Objectives: 1) Analyze the impact of preoperative radiotherapy on total lymph node yield in neck dissection specimens. 2) Analyze the impact of preoperative radiotherapy on the presence of extracapsular‐spread in neck dissection specimens. Methods: Historical cohort study. Setting: Academic medical center. Patients: 525 subjects who underwent neck dissection for a diagnosis of squamous cell carcinoma from 1990 to 2010 were analyzed. Subjects were divided into 2 groups; those who underwent neck dissection alone or had neck dissection before radiation (surgery first group), versus subjects who received radiation therapy before neck dissection (radiation first group). Outcome Measures: The total number of lymph nodes harvested as well as the incidence of extracapsular‐spread was examined between these two groups. Results: A total of 366 patients in the surgery first group and 159 in the radiation first group were analyzed. The mean number of lymph nodes harvested in the surgery first group was 29.4, compared to 20.9 lymph nodes in the radiation first group ( P < 0.001). Of 461 patients with available extracapsular‐spread data, 106 (23.0%) had extracapsular‐spread identified in their pathology report. Preoperative radiation significantly decreased the incidence of extracapsular‐spread (OR=0.296, P < 0.001). The incidence of extracapsular‐spread was 26.9% (84/312) in the surgery first group, and 14.8% (22/149) in the radiation first group. Conclusions: We identified a significantly decreased number of lymph nodes harvested and a decreased frequency of extracapsular‐spread in the neck dissection specimens from patients who had undergone prior neck irradiation as compared to those without prior neck irradiation.
In 1965, Bakamjian described the deltopectoral (DP) flap as a reconstructive option in head and neck surgery. It served as the premier flap for reconstructing complex head and neck defects until the late 1970s. Today, the DP flap is often overlooked; although its role has diminished, its use is still warranted in certain select clinical situations.A retrospective patient chart review of 25 DP flap procedures performed at the University of Iowa Hospitals and Clinics and Iowa City Veterans Administration Hospital between January 1, 1991, and June 1, 2002, was undertaken. The data collected included patient demographics and assessment of DP flap survival and its ability to accomplish established preoperative reconstructive goals.The DP flap was used for the following situations: vascularized skin coverage of the neck, carotid arteries, and face (16 cases), including simultaneous coverage of other reconstructive flaps in 6 cases; controlled orocutaneous fistula development (3 cases) or fistula closure (5 cases); and pharyngoesophageal reconstruction (4 cases). In 3 cases the flap was used for more than one of the preoperative goals described above (n = 25). Minor flap-related complications that required local wound treatment developed in 5 cases (20.0%), but the flaps were successfully salvaged and no subsequent reconstructive procedure was required. In an additional 5 cases (20.0%), the flap failed in some measure to accomplish its preoperative goal, necessitating further surgical reconstruction. Sixteen patients (64%) had undergone previous or simultaneous reconstructive procedures that limited other available reconstructive options.The technical simplicity of the DP flap, coupled with its predictable vascular supply, has allowed it to maintain a niche role in contemporary reconstructive surgery. The DP flap provides an excellent method of reconstruction in select cases in which vascularized skin coverage of the neck is needed. The DP flap also provides a valuable salvage option in situations in which other reconstructive techniques are not possible.
Abstract Background Pharyngeal high‐resolution manometry (HRM) has emerged over the last decade as a valuable assessment tool for oropharyngeal dysphagia. Data analysis thus far has focused primarily on measures of pressure and duration within key anatomic regions. We apply spectral arc length (SPARC), a dimensionless metric for quantifying smoothness felt to indirectly reflect neuromuscular coordination, as a new method of describing manometric curves. We then use it to distinguish swallows from healthy subjects and those with dysphagia related to stroke. Methods Previously collected pharyngeal HRM data from eight subjects with history of stroke and eight age‐ and sex‐matched controls were reviewed. Receiver operating characteristic (ROC) analysis was used to optimize SPARC inputs. SPARC was then computed for the velopharynx, tongue base, hypopharynx, and upper esophageal sphincter (UES), and the values were compared between the two subject groups. Results Optimized parameter settings yielded an ROC curve with area under the curve (AUC) of 0.953. Mean SPARC values differed between control and stroke subjects for the velopharynx ( t = 3.25, p = 0.0058), tongue base ( t = 4.77, p = 0.0003), and hypopharynx ( t = 2.87, p = 0.0124). Values were similar for the UES ( t = 0.43, p = 0.671). Conclusions In this preliminary study, SPARC analysis was applied to distinguish control from post‐stroke subjects. Considering alternative methods of analyzing pharyngeal HRM data may provide additional insight into the pathophysiology of dysphagia beyond what can be gleaned from measures of pressure and duration alone.
