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Objectives: The temporoparietal fascia flap (TPFF) is a versatile tool in head and neck reconstruction. This article aims to describe the spectrum of TPFF applications through a series of case studies and related review of the literature., Methods: Medical records were reviewed to identify cases that represent major TPFF application categories. A literature review was performed to support the presentation and discussion of each case category., Results: Seven cases were identified each representing a distinct application category. These included auricular reconstruction, hair-bearing tissue transfer, facial soft tissue augmentation, cutaneous and mucosal oncologic defect repair, reconstruction after salvage laryngectomy, skull base reconstruction, and orbital reconstruction., Conclusion: The TPFF is a uniquely versatile tool in head and neck reconstructive surgery. Outstanding in its pliable, ultra-thin yet hardy and highly vascular form, the temporoparietal fascia flap is a workhorse for the creative head and neck reconstructive surgeon., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background. Next-generation sequencing of cancers has identified important therapeutic targets and biomarkers. The goal of this pilot study was to compare the genetic changes in a human papillomavirus- (HPV-)positive and an HPV-negative head and neck tumor. Methods. DNA was extracted from the blood and primary tumor of a patient with an HPV-positive tonsillar cancer and those of a patient with an HPV-negative oral tongue tumor. Exome enrichment was performed using the Agilent SureSelect All Exon Kit, followed by sequencing on the ABI SOLiD platform. Results. Exome sequencing revealed slightly more mutations in the HPV-negative tumor (73) in contrast to the HPV-positive tumor (58). Multiple mutations were noted in zinc finger genes (ZNF3, 10, 229, 470, 543, 616, 664, 638, 716, and 799) and mucin genes (MUC4, 6, 12, and 16). Mutations were noted in MUC12 in both tumors. Conclusions. HPV-positive HNSCC is distinct from HPV-negative disease in terms of evidence of viral infection, p16 status, and frequency of mutations. Next-generation sequencing has the potential to identify novel therapeutic targets and biomarkers in HNSCC.

Background. Transoral robotic surgery (TORS) is an emerging treatment option for the treatment of head and neck malignancies, particularly for oropharyngeal squamous cell carcinoma (OPSCC). Preliminary studies have demonstrated excellent oncologic and functional outcomes that have led to a resurgence of interest in the primary surgical management of OPSCC. The aim of the present study was to review the evidence base supporting the use of TORS in OPSCC. Methods. Studies evaluating the application of TORS in the treatment of head and neck squamous cell carcinoma (HNSCC), and more specifically OPSCC, were identified for review. Further searches were made of reference lists for complete evaluation of minimally invasive surgery (MIS) in treating OPSCC. Results. Seventeen results relating to the application of TORS in treatment of OPSCC were identified. Further results relating to the role of transoral laser microsurgery (TLM) in OPSCC were included for review. Feasibility, oncologic, and functional data is summarized and discussed. Discussion. Management strategies for patients with OPSCC continue to evolve. Minimally invasive surgical techniques including TORS and TLM offer impressive functional and oncologic outcomes particularly for patients with early T-classification and low-volume regional metastatic disease. Potential exists for treatment deintensification, particularly in patients who are HPV positive.

Background: The size of the malignancy in well-differentiated thyroid carcinoma (WDTC) is an important factor in patient risk stratification. Final pathologic measurements are currently used for treatment decisions. Measurements are made by both ultrasonography and on final pathology and should, theoretically, agree with each other., Objective: To evaluate the agreement between ultrasound and final pathologic measurements in thyroid nodules and WDTC., Methods: A retrospective chart review of all total thyroidectomies between 1998 and 2007 was completed by four different surgeons at one centre. Thyroid specimens with a solitary nodule and complete ultrasound and pathologic data were included. A comparison of discrepancy and concordance of the largest dimension of the nodule by ultrasound and pathologic measurement was made., Results: A total of 263 thyroid specimens with a solitary nodule were identified. Of these, 68 were found to harbour WDTC. A median underestimation by pathology of 0.54 cm was present in WDTC, averaging 20% of the nodule size by pathology. This trend was consistent with subgroup analysis for size, pathology, and nodularity. An underestimation by pathology of 0.4 cm was present for papillary carcinoma under 1 cm. Grouping nodules by size, a concordance of 80% was present for nodules under 1 cm. Statistical testing revealed weak correlation and a kappa of approximately 0.3 for agreement. Weighted kappa was approximately 0.5 for agreement., Conclusion: The recent advances in ultrasonography and the constraints of pathology preparation allow an argument to be made for investigation of using ultrasound measurements as an adjunct in making treatment decisions.

Hoarseness and dysphonia are often a result of vocal cord polyps which in turn, are linked to vocal trauma. We report the case of vocal polyps in the setting of a 27-year old male with a history only remarkable for Tourette syndrome. We review the literature regarding etiology and pathophysiology of vocal cord lesions and propose vocal tics in Tourette syndrome as an under-recognized etiology. In this way, we also review therapies that may aid in treating not only the vocal cord lesions but also particularly in the setting of vocal tics.

Purpose of Review: This article reviews the buccinator flap, its relevant surgical anatomy, surgical technique, and applications in head and neck reconstruction., Recent Findings: Reconstruction of defects after extirpation of head and neck neoplasms can be challenging and complex. Various reconstructive techniques, including skin grafts, regional flaps, and free tissue transfer, can be employed in restoration of form and function after ablative surgery. Although a wide array of reconstructive options is available, the technique employed will largely depend on the surgeon preference and experience. Commonly used pedicled flaps and free tissue transfer techniques can share several disadvantages, including prolonged operative time, poor cosmesis, donor site morbidity, functional limitations, and excessive tissue bulk for intraoral reconstruction. The ideal reconstructive method would adhere to the plastic surgery principle of replacement of 'like with like'. The ease of dissection and useful application makes the buccinator flap an excellent additional reconstructive option for the head and neck surgeon., Summary: The buccinator myomucosal flap is a versatile and dependable flap for head and neck reconstruction. Its minimal donor site morbidity, pliability, ease of elevation, and flexible usage while offering optimal functional and cosmetic results make it a viable option for select defects.

