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   Table of Contents - Current issue
January-June 2020
Volume 8 | Issue 1
Page Nos. 1-45

Online since Thursday, June 18, 2020

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Reconstruction in head and neck cancer surgery: The ways we came through and the path ahead Highly accessed article p. 1
Subramania Iyer
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Total glossectomy: Technique review Highly accessed article p. 3
Viswanath Neelakantan, Girish S Shetkar, Vikram D Kekatpure
Advanced cancers of oral tongue and recurrent/residual tumors arising from base of tongue may require total glossectomy for curative intent treatment. This procedure is considered morbid due to possibility of life threatening aspiration. This review discusses the technical nuances to reduce functional morbidity. The pull through resection technique allows a compartmental resection of these tumors with adequate margin control without a need for mandibulotomy. Selection of appropriate flap to replace bulk and laryngeal suspension are essential components of reconstruction. With application of these technical advances and adequate post-operative swallow therapy, patients undergoing total glossectomy have acceptable functional outcome.
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Minimally invasive retroauricular approaches to the neck: A paradigm shift p. 8
Priyanko Chakraborty, Pattatheyil Arun, Kapila Manikantan, Jain Prateek Vijay, Rajeev Sharan
Introduction: The conventional approach for surgery of the thyroid and neck is performed through an open transcervical incision. Endoscopic and robotic neck surgery via retroauricular approach is a viable cosmetic alternative with improved functional outcomes. Materials and Methods: This is a retrospective analysis of patients who underwent endoscopic or robotic assisted neck surgeries from September 2016 to December 2019 at a tertiary cancer center in Eastern India. Results: A total of 54 patients were operated by the retroauricular approach. We encountered minimal complications and better cosmetic results compared to the standard open approach. A significant reduction in operative time over the course of the study was observed, signifying an easier learning curve. Conclusion: Retroauricular approach is a feasible cosmetic minimally invasive approach to neck surgeries with satisfactory functional outcomes, which may be implemented in developing country like ours where cosmesis is rapidly gaining popularity.
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Microvascular reconstruction for tumors of the head and neck in the pediatric population p. 12
Deepak Balasubramanian, Narayana Subramaniam, Janarthanan Ramu, Ridhi Sood, Mohit Sharma, Jimmy Mathew, Krishnakumar Thankappan, Pramod Subhash, Arjun Krishnadas, Subramania Iyer
Introduction: Microsurgical tissue transfer in the pediatric population is challenging for several reasons– small vessel diameter, flap size, difficulties with postoperative flap monitoring, and difficulty in anticipating tissue growth and remodeling. In addition, head-and-neck reconstruction is uniquely difficult due to the functional deficits after ablative surgery. We present our series of microvascular reconstruction for tumors of the head and neck in the pediatric population. Materials and Methods: Retrospective review of microvascular reconstruction performed in our institution for benign and malignant tumors of the head and neck for patients aged <10 years of age between 2004 and 2016. Demographic and treatment details were analyzed, and descriptive statistics were performed. Results: The flaps used for reconstruction were anterolateral thigh flap (n = 5), fibula free flap (n = 4), scapular free flap (n = 2), radial forearm free flap (n = 1), and sixth rib with serratus anterior and latissimus dorsi (growth center transfer) (n = 1). Rapid prototyping models and inverse planning were used for bony reconstruction in seven cases. The flap success rate was 100%. The average operating time was 130 min. There were no major intraoperative or postoperative complications. Conclusion: Microvascular reconstruction for head-and-neck tumors in the pediatric age group is safe and is associated with good functional and esthetic outcomes. The anterolateral thigh flap and the fibula flap are the flaps of choice in a majority of cases. Preoperative planning, especially in complex bony reconstruction, is important to maximize outcomes and minimize the operative time. Multidisciplinary care is essential to ensure rapid rehabilitation in the postoperative period.
