Ablative Head Research Articles

Areal differences in the rate of operative care for cancer of the head and neck within one hospital district in Northern Finland

Abstract Aim The relationship between socioeconomic status (SES) and cancers of the head and neck has been described previously. The present study investigated areal differences in the rate of operative care of cancers of the head and neck in terms of SES and rural–urban areas. Methods This retrospective cohort study included operations performed in Northern Finland between 1 January 2014 and 31 December 2019. SES and the rurality of the residence was determined using postal codes. Results Patients from the low-income areas were older and had higher American Society of Anesthesiologists classification than patients from middle- and high-income areas. The number of operated thyroid and parotid gland tumours was higher in the high-income areas (n = 36 [33.0%] vs n = 21 [18.8%] and n = 330 [28.6%], p = 0.049). Patients living in low- or median-income areas were more likely to live in rural areas than patients living in high-income areas (n = 55 [49.1%] and n = 62 [59.0%] vs n = 44 [40.4%], p = 0.024). The age-weighted rate of operations was higher in low-income areas than in high-income areas (29.3 [23.9–29.3] vs 17.9 [14.5–21.2]), and the age-weighted rate of free-flap surgery was highest in the low-income areas (16.8 [12.4–21.2] vs 8.2 [5.7–10.6] and 9.6 [7.0–12.1] /100,000 inhabitants/year). Conclusion There are significant areal differences in the rate of ablative head and neck surgery. Significantly higher rates were found in low-income areas and in rural areas.

Head and neck reconstruction with the superficial circumflex iliac artery perforator (SCIP) free flap: Lessons learned after 73 cases.

Head and neck tissue defects after ablative surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor site morbidity, which may represent the optimal procedure in this setting. Over the last 5 years, we collected a large base of experience, including both simple and chimeric SCIP-based reconstruction, making this flap our first choice for head and neck reconstructions. Seventy-three patients undergoing ablative head and neck surgery for oncologic pathologies were treated by means of a SCIP flap reconstruction. Patients' mean age was 67 years old (range 37-89), 51 were males and 22 were females. Fifty-eight flaps were simple and 15 were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases. All the patients were successfully treated with no flap losses were encountered. Twelve patients encountered postoperative complications: in four cases revision surgery was required for venous congestion, while the remaining cases were managed conservatively (four wound dehiscence and three infections). No patients showed donor site complications. The mean follow-up period was 11 months (range 3-24). Our case series demonstrates the reliability and versatility of the SCIP flap for different kinds of head and neck reconstructions. The chimeric options combined with bone, double skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgeries. Intraoperative indocyanine green perfusion examination provides a valuable tool to assess and ascertain proper vascularization and post-anastomosis vessel patency in complex microvascular flap-based reconstructions.

Is Preoperative Serum Albumin Predictive of Adverse Outcomes in Head and Neck Cancer Surgery?

Patients with head and neck cancer are at increased risk of malnutrition due to tumor burden and surgical morbidity. The purpose of this study was to evaluate the association between preoperative serum albumin and 30-day adverse outcomes in patients undergoing head and neck cancer surgery. This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing an ablative head and neck cancer procedure were included. Patients who had an unclear tumor location based on coding or missing outcome data were excluded. The primary predictor variable was preoperative albumin categorized as low (<3.4g/dL), intermediate (3.4 to 3.9g/dL), or high (>3.9g/dL). The primary outcome variable was intensive care unit (ICU)-level complications scored using the Clavien-Dindo classification system. This is a tool used to grade surgical complications, with grade IV and V complications defined as requiring ICU-level care. Covariates were demographic (age, sex, body mass index), medical (smoking, functional status, weight loss), and perioperative (concurrent procedures, tumor location, reconstructive modality). Descriptive, bivariate, and multiple logistic regression with bootstrap resampling statistics were used to evaluate the association between albumin and adverse outcomes. A significance level of P≤.05 was significant. A total of 4,491 subjects met inclusion criteria and had a documented albumin. There were 435 subjects with low albumin levels, 1,305 with intermediate levels, and 2,751 with high levels. In bivariate analysis, low albumin levels were associated with an increased risk of ICU-level complications, any complication, extended length of stay, and adverse discharge disposition (all P≤.001), while high levels were protective (all P≤.001). In bootstrapped multivariate analysis using intermediate albumin as the reference group and adjusting for demographics, tumor location, and reconstructive modality among others, low albumin levels were an independent predictor of ICU-level complications (P=.008, odds ratio, 1.64; 95% confidence interval, 1.14 to 2.40), while high levels were protective (P=.014, odds ratio, 0.689; 95% confidence interval, 0.521 to 0.923). Preoperative serum albumin was an independent predictor of adverse outcomes following ablative head and neck cancer procedures.