Laryngeal cancer is the most commonly diagnosed head and neck malignancy. Treatment of laryngeal tumors is dependent upon disease stage at diagnosis, and may involve surgery, radiation, chemotherapy or a combination of modalities. Regardless of tumor stage or treatment provided, quality of life (QOL) can be drastically affected. Voice-related outcomes are almost universally affected and can have a negative impact on overall QOL. Thus, treatment outcomes must extend beyond issues of oncological cure alone. Measures of voice and voice-related QOL following treatment for laryngeal cancer are important markers of treatment success. This article will broadly outline laryngeal cancer and its treatment, vocal rehabilitation, and provide insight into the various methods of assessing post-treatment voice and the influence of voice change on quality of life in these patients.

Objective: To assess the feasibility of internal transport disk distraction osteogenesis (ITDDO) for the regeneration of segmental mandibular defects and to evaluate the effect of radiation therapy., Design: Prospective case series., Setting: Tertiary care academic medical centre., Methods: Nine patients were accrued (M:F 6:3; mean age 63 years, range 37-77 years) and underwent ITDDO for the regeneration of segmental mandibular defects. The mean follow-up time was 43 months (range 6-87 months). The average bony defect was 6.1 cm (range 3.0-10.0 cm)., Main Outcome Measures: Construct formation (graded as complete, partial, and none based on evidence of calcification on panorex films and palpation), complications, and plate exposure (grouped by those that were thought to be related to distraction and those that were independent of distraction)., Results: Construct formation was "complete" in two of nine patients (22%), "partial" in four of nine (44%), "none" in two of nine (22%), and one of nine patients (11%) died prior to the 6 month assessment point. Four patients did not undergo radiation therapy, and two had stable constructs 6 years after treatment completion. Five patients underwent radiation therapy, and none of these patients formed stable, ossified constructs. All patients experienced a complication, and seven of nine (78%) developed hardware exposure, with six contributing to construct loss., Conclusions: Construct formation with ITDDO is possible for large composite mandibular defects in patients who have not received radiation. The complication rate was unacceptably high but may improve with better patient selection, refinement in surgical technique and distractor design, and tissue engineering for construct support.

Objectives: Adductor spasmodic dysphonia (ADSD) is a voice disorder characterized by considerable intra- and intersubject variability. Although objective, acoustic measures of voice may provide a metric for ADSD, such measures can be inefficient in documenting such characteristics. This project integrated a simple auditory-perceptual measure termed "laryngeal overpressure" (LO) with measures of acoustic variability., Methods: Ten adults diagnosed with ADSD were sequentially followed over a period of 3 to 6 months. Standard voice recordings were obtained at each point, and acoustic measures were gathered. Additionally, three experienced listeners then rated LO using a visual analogue scale, and acoustic variability was assessed relative to the measure of LO., Results: Listener ratings of LO did not differ across the three-sentence stimuli and were highly correlated (r  =  .828 and .909 for naive and experienced listeners, respectively). A strong correlation was identified between the acoustic measure of harmonics to noise ratio and the all-voiced sentence stimuli (r  =  .710)., Conclusion: LO appears to provide an easy clinical method of documenting voice change over time in those with ADSD. Although additional methods of voice monitoring may be used, the use of LO may provide the opportunity for a standard and reliable approach to the clinical monitoring of voice variability in those presenting with ADSD.

Background: The aim of this preliminary study was to determine the prevalence of trismus in head and neck cancer patients treated with radiotherapy with or without concomitant chemotherapy and surgery., Methods and Materials: Patients with malignant lesions in the head and neck treated with curative intent were comprehensively evaluated for trismus using subjective and objective measures., Results: A large proportion of the 70 patients recruited demonstrated moderate to severe subjective trismus (45.7%). Similarly, the vast majority of patients showed slight to severe trismus (91.4%) according to objective secondary outcome measures. Of these patients, 21 (65.6%) were also treated with concurrent chemoradiotherapy. When the radiation field involved the pterygoid muscles, 30 (93.8%) patients reported subjective trismus. Similarly, bilateral pterygoid muscle inclusion resulted in 28 (87.5%) patients with trismus., Conclusions: Trismus is a significantly prevalent consequence of treatment for head and neck cancer. Predictive factors include treatment with concurrent chemoradiotherapy and bilateral inclusion of the structures of mastication in the high-dose radiotherapy volume.

Background: Malignant submandibular gland tumours are rare tumours treated primarily with surgery., Purpose: This retrospective study was done to determine the effectiveness of adjuvant radiation therapy (RT), to document the patterns of failure, and to define the prognostic variables for treatment outcome., Materials and Methods: Between 1960 and 2002, 74 patients diagnosed as having malignant submandibular gland tumours were treated with radical surgery. The surgery included neck dissection in 37 patients and adjuvant RT in 50 patients with high-risk features., Results: Forty-one (54%) patients experienced disease relapse. The local recurrence rates were 35% in those treated only with surgery and 21% in patients who underwent postoperative RT (p  =  .20). The risk of subclinical nodal metastases in the clinical N0 neck was 21%., Conclusions: The American Joint Committee on Cancer stage approached statistical significance for cause-specific survival. Although not statistically significant, RT probably reduced local recurrence. All patients with malignant submandibular tumours except T1 need elective neck treatment.

Objective: Hematoma is a potentially life-threatening complication of thyroid surgery. Ketorolac is a nonsteroidal anti-inflammatory drug with known antiplatelet activity that is used for analgesia. The goal of this study was to determine the risk of hematoma in patients who received ketorolac in thyroid surgery., Design: Retrospective cohort study., Setting: London Health Sciences Centre., Methods: A retrospective cohort study was conducted of patients who underwent thyroid surgery between 2002 and 2007. Data were analyzed using the Fisher exact test., Main Outcome Measures: Incidence of postoperative hematoma and perioperative ketorolac administration., Results: Thirteen hematomas occurred in 799 patients. Of the 799, 183 patients received ketorolac (22.9%) and 616 did not. Five in the ketorolac group (2.73%) and eight in the nonketorolac group (1.30%) developed hematomas. The calculated relative risk was 2.10 (95% CI 0.70-6.35)., Conclusions: Although there was an increased incidence of hematomas in the group receiving ketorolac, the difference was not statistically significant. The lack of significance may be due to the low number of hematomas.