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Outcomes of incidental pulmonary nodules in head-and-neck squamous cell cancer patients treated with curative intent p. 17
Daniel Tani, Rahul Ladwa, Wen Xu, Zarnie Lwin, Karin Steinke, Brett G M Hughes
Introduction: Incidental pulmonary nodule(s) (IPNs) are a common finding during staging imaging for the head-and-neck squamous cell cancers (HNSCC) treated with curative intent. Currently, the incidence of metastasis or synchronous malignancies and outcomes for IPN in this population is unknown. Methods: All cases (n = 2489) reviewed at a tertiary Australian Institution's head and neck (H and N) multidisciplinary meeting, from January 2010 to December 2014, were included. Of these patients, 310 (12.5%) had an HNSCC with an IPN that had been detected during staging imaging. These patients were also to undergo treatment by curative intent. Clinicopathological characteristics, the incidence of malignancy, progression-free survival, and overall survival (OS) were collected retrospectively over 5 years. Results: The median age of patients with an IPN was 66 (range 25–95) years. Tissue diagnosis of IPN was attempted in 46 (14.8%) patients due to radiological suspicion of malignancy. Malignancy was confirmed in 33 (11.0%) patients. From these, 33 patients, 11 (30.3%) had histological diagnoses of nonsquamous cell lung cancers and hence are not due to metastatic spread from a primary HNSCC. Age, gender, previous malignancies, smoking status, p16 status, stage, or primary site did not predict for malignancy. The incidence of pulmonary metastasis in patients who did not undergo tissue biopsy due to low clinical and radiological suspicion of malignancy (n = 244) occurred in 10 patients (4.1%). At the time of analysis, 91 (29.4%) patients had died, and tumor recurrence had occurred in 82 (26.5%) patients. The mean OS was 48 months (95% confidence interval: 44–51). OS was significantly associated with greater age (hazards ratio [HR] 1.04, P < 0.001); immunosuppression (HR 2.15, P = 0.013); and biopsy being attempted (HR 1.78, P = 0.013). There was no biopsy related mortality. Discussion: Detection of an IPN in patients undergoing workup for H and N cancer is common. The risk of malignancy in these IPNs however, is low. We did not identify any clinicopathological parameters to predict malignancy in this setting. Advanced age, current smoking status, and history of immunosuppression predict for poor outcomes. Further work is being undertaken to analyze radiological features that may predict malignancy in an IPN found during the radiological staging of HNSCC.
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Ten-year review of facial bone fractures in rural population at a teaching institute in Central India (Maharashtra) p. 23
Harish Saluja, Shivani Sachdeva, Seemit Shah, Anuj Dadhich, Mukund Singh, Sumeet Mishra
Objective: The purpose of this study was to review the incidence and characteristics of maxillofacial fractures in Loni (rural population) and compare them with the existing literature. Materials and Methods: A retrospective study of patients' records and radiographs was reviewed during the 10-year period between 2007 and 2017. Statistical analysis was carried out according to age, gender, cause of accident, and fracture site. Results: A total of 1943 cases with 2470 injuries were reviewed during the 10-year period. The age of patients ranged from 0 to 70 years. The ratio of men to women was 3.5:1. Most fractures were caused by road traffic accident (44.12%), followed by fall (26.76%), assault (25.06%), and animal injuries (4.06%). The prevalent anatomic regions of isolated fractures were the mandible (50.64%), followed by Zygomatic complex (ZMC) (9.26%), Le Fort II (4.07%), Le Fort I (3.50%), orbital floor (3.07%), Le Fort III (2.23%), dentoalveolar (1.39%), zygomatic arch (1.13%), and nasal bone (0.77%). In combination fractures, the most common were the midface combinations (12.55%), followed by mandibular and midface combinations (6.13%), mandibular combination fractures (3.25%), and midface and frontal bone fractures (1.444%). Conclusion: The findings of this study compared with similar studies reported in literature support the view that the cause and incidence of maxillofacial injuries vary from one country to another. Animal injury was one of the causes for maxillofacial trauma because of rural location of our center.