The RVU Compensation Model and Head and Neck Surgical Education.

The present study aims to quantify the opportunity cost of training residents and fellows for head and neck surgery. A 2005-2015 review of ablative head and neck surgical procedures was performed using the National Surgical Quality Improvement Program (NSQIP). Work relative value units (wRVU) generated per hour were compared among procedures performed by attendings alone, attendings with residents, and attendings with fellows. Among 34,078 ablative procedures, the rate of wRVU generation per hour was greatest for attendings alone (10.3), followed by attendings with residents (8.9) and attendings with fellows (7.0, p < 0.001). Resident and fellow involvement was associated with opportunity costs of $60.44 per hour (95% CI: $50.21-$70.66/h) and $78.98 per hour ($63.10-$94.87/h, 95% CI), respectively. wRVU-based physician reimbursement does not consider or adjust for the extra effort involved in training future head and neck surgeons. NA Laryngoscope, 134:113-119, 2024.

Advances and Innovations in Ablative Head and Neck Oncologic Surgery Using Mixed Reality Technologies in Personalized Medicine.

The benefit of computer-assisted planning in head and neck ablative and reconstructive surgery has been extensively documented over the last decade. This approach has been proven to offer a more secure surgical procedure. In the treatment of cancer of the head and neck, computer-assisted surgery can be used to visualize and estimate the location and extent of the tumor mass. Nowadays, some software tools even allow the visualization of the structures of interest in a mixed reality environment. However, the precise integration of mixed reality systems into a daily clinical routine is still a challenge. To date, this technology is not yet fully integrated into clinical settings such as the tumor board, surgical planning for head and neck tumors, or medical and surgical education. As a consequence, the handling of these systems is still of an experimental nature, and decision-making based on the presented data is not yet widely used. The aim of this paper is to present a novel, user-friendly 3D planning and mixed reality software and its potential application for ablative and reconstructive head and neck surgery.

First complex maxillofacial reconstruction with free flaps in the Gaza Strip, occupied Palestinian territory: case series from an area under conflict