Objective: Radiation therapy (RT) and transoral laser microsurgery (TLM) are established treatments for early glottic squamous cell carcinoma (SCC). Similar oncologic outcomes have been reported with both modalities, leading physicians to consider other factors when making clinical recommendations. One such factor is voice-related quality of life. This investigation sought to characterize differences in self-reported voice outcomes in patients undergoing RT or TLM for the treatment of Tis or T1a glottic SCC., Methods: A retrospective cohort study was conducted of all individuals who received either RT or TLM for the treatment of Tis or T1a glottic SCC between 2004 and 2009 at the London Regional Cancer Program. The primary outcome measure was voice-related quality of life, as assessed by the Voice-Related Quality of Life questionnaire (V-RQOL). Secondary outcomes included local control, overall survival, and laryngectomy-free survival., Results: Fifty-seven patients were eligible for this study; 34 received RT and 23 received TLM. Forty (70.2%) of the 57 patients completed the V-RQOL. No statistically significant difference in total V-RQOL score was observed between the RT and TLM cohorts (p  =  .228). There was, however, a trend toward higher scores (ie, less voice disability) in the physical function domain of the V-RQOL for the RT group (90.0%) compared to the TLM group (80.2%) (p  =  .05). No significant differences were observed in recurrence or overall survival between the two groups., Conclusion: Both oncologic outcomes and self-rated voice-related quality of life are similar in patients treated with RT and TLM for early glottic carcinoma.

Objectives: To determine the long-term retention of a 3-dimentional (3-D) educational computer model of the larynx to teach laryngeal anatomy and to compare it with standard written instruction (SWI)., Design: Prospective randomized controlled trial., Setting: University education program., Participants: One hundred health care students., Interventions: For short-term assessment, 50 students were randomized to the 3-D model and 50 to SWI and were tested using a 20-question laryngeal test. Six months later, the same students were invited to retake the laryngeal anatomy test to examine long-term retention., Main Outcome Measure: The score on a 20-item Web-based test that assessed the students' level of knowledge of laryngeal anatomy approximately 6 months after their initial exposure to the laryngeal anatomy teaching intervention., Results: Sixty-two students retook the test: 3-D (n = 30) and SWI (n = 32). No significant difference was noted in mean scores (P = .54) and change in scores (P = .59) between short- and long-term retention on the laryngeal anatomy test. There was a trend toward an increase in 3-D scores in both groups (P = .07) and a significant increase in 3-D scores in the 3-D group only (P = .049)., Conclusions: A low-fidelity model (SWI) is just as effective as a high-fidelity model (3-D) in teaching laryngeal anatomy. The acquired knowledge from either educational intervention may last up to 6 months for long-term retention. This study is one of the few in medical education to examine long-term retention.

Objective: To study the treatment outcomes of N3 neck disease following primary chemoradiotherapy., Design: Retrospective cohort., Setting: Tertiary care centre., Methods: A review was conducted of 25 consecutive patients with N3 neck disease treated with primary platinum-based chemoradiotherapy. A neck dissection (ND) was offered in the event of clinical and/or radiologic evidence of residual disease on follow-up., Main Outcome Measures: Recurrence-free, disease-specific, and overall survival and patterns of failure., Results: A regional complete response (CR) was noted in 48% of the patients. ND was performed in 36% of the cases. The median duration between the end of radiation and ND was 71 days. The recurrence-free survival rates at 1 and 2 years were 73% and 64%, respectively. The 2-, 3-, and 5-year overall survival rates were 66.7%, 52%, and 31.2%, respectively. Disease-specific survival rates were 69.6%, 63.3%, and 50.6%, respectively. Nine patients developed distant recurrence, with one having concurrent local and regional recurrence as well. Patients in the CR group remained free of regional recurrence. Among the initial partial responders, 54% eventually developed distant metastasis compared to 17% in the CR group., Conclusion: Patients with N3 disease may be managed with chemoradiotherapy, with ND reserved for salvage. Distant metastasis accounts for most recurrences and for the reduction in survival.

Advancements in technology and personal computing have allowed for the development of novel teaching modalities such as online web-based modules. These modules are currently being incorporated into medical curricula and, in some paradigms, have been shown to be superior to classroom instruction. We believe that these modules have the potential of significantly enriching anatomy education by helping students better appreciate spatial relationships, especially in areas of the body with greater anatomical complexity. Our objective was to develop an online module designed to teach the anatomy and function of the cranial nerves. A three-dimensional model of the skull, brainstem, and thalamus were reconstructed using data from the Visible Human Project and Amira®. The paths of the cranial nerves were overlaid onto this 3D reconstruction. Videos depicting these paths were then rendered using a "roller coaster-styled" camera approach. Interactive elements adding textual information and user control were inserted into the video using Adobe Creative Suite® 4, and finally, the module was exported as an Adobe Flash movie to be viewable on Internet browsers. Fourteen Flash-based modules were created in total. The primary user interface comprises a website encoded in HTML/CSS and contains links to each of the 14 Flash modules as well as a user tutorial., (Copyright © 2010 American Association of Anatomists.)

Background: Laryngeal cancer has a significant impact on patients. This study compared the Voice-Related Quality of Life (V-RQOL) outcomes specific to 3 different postlaryngectomy voice rehabilitation methods., Methods: We conducted a retrospective review of 75 patients with laryngectomy from our V-RQOL questionnaire database., Results: The database included 18 electrolaryngeal speech (ELS), 15 esophageal speech (ES), and 42 tracheoesophageal speech (TES) patients. Pairwise comparisons of V-RQOL outcomes showed that TES was perceived to be better than ELS (p < .001). ES was perceived as better than ELS, but this was driven by a difference in the total and social-emotional V-RQOL scores (p < .05). There was no difference between TES and ES groups. Only ELS showed a positive correlation with time after surgery and older age., Conclusions: Patients using TES had similar V-RQOL outcomes compared to ES and both performed significantly better than ELS. For ELS, the total V-RQOL score was better with longer time after surgery and older age., (© 2010 Wiley Periodicals, Inc. Head Neck, 2011.)

Background. There are a variety of described noninvasive optical detection techniques for evaluation of head and neck mucosal lesions. Contact endoscopy is a promising method of in vivo microscopic examination whereby a rigid telescope is placed on a previously dye-stained mucosa allowing evaluation of the superficial cell layers of the epithelium. This technique produces real-time, magnified images of cellular architecture of surface mucosa comparable to histology without the need for biopsy. In this review, we will briefly summarize the efficacy of CE in the detection of precancerous and cancerous mucosal lesions and its potential as a novel technique in early diagnosis, monitoring, and preoperative assessment of mucosal lesions of the head and neck. Methods. PUBMED, MEDLINE, and COCHRANE search revealed five prospective articles on contact endoscopy for the diagnosis of mucosal lesions in the head and neck. Results. The literature search yielded five prospective studies examining contact endoscopy for the diagnosis of benign versus malignant head and neck mucosal lesions. These reported a sensitivity and specificity of 77-100%, specificity of 66-100% and an accuracy of 72-92%. Conclusion. Contact endoscopy is a promising optical technology that may be a useful adjunct in the evaluation and diagnosis of benign and malignant head and neck mucosal lesions. Future prospective randomized double-blind studies of this detection method are required.