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The use of hyperbaric oxygen therapy in head-and-neck conditions p. 27
Syed Nabil, Rifqah Nordin, Firdaus Hariri, Ahmad Fahmi Mohamad Bustaman, Sharifah Azlin Juliana Syed Zainal, Divya Panicker, Abdul Jabar Nazimi
Introduction: Hyperbaric oxygen therapy (HBOT) has been suggested to be beneficial in managing compromised acute and chronic wounds. To shed some light on its effectiveness in head-and-neck wounds, a retrospective review on the use of HBOT was done. Materials and Methods: The medical records of patients receiving HBOT for head-and-neck conditions were reviewed. The demographics and clinical data were collected. Results: Seventeen patients were identified. Four major indications for therapy were identified being osteoradionecrosis (ORN) treatment, ORN prophylaxis, treatment of compromised flaps/grafts, and treatment of medication-related osteonecrosis of the jaw. Favorable outcome following HBOT was seen in 77% of patients. In the treatment of ORN, 56% cases treated were successful. In the remaining groups, 100% success rates were obtained. The majority of patients had HBOT as an adjunctive treatment. HBOT as an adjunct was successful in 71% of patients, while prophylactic HBOT were successful in all patients. Complications including ear barotrauma and sinus squeeze were seen in 24% of patients. Conclusions: HBOT can be successfully used in various head-and-neck conditions, especially when used in cases with compromised flaps/graft or ORN prophylaxis. It is well tolerated and thus provides a valid adjunctive therapy in the management of tissue with compromised healing capability in the head-and-neck region.
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The use of tumor-to-tongue thickness ratio to predict the need for microvascular flap reconstruction following glossectomy in carcinoma tongue p. 34
Adharsh Anand, Deepak Balasubramanian, Sandhya C Jayasankaran, K Milind, Samskruthi Murthy, Narayana Subramaniam, Renjitha Bhaskaran, Jimmy Mathew, Mohit Sharma, Krishnakumar Thankappan, Subramania Iyer
Background: Microvascular flap reconstruction (MFR) of medium–large tongue defects following ablative surgery is the standard of care. The decision for MFR is often made prior to surgery or intraoperatively depending on the extent of the defect and the volume of remnant tongue. However, there exists no objective technique to predict this requirement preoperatively. This knowledge is crucial for counseling and planning. We aimed to identify an objective magnetic resonance imaging (MRI) measurement tool to predict the need for MFR of tongue tumors. Materials and Methods: This was a retrospective analysis of patients undergoing surgery (with or without reconstruction) for squamous cell carcinoma of the tongue. Patients had a preoperative MRI as part of their assessment. As per our institution protocol, the decision for the requirement of MFR was made by a consensus of two experienced reconstructive surgeons intraoperatively. This decision was correlated with the ratio of tumor volume to the total tongue volume (tv) as observed in the MRI. Results: A total of 47 patients were identified. Twenty-eight patients underwent reconstruction, while 19 did not. The ratio of tumor thickness to tongue thickness (Tt/tt) was calculated, and a cutoff of >0.395 (sensitivity 89.3% and specificity 89.5%) was found to significantly correlate with the decision for MFR (P < 0.001). The volume of a tumor to total tv ratio was calculated from the data of 22 cases, and a cutoff of >4.2 (sensitivity 83.3 and specificity 90) was found to be correlated significantly with the decision for MFR (P < 0.001). Conclusion: Tt/tt ratio is a useful tool to determine the need for MFR of tongue tumor excision defects in the preoperative setting and can help guide counseling.
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Primary squamous cell carcinoma thyroid: A rare case p. 39
Nitin Khunteta, Shikha Tewari
Primary Squamous Cell Carcinoma of Thyroid gland is a very rare disease. It forms less than 1% of all Thyroid cancers. Due to rarity, It is generally diagnosis of exclusion.
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Giant cervico-pectoral schwannoma p. 42
Suresh C Sharma, Kuldeep Thakur, Prem Sagar, Dhananjay Kumar
Benign tumors of brachial plexus (BP) are relatively rare. However, these tumors pose a surgical challenge due to their origin in an anatomically complex region containing neurovascular tissue nexus. We describe a case of giant BP schwannoma involving the right neck and supraclavicular fossa extending to the right pectoral region without any associated neurological deficit.
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