BackgroundLarge mandibular and maxillary defects are repaired by maxillofacial reconstructive microsurgery (MRM) using free flaps, which is challenging to perform in austere settings owing to its demanding nature in terms of time, equipment, and trained personnel. Humanitarian missions refrain from performing MRM procedures in the host country and instead transfer patients to their home country to perform surgery. We report on the first nine MRM procedures in Gaza. MethodsA French medical mission performed the surgical operations at Al Shifa Hospital, Gaza, occupied Palestinian territory. Fibula free flap, radial forearm free flap, scapular free flap, and thoracodorsal perforator free flap were performed. We recorded the patients’ demographics, diagnoses, and immediate postoperative and follow-up status. We also report the special considerations required to perform the surgery in Gaza's austere and resource-poor environment. FindingsNine patients (five female, four male; mean age 22 years) underwent ablative head and neck surgery from January, 2017, to March, 2019. Before arrival, the missions closely coordinated with local surgeons, who assisted in performing the surgeries and followed the patients postoperatively. Essential surgical equipment needed for the surgery (such as loupes, microvascular sutures, and titanium plates) were donated by the foreign missions. Patients were followed up by local surgeons for a period ranging from 5 to 12 months. No complications occurred at the donor or recipient sites. There was no extrusion of hardware or breakage of the titanium mini plates or reconstructive plates. Patients remained in the intensive care unit postoperatively for at least 48 h. Owing to financial restraints, removable prostheses were used. Rehabilitation was provided by a local dental team despite the lack of professional dental rehabilitation services. Patients had stable bony union and acceptable facial contour. Patients regained satisfactory masticatory function, resumed their normal diets after 6 months without weight loss, and maintained intelligible speech. InterpretationMRM can be successfully performed in conflict settings such as Gaza. Although the study population was small, the study suggests that further investigation into the conditions and elements needed to perform complex surgeries in conflict settings is warranted. Selection of health-care professionals in the surgical and postoperative care teams, effective coordination with local doctors, availability of essential equipment, and postoperative follow-up protocols could all be carefully considered to optimise the results of surgery. In addition, starting rehabilitation as soon as possible following surgery may restore and improve functional and aesthetic outcomes. FundingThe Palestine Children's Relief Fund (PCRF).

Superficial Circumflex Iliac Artery Perforator Flap in Advanced Head and Neck Reconstruction: From Simple to Its Chimeric Patterns and Clinical Experience with 22 Cases.

Head and neck tissue defects after ablative head and neck surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor-site morbidity. The authors present their experience with both simple and chimeric SCIP flap reconstructions for complex defects in various head and neck regions. Twenty-two patients undergoing ablative head and neck surgery for oncologic abnormalities were treated by means of a SCIP flap reconstruction. Patients' mean age was 62 years; 21 were men and one was a woman. Seventeen flaps were simple and five were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases. Twenty-one of 22 patients (95.5 percent) were successfully treated with good aesthetic and functional results. Two patients (9 percent) showed minor donor-site complications that were managed conservatively. The mean follow-up period was 5.3 months (range, 2 to 8 months). This case series demonstrates the reliability and versatility of the SCIP flap for head and neck reconstruction. The chimeric options combined with bone, double-skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgery. Intraoperative indocyanine green perfusion examinations are a valuable tool to assess and ascertain proper inset, vitality, and postanastomosis vessel patency in these complex microvascular flap reconstructions. . Therapeutic, IV.

Microsurgical reconstruction of Stensen's duct using autologous vein graft and venous coupler after ablative head and neck surgery.

We describe our technique which is simple and feasible to reconstruct the parotid duct orifice after cancer ablative surgery.

Postoperative Pain Treatment With Continuous Local Anesthetic Wound Infusion in Patients With Head and Neck Cancer