Background: type I thyroplasty is an effective and safe procedure for unilateral vocal fold paralysis and is shifting toward outpatient postoperative care. However, serious airway complications have been reported., Objectives: the aims of this study were to investigate whether risk stratification into inpatient/outpatient postoperative care reduces outpatient airway complications and to compare the cost-effectiveness and surgical outcomes of risk stratification to a historical inpatient control group (non-risk stratified)., Setting: tertiary, university-based medical centre., Design and Results: Three retrospective groups were examined: historical inpatient control (n = 15), risk-stratified (RS)- inpatient (n = 16), and RS outpatient (n = 17). Laryngeal edema was encountered in two historical controls (13.3%), two RS inpatients (12.5%), and one RS outpatient (5.9%). One case of implant extrusion occurred in the RS outpatient group. There was no difference in maximum phonation time or voice-related quality of life between RS versus historical controls (p > .5). The cost savings of risk stratification versus entirely inpatient care was $CAD 633.12/patient. The average duration in hospital for RS inpatient versus RS outpatient was 29.8 and 8.3 hours, respectively., Conclusions: postoperative RS may reduce potentially serious outpatient airway complications and cost while improving patient satisfaction.

Objective: To review the experience with scapular free tissue transfer at the University of Western Ontario and to describe the various applications of both the fasciocutaneous and osteocutaneous versions., Design: Retrospective review., Setting: Tertiary care centre., Methods: A retrospective review was conducted of patients who underwent a scapular free flap reconstruction between 1997 and 2007. Osteocutaneous and fasciocutaneous flaps were included. Demographic data including gender and age were collected. Defect analysis and complications were also reviewed., Main Outcome Measures: Defect analysis, flap-related complications, and non-flap-related complications., Results: Sixty procedures, including 31 osteocutaneous and 29 fasciocutaneous flaps, were performed. Most fasciocutaneous flaps were used for large lateral skull base and facial defects (70%). The skin paddle dimensions ranged from 4 × 3 to 15 × 10 cm. All osteocutaneous flaps were used for mandibular reconstruction. The length of the bony defect ranged between 4 and 12 cm. Eleven patients required osteotomies. In most cases, the facial or external carotid arteries and internal jugular or facial veins were selected as recipient vessels. A vein graft was required in four cases. The total flap failure rate was 5%. Seven patients who had osteocutaneous flaps suffered medical complications, including one mortality., Conclusions: Scapular free flaps are reliable options. Fasciocutaneous applications are suitable for defects requiring facial contouring or complex skull base defects. Osteocutaneous flaps are acceptable options for patients with comorbidities requiring bony reconstructions. The flap complication rates were acceptable even in medically higher-risk patients.

Introduction: Adductor spasmodic dysphonia (ADSD) is a focal dystonia treated most commonly by chemodenervation of the thyroarytenoid (TA) muscles with botulinum toxin. Currently, there are no consensus guidelines regarding this treatment and the management of ADSD. The objective of this study was to assess current practice patterns among physicians who treat ADSD., Methods: A cross-sectional survey study was conducted regarding treatment choices and specific technical aspects of injection technique and botulinum toxin use. The study population consisted of laryngologists from the Canadian Society of Otolaryngology-Head and Neck Surgery and laryngologists obtained from the American Laryngological Association member database and the American Academy of Otolaryngology-Head and Neck Surgery Neurolaryngology Study Group., Results: An overall response rate of 13% was achieved, with a high absolute number of physicians who manage ADSD responding (n = 37). Most respondents treat ADSD by injecting botulinum toxin type A (Botox) through the cricothyroid membrane submucosally at a mode starting dose of 2.5 units per TA muscle using electromyographic guidance with or without fibre-optic laryngoscopy every 3 to 4 months, with the frequency of reinjection being based on patient symptomatology. There is much variability with regard to starting injection dose, alternate treatments for ADSD, unilateral versus bilateral injections, and guidance technique. Most physicians (36 of 37) share one vial among more than one patient, and some (7 of 37) freeze a reconstituted vial that has remaining toxin for reuse at a later time., Conclusions: There is considerable variability in treatment practices for the management of ADSD. Further study is warranted to define an optimal therapeutic paradigm.

Introduction: Didactic head and neck anatomy teaching has been replaced by a novel self-directed, multimodal, and multidisciplinary approach at the Schulich School of Medicine and Dentistry (SSMD)., Objectives: To describe the use of a novel teaching paradigm at SSMD and to enable readers to determine how this methodology may benefit medical students at other academic institutions and disciplines., Design: Prospective cohort study., Methods: The paradigm consists of multimedia learning modules to guide independent anatomy learning. Students received a case-based assignment based on the content of the learning modules to guide them through cadaveric dissections facilitated by a multidisciplinary team of surgeons and anatomists., Primary Outcome: Postcourse survey and mean scores comparison. The survey collected data, including demographics and previous anatomic and computer-assisted learning (CAL) experiences, and focused on measuring student perception of the proposed paradigm. Secondary outcome: Correlation of demographics., Results: The paradigm was successfully implemented and warmly received, but it still requires further development. Although CAL allows increased individual engagement, students still enjoy and value lectures. In addition, students view instruction by surgeons in laboratories as the most valuable component of their anatomy teaching as it not only deepened the students' understanding of anatomic structures but also provided them with the clinical relevance. Technological innovations were welcomed by the students but have not replaced their appreciation of dissection and lecures.

Objective: The goal of our study was to identify factors in intermediate-risk fine-needle aspiration (FNA) results that are predictive of malignancy., Design: Retrospective chart review., Setting: Head and neck oncology clinic at the London Health Sciences Centre., Methods: A database of 665 patients who had received thyroid surgery between 2001 and 2007 was created. FNA biopsy data were collected for each patient, as well as pathologic, patient, and ultrasound data. Of the 665 patients, 302 FNA biopsies were considered intermediate risk, and these data were analyzed., Main Outcome Measure: Presence of malignancy., Results: Intermediate-risk patients were significantly more likely to have a benign nodule if the width to length (W/L) ratio of their nodule was < 0.6. The relative risk was 5.64 (95% confidence interval [CI] 0.81-39.65) (p < .05). As well, patients who were in the intermediate-risk category were significantly more likely to have a malignancy if they were < 40 years old compared to those patients who were > or = 40 years old., Conclusions: Both age and W/L ratio of a nodule can be used to help predict whether a nodule in an intermediate-risk patient is malignant. An intermediate-risk patient who has a W/L ratio < 0.6 can be treated conservatively based on the extremely low risk of malignancy (2.86%).

