sensitive to identify small foci of micrometastasis and isolated tumor cells within the SLN. The clinical relevance of micrometastasis and isolated tumor cells needs to be established. It is necessary to develop a better method for intraoperative pathological confirmation of SLN metastasis. There exists no randomized clinical trial with adequate power that compares SNB and elective neck dissection in head and neck cancer. SUMMARY: SNB in head and neck squamous cell carcinoma should be considered as an investigational tool pending validation by larger randomized clinical trials; therefore, it should not be recommended at present outside a clinical trial setting.

Free flaps are being widely used for reconstruction of defects following head and neck cancer ablation. The pedicle of the flap is usually tunneled into the neck wound for anastomosis to the neck vessels. This transfer of the pedicle can be technically difficult to execute and associated with difficulties of torsion and kinking. No effective method has been so far reported to make this procedure easy and safe. A very easy and effective method for the pedicle transfer is described in this report, which has been practiced successfully in our head and neck service in more than 175 free flaps.

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.

BACKGROUND: Plate osteosynthesis is a widely used technique in head and neck reconstructive surgery. The objective of this study was to determine whether postoperative chemoradiotherapy, which was recently introduced for high-risk head and neck cancer, affects plate and osteosynthesis related complications. METHODS: Fifty-two consecutive patients, who had undergone plate osteosynthesis for mandibular reconstruction between October 2003 and September 2006, were included in the study. The patients were divided into 3 groups: (1) surgery alone (n = 19), (2) surgery with postoperative radiotherapy (n = 14), and (3) surgery with concurrent chemoradiotherapy (n = 19). Outcome measures included any bone or plate related complications. RESULTS: The plate and osteosynthesis related complications occurred in 10.5% of patients in surgery-alone group, 28.6% in surgery with postoperative radiation group, and 63.2% in surgery with postoperative concurrent chemoradiotherapy group. The differences in the complication rates among these 3 groups were statistically significant (p = .003). In univariate analysis, postoperative radiation (p = .007) and concurrent chemotherapy (p = .003) were found to be significantly associated with complications. In multivariate analysis, only concurrent chemotherapy was found to be statistically significant (p = .002) with odds ratio of 7.72. CONCLUSION: Postoperative concurrent chemoradiotherapy significantly increases plate and osteosynthesis related complications in oral cancer.

OBJECTIVE: To compare quality of life (QOL) of patients with advanced laryngeal cancers treated by total laryngectomy with those who received concurrent chemoradiotherapy. STUDY DESIGN: This is a cross-sectional study of the patients treated in our institution who have completed one year of follow-up and were disease-free at the time of evaluation. SUBJECTS AND METHOD: Forty patients treated for advanced cancer of the larynx (stage III/IV), either by concurrent chemoradiation (11) or total laryngectomy and postoperative radiation (29), have been included in this study. The Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) version 4 questionnaire was used. RESULTS: Total scores for overall QOL are equal in both treatment groups (P = 0.69). Scores for individual components are similar in both treatment groups. However, dryness of mouth is significantly worse in the chemoradiotherapy group (P = 0.01) and ability to communicate with others is poorer in the laryngectomy group (P = 0.03). CONCLUSION: Long-term overall QOL remains similar in all the patients treated for advanced carcinoma of the larynx irrespective of treatment modality.

BACKGROUND: Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. AIM: To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. SETTINGS AND DESIGN: Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. MATERIALS AND METHODS: A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. STATISTICAL ANALYSIS: Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. RESULTS: Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. CONCLUSIONS: This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.

Objective: To compare the extent of exposure and surgical maneuverability provided by facial translocation and transtemporal approaches for access to the infratemporal fossa and anterolateral skull base. Materials and Methods: Surgical procedures were performed on five fresh frozen adult cadavers (ten sides) with no known pathology. Facial transfacial approaches with and without a mandibulotomy and transtemporal approaches were evaluated. Objective measures were (1) the distance from the surgical plane to designated anatomic landmarks and (2) the surgical angle of exposure. Results: Distances from the surgical plane to the anatomic reference points were comparable for most of the access procedures (3 to 6 cm). The extended midfacial translocation and bilateral facial translocation approaches did, however, provide a shorter operative distance (1 to 3 cm) for access to the infratemporal fossa and contralateral structures, respectively. The transtemporal approaches facilitate a better angle of exposure (74 to 84 degrees) to the petrotemporal region, while the transfacial approaches were superior for access to the infratemporal structures. Conclusions: Based on the results, we propose a clinical algorithm for selecting a surgical approach based on the position and extent of an infratemporal or petrotemporal lesion