Up to 80% of patients with head and neck cancer undergoing ablative surgery and neck dissection develop postoperative pain with detrimental effects on quality of life that also contributes to neuropathic and chronic postoperative pain. To investigate the association of continuous local anesthetic wound infusion with pain management after head and neck surgery. This prospective, longitudinal, nonrandomized clinical study carried out in a single tertiary referral center (December 1, 2015, to July 1, 2017) included 2 groups of 30 patients. Patients were consecutively enrolled and presented for ablative head and neck surgery including selective neck dissection and studied from the preoperative through the fourth postoperative day. The control group was treated according to a standardized escalating oral treatment protocol (ibuprofen, metamizole, opioids). The intervention group was treated with an intraoperatively applied pain catheter (InfiltraLong plus FuserPump, Pajunk, ropivacaine, 0.2%, 3 mL/h) that was removed 72 hours after operating. Average and maximum pain intensities on a numeric rating scale; quality of life using the acute version of the validated 36-Item Short Form Survey; and neuropathic pain using the validated 12-Item painDETECT questionnaire. Consumption of opioid and nonopioid analgesics and evaluation of catheter-associated complications. During postoperative days 1 through 4, patients of the intervention group (mean [SD] age, 63.2 [13.3 years; 9 [30%] women) experienced lower mean (SD) (1.6 [1.4] vs 2.7 [1.8]; η2p = 0.09 [0.01-0.21]) and maximum (2.4 [2.2] vs 4.2 [2.0]; η2p = 0.11 [0.01-0.24]) pain intensities compared with the control group (mean [SD] age, 62.5 [13.6] years; 5 [17%] women). The intervention group also reported less neuropathic pain (mean [SD], 5.4 [3.4] vs 7.6 [5.1]; η2p = 0.09 [0.004 - 0.22]) and higher quality of life regarding vitality (56.2 [21.5] vs 43.8 [20.9], r = 0.29; 95% CI, 0.01-0.52) and pain (66.8 [27.3] vs 49.5 [27.7], r = 0.31; 95% CI, 0.04-0.54). Patients from the intervention group requested nonopioid analgesics considerably less often (n = 17 [57% ]vs n = 29 [97%]; ϕ = 0.47; 95% CI, 0.30-0.67) associated with a noticeably lower need to escalate pain treatment (n = 3 [10%] vs n = 9 [30%]; mean [SD] ibuprofen dose: 500 [173] mg vs 1133 [650] mg; r = 0.64; 95% CI, 0.02-0.91). No catheter-associated complications were observed. Continuous anesthetic wound infusion is associated with reduced postoperative pain and decreased demand for analgesics. It therefore expands the treatment options for postoperative pain in head and neck cancer. German Clinical Trials Register: DRKS00009378.

Processed nerve allografts in reconstructive microneurosurgery after ablative head and neck surgery: an overview

: Peripheral nerve reconstruction has become increasingly important in functional rehabilitation in head and neck surgery in recent years. Important neural structures can be damaged or sacrificed in the treatment of malignant and benign pathology, and can result in significant morbidity for patients postoperatively, impacting their quality of life. Restoration of nerve function represents an important tool in head and neck reconstructive surgery, with advances in microneurosurgical techniques and the introduction of biologics including conduits, connectors, and processed allogenic nerve grafts, permitting surgeons to optimize results without additional morbidity to the patient. We present an overview of nerve repair and reconstruction in the head and neck for post-ablative defects, with a focus on the lingual and inferior alveolar nerves of the trigeminal system. A review of various methods of management of neural structures in different types of pathology, as well as operative techniques in nerve reconstruction is presented, with a focus on the use of processed nerve allografts for this purpose. This manuscript highlights that nerve preservation should only be performed if it permits an “oncologically-safe” procedure, with minimal to no risk of leaving pathology behind. Immediate or delayed nerve reconstruction can be performed; however, the former allows for a technically easier procedure and more predictable results. Nerves can either be repaired primarily, or reconstructed with “conduit-assisted” and/or interpositional grafting, with the goal of having a tension-free and well-aligned coaptation. In gaps larger than 6mm, grafting with either autogenous or allogenic nerves yields more optimal results, with processed nerve allografts showing excellent outcomes in this setting. In conclusion, nerve reconstruction has gained significant ground in the restoration and rehabilitation of head and neck defects. There exist several techniques for nerve reconstruction, however the use of processed nerve allografts has significantly improved results while eliminating the morbidity associated with autogenous grafting. Head and neck oncologic and reconstructive surgeons should be aware of the predictability of nerve reconstruction techniques to optimize patients’ functional recovery in the postoperative period.