Objectives/hypothesis: To conduct a comprehensive assessment of shoulder and neck function following the pectoralis major pedicled flap (PMPF) for head and neck reconstruction., Design: Case-control study., Methods: The study group consisted of laryngectomized patients who underwent PMPF and a control group of those who underwent standard laryngectomy. Bilateral quantitative measurements of shoulder strength and range of motion (ROM) and neck ROM by a blinded physiotherapist and subjective quality-of-life assessment using the Shoulder Pain and Disability Index (SPADI) and Neck Disability Index (NDI) questionnaires were collected. Lateral cervical radiographs in the neutral, flexion, and extension positions were evaluated by a blinded neuroradiologist. The main outcome measures were shoulder ROM, strength, and SPADI scores; physical and radiologic measurements of neck ROM; and NDI Score., Results: Shoulder analysis showed a significantly reduced flexion angle (P = .043) and combined internal/external rotation angle on the operated side (P = .027) and a significant strength reduction for the flexion, external rotation, and adduction domains (P < .05). SPADI score analysis showed a significantly higher disability score (P = .017) and total score (P = .009) on the PMPF side. Neck physical analysis showed significant differences in extension (P = .013) and total ROM distances (P = .002) but not flexion (P = .184). The total flexion/extension angular ROM was reduced in the PMPF population (P = .05) due to a reduced neck extension excursion angle from a neutral position (P = .04)., Conclusions: The PMPF for head and neck reconstruction is associated with a limitation in neck ROM attributed to a loss in extension and reduced shoulder strength and ROM.

Objective: To evaluate a novel method of teaching laryngeal anatomy., Design: Prospective, randomized, controlled trial., Setting: University educational program., Methods: Computer model development: A three-dimensional (3D) educational computer model of the larynx was created from high-resolution computed tomography and magnetic resonance images of cadaveric necks using segmentation software (Amira) (Visage Imaging, Inc., Carlsbad, CA). E-learning authoring software (Articulate, Articulate Global, Inc, New York, NY) then was used to make the model interactive and multimedia. The model was launched on a Web-based platform. Model evaluation: One hundred students (age 23.8 +/- 2.2 years; 55% male) were randomized to either the 3D computer model group (3D group) (n = 50) or the standard written instruction group (SWI group) (n = 50)., Main Outcome Measures: The primary outcome measure was the score on a 20-question laryngeal anatomy test; the secondary outcome measure was a student opinion questionnaire., Results: The mean score on the laryngeal anatomy test was 14.2 +/- 2.8 (72.0 +/- 15.1%). The mean score for the 3D group was 13.6 +/- 3.0 (67.0 +/- 16.1%) versus 14.8 +/- 2.5 (76.0 +/- 12.7%) for the SWI group (t = 2.194, df = 98, p < .031). A majority of students felt that the 3D model was effective, clear, user-friendly, and a preferred supplement to traditional methods of instruction. The 3D group rated the computer model more enjoyable than the SWI group., Conclusions: A 3D educational computer model of the larynx was not shown to be superior to written lecture notes in its efficacy in teaching anatomy; however, it was judged to be a preferred and valuable supplement to traditional teaching methods.

Objective: To analyze the expression of human kallikrein 14 (KLK14) in salivary gland tumors., Methods: A standard immunoperoxidase staining technique was used to assess the expression profile of KLK14 in normal salivary glands and tumors including pleomorphic adenoma (PA; n=17), adenoid cystic carcinoma (ACC; n=13) and mucoepidermoid carcinoma (MEC; n=9). Tumor stage, grade, patient age and gender, and site of occurrence were recorded. These clinical parameters were correlated with KLK14 levels in malignant tumors. The expression profiles for KLK3, 5, 6, 8 and 13 were also retrieved., Results: Normal salivary glands, PA, ACC and MEC showed strong expression of KLK14 in ductal and non-ductal cells. Both PA and ACC showed higher KLK14 levels than normal glands and MEC tissues. There were no statistically significant associations between levels of KLK14 and clinical parameters., Conclusions: The differences in the levels of KLK14 suggest that KLKs may aid in the differential diagnosis of salivary gland tumors. The coexpression of KLKs suggests their possible involvement in an enzymatic pathway activated in salivary gland. KLK14 may be a promising new biomarker in salivary gland tumors.

Objectives: To create a 3-dimensional (3D) educational computer model of the larynx, to assess the feasibility of this learning module on a Web-based platform, and to obtain student feedback on the module., Design: Male and female adult cadaveric necks were scanned with microcomputed tomographic and magnetic resonance imaging scanners. Key structures were identified on each slice of the computed tomogram and/or magnetic resonance image and analyzed with a segmentation software package. Then, the images were exported into Microsoft Powerpoint. Visual text and audio commentary were added. Real cases of a child's larynx, an adult with a tracheostomy, and a patient with laryngeal carcinoma were included. The computer module was launched on a password-protected, Web-based platform., Participants: Fifty-eight first-year medical students (38% male; mean [SD] age, 23 [1.8] years) were invited to evaluate the module and to complete a survey., Results: Most students thought that the 3D computer module was effective (60%), clear (66%), and user friendly (72%); most students (81%) thought that it was easier to understand laryngeal anatomy when they could visualize it in 3D; and most students (83%) said that they would like lectures better if they were supplemented with 3D computer modules., Conclusion: A 3D educational computer model of the larynx has been successfully created and warmly received by medical students.