5518 Background: A Phase I trial has been completed to examine the safety and feasibility of combining bevacizumab (bev) with radiation and cisplatin in patients with locoregionally advanced head and neck squamous cell carcinoma (LA-HNSCC). We assessed the capacity of bev monotherapy to induce tumor response as measured by functional imaging and biomarker evaluation. We report preliminary clinical outcome as well as correlative imaging and biomarker results. Methods: All patients underwent experimental imaging [FLT-PET (proliferation), CuATSM-PET (hypoxia), DCE-CT scans (flow/perfusion)] and biomarker evaluation prior to bev monotherapy. At three weeks, repeat tumor biopsy and imaging/serum studies were performed. Comprehensive H&N chemoradiation (CRT) was then delivered to 70 Gy in 33 fractions with concurrent weekly cisplatin at 30 mg/m2 and Q3 week bev (wks 1, 4, 7) with dose escalation from 5 to 10 to 15 mg/kg. Results: Between 2007-2010, ten LA-HNSCC pts were enrolled. All had stage IV HNSCC and remain alive (9 NED) with a mean survival of 22.4 months. There have been two recurrences at 15 and 16 months respectively. Nine patients experienced grade 3 toxicity (dysphagia-9, mucositis-7, tumor pain-3, weight loss-4, nausea/vomiting-2), with two cases of grade 4 lymphopenia. No significant bleeding was observed. Tumor proliferation (FLT) following bev monotherapy and at mid-course showed significant reduction (p<0.05). Tumor hypoxia (Cu-ATSM) showed minimal change following bev alone, but showed reduction during CRT. AQUA histology confirmed reduction in VEGFR2 expression from tumor biopsies following bev therapy. Conclusions: The incorporation of bev with comprehensive CRT for LA-HNSCC appears safe and feasible. Several patients manifested tumor regression following administration of bev alone. Three patients experienced pronounced tumor pain early in the treatment course. Experimental imaging and biomarker evaluation demonstrated clear changes following bev alone and during CRT. These findings may afford opportunities to forecast clinical outcome for individual patients and thereby tailor therapy approaches in future clinical trials.
Objectives/Hypothesis Airway access in the setting of unsuccessful ventilation and intubation typically involves emergent cricothyrotomy or tracheotomy, procedures with associated significant risk. The potential for such emergent scenarios can often be predicted based on patient and disease factors. Planned tracheotomy can be performed in these cases but is not without its own risks. We previously described a technique of pre‐tracheotomy or exposing the tracheal framework without entering the trachea, as an alternative to planned tracheostomy in such cases. In this way, a tracheotomy can be easily completed if needed, or the wound can be closed if it is not needed. This procedure has since been used in an array of indications. We describe the clinical situations where pre‐tracheotomy was performed as well as subsequent patient outcomes. Methods Retrospective series of patients undergoing a pre‐tracheotomy from 2015 to 2020. Records were reviewed for patient characteristics, indication, whether the procedure was converted to tracheotomy or closed at the bedside, and any post‐procedural complications. Results Pre‐tracheotomy was performed in 18 patients. Indications included failed extubation after head and neck reconstruction, subglottic stenosis, laryngeal masses, laryngeal edema, thyroid masses, and an oropharyngeal bleed requiring operative intervention. Tracheotomy was avoided in 10 patients with wound closed at the bedside; procedure was converted to tracheotomy in the remaining eight. There were no complications. Indications for conversion included failed extubation, intraoperative hemorrhage, significant stridor with dyspnea, and inability to ventilate. Conclusion Pre‐tracheotomy offers simplified airway access and provides a valuable option in scenarios where tracheotomy may, but not necessarily, be needed. Level of Evidence 4 Laryngoscope , 131:E2802–E2809, 2021
The objective of the study was to evaluate the results of autologous fat injection laryngoplasty in the long-term management of unilateral vocal cord paralysis.A retrospective chart review and clinical voice re-evaluation of patients treated for unilateral vocal cord paralysis with autologous fat injection at the University of Iowa Hospitals and Clinics (Iowa City, IA) between May 1992 and September 1999.The data analyzed included patient demographics, early and long-term vocal outcomes, additional surgical treatments, and patient survival.Fifty patients were treated with fat injection laryngoplasty, which included 44 treated for unilateral vocal cord paralysis. Thirty-one of the patients had fat injection as their primary procedure for permanent voice restoration. Eight patients treated had preoperative and postoperative voice data available. Using the GRBAS subjective voice assessment scale (0, normal; 3, severely abnormal), mean grade improved from 2.1 to 1.3 and breathiness improved from 1.4 to 0.5, at a mean period of 52 days. Thirteen of the 31 patients (41%) required additional procedures to achieve acceptable vocal outcomes. The median time to failure for these patients was 163 days. The initial treatment failure rate at 2 years was 30%, and the rate reached 45% by 4 years.Although fat injection laryngoplasty reliably improves the voice over the short term, the long-term voice outcome is unpredictable. Additional surgeries to deal with subsequent vocal deterioration are common. The role of autologous fat injection laryngoplasty in the modern era is limited.
A) Axial T1-weighted MRI with gadolinium demonstrated a small right-sided vestibular schwannoma that extended 0.5cm into the cerebellopontine angle.(B) Following treatment with stereotactic radiosurgery, the tumor exhibited continued growth on serial imaging over a 3.4-year period, which necessitated salvage microsurgical resection.Gross total resection via a translabyrinthine approach was performed with no evidence of recurrence to date.
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