Complications, Mortality, and Functional Decline in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction

Data regarding outcomes after major head and neck ablation and reconstruction in the growing geriatric population (specifically ≥80 years of age) are limited. Such information would be extremely valuable in preoperative discussions with elderly patients about their surgical risks and expected functional outcomes. To identify patient and surgical factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline; to explore whether an association exists between the type of reconstructive procedure and outcome; and to create a preoperative risk stratification system for these outcomes. This retrospective, multi-institutional cohort study included patients 80 years or older undergoing pedicle or free-flap reconstruction after an ablative head and neck surgery from January 1, 2015, to December 31, 2017, at 17 academic centers. Data were analyzed from February 1 through April 20, 2019. Thirty-day serious complication rate, 90-day mortality, and 90-day decline in functional status. Preoperative comorbidity and frailty were assessed using the American Society of Anesthesiologists classification, Adult Comorbidity Evaluation-27 score, and Modified Frailty Index. Multivariable clustered logistic regressions were performed. Conjunctive consolidation was used to create a risk stratification system. Among 376 patients included in the analysis (253 [67.3%] men), 281 (74.7%) underwent free-flap reconstruction. The median age was 83 years (range, 80-98 years). A total of 193 patients (51.3%) had 30-day serious complications, 30 (8.0%) died within 90 days, and 36 of those not dependent at baseline declined to dependent status (11.0%). Type of flap (free vs pedicle, bone vs no bone) was not associated with these outcomes. Variables associated with worse outcomes were age of at least 85 years (odds ratio [OR] for 90-day mortality, 1.19 [95% CI 1.14-1.26]), moderate or severe comorbidities (OR for 30-day complications, 1.80 [95% CI, 1.34-2.41]; OR for 90-day mortality, 3.33 [95% CI, 1.29-8.60]), body mass index (BMI) of less than 25 (OR for 30-day complications, 0.95 [95% CI, 0.91-0.99]), high frailty (OR for 30-day complications, 1.72 [95% CI, 1.10-2.67]), duration of surgery (OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), flap failure (OR for 90-day mortality, 3.56 [95% CI, 1.47-8.62]), additional operations (OR for 30-day complications, 5.40 [95% CI, 3.09-9.43]; OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), and surgery of the maxilla, oral cavity, or oropharynx (OR for 90-day functional decline, 2.51 [95% CI, 1.30-4.85]). Age, BMI, comorbidity, and frailty were consolidated into a novel 3-tier risk classification system. Important demographic, clinical, and surgical characteristics were found to be associated with postoperative complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck surgery. Free flap and bony reconstruction were not independently associated with worse outcomes. A novel risk stratification system is presented.

Head and Neck Reconstructive Surgery: Characterization of the One-Team and Two-Team Approaches

To the best of our knowledge, no studies have compared the patient profiles for 1- versus 2-team surgery within head and neck oncosurgery. A retrospective study of the data from 2968 patients who had undergone concurrent head and neck extirpative and reconstructive surgery in the National Surgical Quality Improvement Program (2010 to 2017) was conducted. Patients were stratified into 1- and 2-team surgery groups, and the demographic data were compared. Univariate analyses of the outcomes before and after propensity score matching were conducted. Most ablative and reconstructive head and neck procedures (68.5%) were performed using a 1-team approach. The patients who had undergone 2-team surgery were more likely to have a higher American Society of Anesthesiologists classification (P<.001), to require mandibulectomy (P<.001) or glossectomy (P<.001), and to receive a microvascular free flap (P<.001) but were less likely to require parotidectomy (P<.001) or to receive a rotational flap (P<.001). Before propensity score matching, the patients undergoing 2-team surgery had longer operative times (P<.001), longer postoperative stays (P<.001), greater rates of a return to the operating room (P=.001), and an increased rate of complications (P<.001). After propensity score matching, the 2-team approach continued to have longer operative times (P<.001) and an increased incidence of complications (P<.001) but no significant differences in the length of stay or rate of return to the operating room after Bonferroni's correction. Nationally, most head and neck ablative and reconstructive surgeries were completed by 1 team. More complicated reconstructive procedures involving microvascular free flaps have been more commonly performed by 2 teams, resulting in slightly longer operative times and greater associated complication rates.