Objectives/hypothesis: To determine the efficacy of interventions to improve and monitor skin scarring, a valid assessment instrument must be used. Current tools used for the evaluation of skin scarring employ equal appearing interval (EAI) scales that assume scar dimensions conform to linear models. Some scar features meet these assumptions, whereas others may not be accurately described. This study determined if current methods of scar evaluation validly characterize inherent features of scars, and in doing so, empirically validate if specific scar dimensions were best represented by linear or nonlinear mathematical models., Study Design: Prospective, randomized, cross-over trial., Methods: Twenty-seven observers evaluated 30 scar photos utilizing both EAI and direct magnitude estimation (DME) scaling methods. The method of scaling and the assessed dimensions of vascularity, pigmentation, thickness, pliability, and surface area were randomized. EAI and DME data were evaluated to identify whether each scar dimension conformed to linear or curvilinear mathematical models., Results: Best-fit analysis revealed the dimensions of vascularity and pigmentation to be more accurately described using curvilinear functions, whereas pliability, thickness and surface area were best defined using linear models., Conclusions: The scar dimension under assessment must be considered when attempting to validly apply an assessment instrument. Several commonly evaluated dimensions of skin scarring are not appropriately characterized using linear EAI scales. Thus, present assessment instruments must be revised to account for this aberration to allow for a valid means of objectively evaluating skin scarring.

Background: Dermal fat grafts are used to reconstruct facial contour defects but may undergo variable resorption. Application of autologous platelet adhesive may improve outcomes. The primary objective was to compare resorption of dermal fat grafts for parotidectomy defects, between patients receiving autologous platelet adhesive versus controls., Methods: This was a double-blinded prospective cohort at a tertiary care center. Volumetric analyses of dermal fat graft measured by MRI scans. Resorption was determined by comparing 1- and 6-month MRIs in each patient. Complications, Frey's Syndrome, and patient satisfaction were also assessed., Results: Twelve patients completed the study. A significant reduction in graft resorption was seen in the treatment group (57% vs. 31%, p = .01). Three patients in the control group developed fat liquefaction. Patient perceived significant differences in scar and contour., Conclusion: Application of autologous platelet adhesives improved graft viability and patient satisfaction at 6 months.

Objectives: To determine whether computer-assisted learning (CAL) is an effective tool for the instruction of technical skills., Study Design: Prospective blinded randomized-control trial conducted on a cohort of 47 first-year medical students., Methods: Students were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis, using either a standard text-based article or a novel computer-based learning module. Students were evaluated on proper nasal packing technique using standardized subjective and objective outcome measures by three board-certified otolaryngologists. Blind assessments took place prior to and following instruction, using the assigned learning modality., Results: There were 47 participants enrolled in the study. Both groups demonstrated improvement in performance of both packing procedures following training. A significant post-training difference favoring CAL learners over text-based learners was observed, using the global assessment of skill for both packing techniques (P < .001). Additionally, a significant post-training difference favoring CAL learners over text-based learners was observed for all checklist items for the tampon pack and five of eight items on the formal pack checklist. The vast majority of students (94.6%) indicated that if given the choice, they would prefer to learn using CAL rather than by using text-based learning materials., Conclusions: CAL learners demonstrated significantly greater improvement across both subjective and objective outcome measures when compared to the text-based group. Additionally, students favored learning via the CAL modality, which further suggests that CAL is a valuable means of imparting procedural knowledge to novice medical trainees.

Objectives: To determine the feasibility and effectiveness of virtual-patient computer-assisted instruction (CAI) in pre-clerkship undergraduate otolaryngology education., Study Design: Prospective, randomized, controlled trial., Subjects and Methods: Second-year medical students at the University of Western Ontario, Canada, were randomized into two groups: group A was given a CAI module and group B was presented with two Internet review articles, both covered specific learning objectives for pediatric stridor. Students completed randomized pre- and post-tests and a questionnaire one week later., Results: Fifty-five students completed the study with 28 in group A and 27 in group B. Mean pretest scores were 59.1% in group A and 59.8% in group B (95% CI = -7.9% to 10.4%). Mean post-test scores were significantly elevated in group A (84.6%, P < 0.001) and group B (74.3%, P = 0.008). Group A had a significantly higher (P = 0.02) mean post-test score than group B (mean difference of 10.2%). Students spent significantly more time (P < 0.001) reading text articles (25.5 minutes) than completing the CAI (9.06 minutes). Forty-one (66%) students completed the survey. Thirty-six (88%) respondents indicated that they preferred CAI to online articles., Conclusion: CAI is a feasible, effective, and efficient means of enhancing self-directed learning as supplementation to the pre-clerkship undergraduate otolaryngology curriculum.

Objectives: Otolaryngologic problems are common in primary care but are underrepresented in undergraduate medical education (UME). A significant portion of the total structured teaching received by physicians in primary care specialties is spent in UME, but teaching of otolaryngology in UME is limited and not standardized across Canadian medical schools. This study assessed the content and structure of otolaryngology UME at Canadian undergraduate medical programs and postgraduate primary care programs and surveyed community otolaryngologists to identify important clinical topics for inclusion in an otolaryngology curriculum., Methods: A survey was created based on previously validated and published curriculum needs assessment instruments for medical education. Surveys were distributed to (1) undergraduate directors of otolaryngology, (2) postgraduate program directors of family and emergency medicine at English-language medical schools, and (3) community otolaryngologists in Canada., Results: There is large variation in the quantity of otolaryngology teaching in UME. Knowledge of otolaryngology is formally evaluated at half of the responding programs, although skills in otolaryngology are rarely tested. Clerkship rotations are not uniformly offered, and the length of these placements is limited. Opportunities in postgraduate training for formal education in otolaryngology are rare. Several important topics that are not uniformly taught include sudden sensorineural hearing loss, sleep apnea, and nasal trauma. Important skills that are not uniformly taught include treatment of benign paroxysmal positional vertigo and epistaxis., Conclusions: There is limited time for teaching otolaryngology in UME; therefore, it is essential to emphasize teaching key topics and skills, which are highlighted in the results of this study.

Objective: Clinical scar assessment lacks standardized methodology and consensus on the most appropriate evaluation instrument. This study empirically evaluated whether area scars could be validly assessed by naive observers with the objective to develop and validate a novel multidimensional visual analogue scale (VAS) for the assessment of area scars., Methods: Standardized digital photographs of radial forearm free flap (RFFF) donor sites were obtained. Naive observers evaluated the images in three sequential psychophysical experiments, which led to the development of the new scar scale. These experiments involved initial evaluation of four dimensions (pigmentation, vascularity, observer comfort, acceptability) using a paired comparison (PC) paradigm and correlation with ratings of overall severity using a VAS, and initial VAS test phase followed by formal debriefing, and, subsequently, evaluation of a VAS for the four dimensions in addition to contour. Validation involved determination of intra- and interrater reliability and correlational analysis., Results: Across all three experiments, 56 observers evaluated 101 images, generating 12 720 observations for analysis. PC data demonstrated that observers could assess scars with high reliability and internal consistency for all dimensions (> 95%). Overall (VAS) severity correlated highly with all dimensions, including contour. The new VAS yielded high levels of correlation (r = .72-.98, p < .01)., Conclusion: Comprehensive VAS analysis demonstrates high reliability in mirroring PC results for multiple dimensions of area scars. These data support our novel multidimensional VAS method as a valid, reliable, simple, and time-efficient instrument for clinical and research use. We introduce the Western Scar Index as a new measurement tool with many potential applications.

Background: Platelet-rich plasma (PRP) and platelet-poor plasma (PPP) have been used to improve hemostasis and wound healing after surgery; however, randomized controlled trials proving their efficacy are lacking., Methods: Hemithyroidectomy was performed on 52 patients. Autologous PRP and PPP were applied during wound closure in the treatment group, while saline was applied in the controls. Outcome measures were postoperative drainage, pain, analgesic use, and length of hospital stay., Results: The 24-hour cumulative drainage was reduced by 29.3% in the treatment group (44.9 mL vs 63.5 mL, p = .039). The treatment group required less analgesic medication despite similar pain scores; however, the difference was not significant. There was a trend toward decreased length of stay for the PRP/PPP group (p = .059)., Conclusions: Hemithyroidectomy served as a stringent test to evaluate the wound-healing capacity of platelet-rich and platelet-poor plasma. This study provides evidence that PRP and PPP reduced postoperative drainage in soft-tissue surgery., ((c) 2008 Wiley Periodicals, Inc.)

Background: Mucositis is one of the most debilitating side effects of head and neck cancer therapy and is currently believed to arise from an inflammatory cascade leading to cellular damage. However, no effective treatment has been identified despite extensive attempts with anti-inflammatory medications., Objective: To compare real-time microvascular inflammatory changes with oral mucositis levels in patients undergoing radiotherapy or chemoradiotherapy for head and neck tumours., Design: Prospective, longitudinal, cohort, observational study., Setting: Regional cancer program., Methods: Twenty patients with head and neck tumours were assessed on a weekly basis throughout the course of radiotherapy. Levels of mucositis were graded objectively using the Oral Mucositis Assessment Scale and subjectively using a patient symptom questionnaire. Video imaging of the sublingual microcirculation was obtained using orthogonal polarized spectral imaging to quantify inflammatory markers such as microcirculatory velocity, white blood cell margination, and extravasation., Results: Despite very high levels of objective and subjective mucositis, inflammatory changes were not present in the microcirculation., Conclusions: Typical microvascular inflammatory changes are not demonstrated in radiation-induced mucositis. These findings contradict the currently proposed mechanism of mucosal damage and may therefore have important implications in the development of novel therapeutic interventions.

Objectives: To investigate the adequacy of otolaryngology teaching in undergraduate medical education (UME) and to determine the general level of comfort of family medicine residents in managing and assessing diseases affecting the ears, nose, and throat., Design: Cross-sectional survey., Methods: A sample of family medicine residents at the University of Western Ontario (N = 68) completed a questionnaire inquiring into their exposure to topics in otolaryngology during their UME. They were also asked to comment on their present comfort with knowledge and skills specific to otolaryngology., Results: Family medicine residents suggest that there is generally little otolaryngology training in UME; 66.7% of respondents who received UME in Canada suggested that they received very little classroom instruction and 75.6% received very little clinical otolaryngology instruction. Residents identified specific otolaryngologic conditions with which they felt particularly uncomfortable., Conclusions: This study demonstrated that students receive very little exposure to otolaryngology in UME and highlighted specific conditions and procedures that family medicine residents lack confidence in managing and performing.

Background: A quasi-experimental retrospective study was undertaken to evaluate a new concept of free tissue volume restoration combined with bridging reconstruction plate (compartment approach) to reduce plate-related complication rates., Methods: We evaluated 40 patients with large lateral mandible defects and associated complex soft tissue defects reconstructed with a revascularized soft tissue flap and titanium hollow screw reconstruction plates. A case-control comparison was performed based on reconstruction type: restoration of soft tissue defect (conventional approach-group 1) versus over-reconstruction of soft tissue defect (compartment approach-group 2)., Results: Plate exposure rate was 6 of 16 (38%) in group 1 versus 2 of 24 (8%) in group 2, and the difference was statistically significant (p = .04). The mean time to exposure was 10 months. Plate fracture rate was 6 of 23 (26.1%) in dentulous patients versus 1 of 17 (5.9%) in edentulous patients. Gastrostomy tube dependence was 6 of 16 (38%) in group 1 versus 6 of 24 (25%) in group 2., Conclusion: The "compartment approach" reduces plate exposure rate and gastrostomy tube dependence. Revascularized osseocutaneous reconstruction is still required in dentulous patients.

Objectives: Efforts to assess the level of voice-related disability through application of written instruments are gaining wider acceptance in clinical practice. However, based on the questions posed, additional diagnostic information may be obtained. This study evaluated the potential extended utility of the Physical Functioning (PF) subscore of the Voice-Related Quality of Life (V-RQOL) measurement instrument. Specifically, we examined whether the PF subscore could distinguish between the presence or absence of vocal fold lesions in patients who presented with dysphonia secondary to hyperfunctional voice disorders. A normative control database was also used for comparative purposes., Design: Comparative analysis., Setting: Academic tertiary care centre., Methods: Forty adults with a hyperfunctional voice disorder. All had been seen for medical evaluation to confirm laryngeal status., Main Outcome Measures: V-RQOL total and domain scores., Results: Although variability in V-RQOL scores was observed, differential profiles emerged from comparisons of participants who presented with vocal fold pathology and those who did not. Significantly lower PF and total V-RQOL scores were observed for those with benign mass lesions of the vocal folds. Additionally, discriminant analysis of the data permitted the generation of a cutoff value for the PF subscore, which identified 80% of those with mass lesions. These data also permitted calculation of sensitivity, specificity, and positive predictive and negative predictive values., Conclusions: The findings suggest that the PF subscore may exhibit the capacity to distinguish dysphonic patients who present with a mass lesion of the vocal folds from those who do not within the context of a hyperfunctional voice disorder. Clinical implications and applications of the V-RQOL are discussed.