SYM6 Microvascular Free Tissue Transfer in Pediatric Craniofacial Reconstruction

Introduction: Free tissue transfer is an integral part of modern head and neck surgery in the adult population, while its use is often avoided in children. This is based on presumed technical challenges and increased risks of complications including flap failure, smaller vessels prone to vasospasm, challenging post-operative management, and concerns regarding donor-site morbidity and negative effects on patient craniofacial growth. The current literature on microsurgical pediatric reconstruction is sparse and only few data is available regarding the survival of microvascular free flaps following head neck tumor extirpation. Methods: This retrospective study included 100 patients (43 females; 57 males) who had undergone microvascular reconstruction (mean age at surgery: 12,4 years; range: 1–18 years) following ablative head and neck surgery between 1999 and 2018. Results: A total of 100 patients underwent 120 microvascular free tissue transfers. In our pediatric cohort, 16 patients required a second or multiple free flap procedures. The three most commonly used flaps were latissimus dorsi (n=47; 39 %), fibula (n=27; 22 %) and dorsal scapular (n=20; 17 %) free flaps. The majority of cases (87%) had a malignant disease, predominately sarcomas (n=64) and epidermoid carcinomas (n=10), while benign tumors constituted 13 cases. Primary reconstruction sites were the infratemporal fossa (35%), mandible (27%) and maxilla (18 %). Immediate post-operative complications (within 30 days) occurred in 6% and were mostly related to local infection, partial flap necrosis and cervical hematoma, while the overall microvascular free flap success rate was 99% (1 flap failure out of 120). Conclusion: Free tissue transfer should be considered a gold-standard in pediatric patients requiring soft tissue or bony reconstruction following extensive ablative tumor surgery. Despite the fact that a significant proportion of our patients received preoperative chemotherapy or radiation which are known risk factors for flap failure, the overall success rate (99%) was still comparable or better to those observed in the adult population. Conditions such as atherosclerosis, diabetes, hypertension, smoking, and alcohol abuse that deteriorate blood vessel quality are rather uncommon in children and may therefore explain the good outcomes in our study. However, long-term sequelae, such as donor-site morbidity and craniofacial growth impairment must be anticipated as they may result in repetitive corrective procedures throughout adolescence.

Evaluation of a Preoperative Adverse Event Risk Index for Patients Undergoing Head and Neck Cancer Surgery

Patients 65 years or older are the most frequent users of operative resources and are also the most vulnerable to postoperative adverse events (AEs). Frailty indices are increasingly being used for preoperative risk stratification within head and neck cancer surgery, but most models lack a multifactorial basis and cannot be directly applied to clinical practice. A practical risk index is needed for clinicians to gauge risk factors preoperatively. To develop a preoperative risk index of short-term major postoperative AEs for patients undergoing head and neck cancer surgery. Cohort analysis of patients from multiple medical centers undergoing inpatient ablative or reconstructive head and neck cancer surgery and registered in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) from 2006 to 2016. Inpatient ablative or reconstructive head and neck cancer surgery. Sociodemographic, frailty-related, and surgical factors in the derivation cohort were evaluated using simple and multiple logistic regression. Risk factors were subsequently integrated into a preoperative head and neck surgery risk index (HNSRI) and compared with existing models using the validation cohort. A composite variable of major postoperative AEs was used, including death within 30 days of surgery. A total of 43 968 operations were found using the ACS NSQIP database. Of these, 12 569 cases were excluded as non-head and neck cancer or emergency surgery. Of the included 31 399 operations reviewed, the mean (SD) patient age was 56.9 (15.4) years, and 16 994 of the patients were women (54.1%). A total of 4556 (14.5%) patients had a major postoperative AE, and 209 (0.7%) died. Older age, male sex, smoking, anticoagulation, recent weight loss, functional dependence, free-tissue transfer, tracheotomy, duration of surgery, wound classification, anemia, leukocytosis, and hypoalbuminemia were independently associated with major AEs or death on multiple regression analysis (C statistic, 0.83). The area under the curve of the HNSRI to predict major AEs including death using the validation cohort (n = 15 699) was 0.84 (95% CI, 0.83-0.85) with a sensitivity of 80.1% (95% CI, 79.4%-80.8%) and specificity, 72.3% (95% CI, 70.3%-74.2%). The HNSRI outperformed existing risk models for prediction of AEs: delta C index of the HNSRI to the modified frailty index 11, 0.23 (95% CI, 0.22-0.25); the American Society of Anesthesiologists classification, 0.14 (95% CI, 0.13-0.16); and the ACS risk calculator, 0.02 (95% CI, 0.01-0.03). The proposed HNSRI demonstrated a high sensitivity and specificity for major postoperative AEs and death in the studied population. This risk index can be used to counsel patients awaiting head and neck cancer surgery.

Immediate parotid duct reconstruction using an autologous vena comitans of the anterolateral thigh free flap pedicle in ablative head and neck surgery.

Immediate parotid duct reconstruction using an autologous vena comitans of the anterolateral thigh free flap pedicle in ablative head and neck surgery.

Visualization and quantification of tongue movement during articulation: Is ultrasound a valid alternative to magnetic resonance imaging?

BackgroundQuality of life in tumour patients following combined ablative and reconstructive head and neck surgery varies significantly. This is at least partially due to differences in speech and swallowing function. A tool to objectively evaluate articulation by magnetic resonance imaging (MRI) has now been tested alongside ultrasound examination. Patients and methodsA standardized sequence of phonemes from the German language was established in 20 healthy volunteers and recorded in different planes by MRI and ultrasound. Phonemes were identified through recognition of typical tongue configurations by two different observers. An algorithm for metric analysis of articulation in terms of distances and angles for five extreme points on the tongue (anterior, posterior, cranial and two basal corners) was designed. The findings in these volunteers were subsequently compared with the results of an examination of a tumour patient. ResultsPhysiological articulation was visualized and evaluated both by MRI and ultrasound. There was a high intra-class correlation coefficient for measurements between independent observers. Tongue position for certain phonemes was mostly constant in healthy patients of different age groups, with gender-specific differences. In a first comparison, tongue position in a patient with tongue cancer differed significantly from this position, both pre- and postoperatively. In agreement with clinical articulation quality, the tongue position of the patient returned to almost normal within 12 months postoperatively. ConclusionBoth ultrasound and MRI are appropriate instruments for visualization of articulation and objective measurements to evaluate speech in tumour patients. Whilst MRI is more precise and can identify more subtle differences, ultrasound is a valid alternative due to its wider availability and broader applicability.

Prediction of mortality and morbidity in head and neck cancer patients 80 years of age and older undergoing surgery.

To determine postoperative complications and mortality rates in octogenarian and older head and neck cancer patients undergoing ablative surgical resections and to identify factors associated with postoperative morbidity and mortality. Retrospective cohort study investigating risk factors for 30-day serious complication risk and 90-day mortality risk for patients aged 80 years and older who underwent ablative head and neck oncologic surgical procedures at an academic tertiary care center between 2005 and 2015. Of the 219 patients who underwent 241 surgeries, 74 patients experienced serious complications within 30 days and 25 died within 90 days of surgery. American Society of Anesthesiologists (ASA) score of 4 or greater, and operating room (OR) time ≥6 hours were independently associated with serious complications, whereas age ≥90 years, overall severe comorbidity score, presence of preoperative dysphagia, and large extent of resection were associated with increased risk of death in 90 days. Models to predict risk of 30-day serious complications and 90-day mortality were then developed. Patient and surgical treatment factors predict risk of serious complications and mortality in patients aged 80 years and older undergoing ablative head and neck surgery. Predictive models may guide preoperative discussion with patients. 2b. Laryngoscope, 128:871-877, 2018.

215 Laser Thermal Ablation for Mesiotemporal Epilepsy

Abstract INTRODUCTION Laser interstitial thermal therapy (LiTT) has dramatically changed the management of mesiotemporal epilepsy (mTLE) in recent years. The goal of this study was to identify features of ablations and trajectories that correlate with optimal seizure control and minimize the risk of neurocognitive deficits in patients undergoing LiTT for mTLE. METHODS Clinical and radiographic data were reviewed from a prospectively maintained database of patients undergoing LiTT for epilepsy at the University of Miami. Standard preoperative and postoperative evaluations, including contrast-enhanced MRI and neurocognitive testing, were performed in all patients. Laser trajectory and ablation volumes were computed both by manual tracing of mesiotemporal structures and by nonrigid registration of ablation cavities to a common reference system based on 7T MRI data. RESULTS &gt;Of the 28 patients with at least 1-year follow-up, sparing of the mesial hippocampal head was significantly correlated with persistent disabling seizures (P = 0.01). Projecting all ablation cavities onto a common reference frame showed a clear tendency towards lateral placement of the laser with inadequate mesial hippocampal head ablation in these patients compared to those free of seizures. Patients that suffered deficits in memory, on the other hand, tended to have larger ablations with greater insult to entorrhinal and perirhinal cortex than those free of memory deficits. CONCLUSION Better understanding of the impact of ablation volume and location through the use of image normalization tools could potentially fine-tune this novel technique to improve seizure-freedom rates and associated neurocognitive deficits.

Simultaneous reconstruction of orbital defect and parotid contour deformity by a single muscle-sparing VRAM flap with double-skin islands

Reconstruction of complex three-dimensional defects or defects in separate locations after ablative head and neck surgery can be achieved with two simultaneous free flaps, a combination of a free flap and a pedicle flap, or a single multi-island free flap. The rectus abdominis flap is often used for reconstructions with a single multi-island free flap, but the flap is excessively bulky in some cases, leading to the unnecessary sacrifice of muscle. To overcome this issue and to preserve the muscle, we used a single muscle-sparing vertical rectus abdominis musculocutaneous flap with two completely separated skin islands based on two different skin perforators to simultaneously reconstruct separate locations (the orbit and parotid region) after orbital exenteration and total parotidectomy. Our findings highlight the feasibility of simultaneously reconstructing orbit and parotid contour deformities with a single double-island flap.

The Effect of Norepinephrine and Dopamine on Radial Forearm Flap Partial Tissue Oxygen Pressure and Microdialysate Metabolite Measurements: A Randomized Controlled Trial.

Patients undergoing ablative and reconstructive head and neck surgery with a microvascular flap have multiple factors that potentially decrease postoperative mean arterial pressure, which may endanger flap survival. The safety of vasopressor use has long been a topic of discussion. The authors analyzed the effect of vasopressors on microvascular flap perfusion after head and neck cancer reconstruction. A total of 27 patients were enrolled in a randomized, controlled, clinical trial. A microvascular radial forearm flap was used for reconstruction. Patients were allocated into one of three groups: dopamine, norepinephrine, and control. The intervention groups received the vasoactive drug, aiming to maintain the mean arterial pressure between 80 and 90 mmHg. Normovolemia was maintained according to central venous pressure. Flap perfusion was monitored with continuous tissue partial pressure of oxygen and microdialysate metabolite (lactate-to-pyruvate ratio) measurements. No adverse effects were observed, and postoperative recovery was free of complications in all groups. Neither the lactate-to-pyruvate ratio nor continuous tissue partial pressure of oxygen values differed significantly between groups during the first 24 hours of the vasoactive drug infusion period or during the 72-hour follow-up. Norepinephrine and dopamine are safe and effective vasopressors for use during the postoperative period following head and neck cancer surgery with microvascular reconstruction. Dopamine should be used with caution, however, because of the risk of side effects. Therapeutic, II.