Objective: To comprehensively evaluate long-term quantitative and qualitative donor-site morbidity following radial forearm free tissue harvest., Design: A single-centre retrospective cohort study with internal controls was undertaken., Methods: Quantitative measurements of range of motion (ROM) of the forearm, wrist, and digits were performed. Grip and pinch strength and hand dexterity were also evaluated. Qualitative assessment was performed using the Michigan Hand Outcomes Questionnaire (MHQ), a validated quality of life instrument., Main Outcome Measures: Quantitative primary outcome measures were (1) wrist flexion and extension, (2 forearm pronation and supination, and (3) hand dexterity. The qualitative primary outcome measure was overall MHQ score., Results: The operated side demonstrated decreased hand dexterity (p = .008), with no change in wrist and forearm ROM. An increase in ROM of the little finger was found (p = .002). The MHQ demonstrated a perceived decrease in function (p = .031), an increase in pain (p = .045), and no difference in appearance (p = .486)., Conclusions: The radial forearm free flap results in measurable quantitative changes in hand function and limited changes in patient perception. Donor-site appearance does not seem to be an important factor.

Background: This study evaluated the accuracy of single photon emission computed tomography (SPECT)-CT imaging for the preoperative localization of parathyroid adenomas., Methods: This study included both a quantitative and qualitative accuracy measure. The quantitative measure was the distance between the location of the adenoma on the SPECT-CT scan and the location of the adenoma intraoperatively. Qualitatively, surgeons were asked whether or not the adenoma was in the exact location predicted by the SPECT-CT scan. The time from initial incision to identification of the parathyroid was recorded. Patients referred to London Health Sciences Centre for a suspected parathyroid adenoma were eligible for this study., Results: Twenty-three patients participated in this study. Eighteen (78.3%) had a single adenoma, 2 (8.7%) had double adenomas, and 3 (13.0%) had multiglandular hyperplasia. SPECT-CT correctly detected and localized 16 of 18 (88.9%) cases of single parathyroid adenomas. The mean distance between the location of the adenoma on the SPECT-CT scan and the location of the adenoma intraoperatively was 16.3 mm (95% < or = 19.0 mm). For single adenomas, the median time from skin incision to identification was 14 minutes (range, 8-40 minutes). The preoperative detection and localization of a single focus of sestamibi uptake yielded a parathyroid adenoma in the specified location in 80.0% of cases (95% CI, 97.4-66.5%)., Conclusions: SPECT-CT predicted the intraoperative location of a single parathyroid adenoma within 19.0 mm with 95% confidence. The correct detection and localization of multiglandular disease remains difficult.

Objective: To review the anatomy, indications, technique, advantages, and limitations of vastus lateralis muscle-only free tissue transfer for reconstruction of head and neck defects following tumour ablation., Design: A single-centre retrospective chart review was undertaken., Methods: Patients undergoing free tissue transfer of the vastus lateralis muscle for reconstruction of head and neck defects between May 1, 2003, and April 30, 2006, were identified. Demographic data, surgical details, outcome, and complications were determined., Results: Nine patients were identified. A variety of tumour types and sites were treated. Three suffered flap-related complications consisting of distal flap vascular compromise., Conclusions: The vastus lateralis muscle-only free flap has numerous advantages, including versatility, ease of harvest, and ability to perform a two-team operation. There are also some limitations, including variable anatomy and tenuous distal circulation. Judicious use of this free flap in noncritical areas is preferable.

Objectives/hypothesis: To compare the pass rate of residents performing the Particle Repositioning Maneuver (PRM) after one of three interventions: 1) small group PRM instruction (SG); 2) standard classroom instruction (CI); and 3) Web-based learning module (WM). We hypothesize that our Web-based learning module is more effective than CI and as effective as SG., Study Design: Prospective randomized control trial., Methods: The study population includes all family medicine residents at the University of Western Ontario. On day 0, all subjects were tested. Residents were then randomized to one of three intervention groups: 1) SG, 2) CI, or 3) WM. On day 7, the residents were again tested. Observers were blinded to the intervention type. Testing (day 0 and day 7) was performed using the DizzyFIX (Clearwater Clinical Ltd., London, Ontario, Canada), a pass/fail test, and evaluation by a trained observer (correct or incorrect)., Results: There were no statistically significant differences in pass rates between the three groups before the interventions (DizzyFIX: P = .2096, observer: P = .3710). After the interventions, DizzyFIX testing pass rates were 50.0% SG, 60.0% CI and 100.0% WM (P = .3564). Observer testing pass rates were 85.7% SG, 28.6% CI, and 83.3% WM (P = .0431)., Conclusions: This study demonstrated that our Web-based learning module for the PRM is comparable to small-group clinical instruction, and superior to standard classroom instruction for teaching the PRM when evaluated by a trained observer.

In our search for improved therapeutic agents against HCV we synthesized 7-deaza-7-ethynyl-2'-C-methyladenosine (1) and its 2'-deoxy-2'-fluoro analogue 2. The corresponding nucleoside triphosphates were efficient chain terminators of the HCV NS5b polymerase with IC(50)'s of 0.75 microM and 0.4 microM respectively. However, only the ribo-nucleoside 1 exhibited activity in a Huh7 cell based replicon assay with an EC(50) of 0.09 microM. In order to overcome the lack of activity of the fluoro analogue 2 we synthesised several phosphoroamidate prodrugs.

Injury to the recurrent laryngeal nerve causes vocal fold paresis or paralysis resulting in poor voice quality, and possibly swallowing dysfunction and/or airway compromise. Injury can occur as part of a neurodegenerative disease process or can be due to direct nerve trauma or tumor invasion. Management depends upon symptoms, the cause and severity of injury, and the prognosis for recovery of nerve function. Surgical treatment techniques can improve symptoms, but do not restore physiologic motion. Gene therapy may be a useful adjunct to enhance nerve regeneration in the setting of neurodegenerative disease or trauma. Remote injection of viral vectors into the recurrent laryngeal nerve is the least invasive way to deliver neurotrophic factors to the nerve's cell bodies within the nucleus ambiguus, and in turn to promote nerve regeneration and enhance both nuclear and nerve survival. The purpose of this review is to discuss the potential role for gene therapy in treatment of the unsolved problem of vocal fold paralysis.

Background: Total laryngectomy following radiation therapy or concurrent chemoradiation therapy is associated with unacceptably high complication rates because of wound healing difficulties. With an ever increasing reliance on organ preservation protocols as primary treatment for advanced laryngeal cancer, the surgeon must develop techniques to minimize postoperative complications in salvage laryngectomy surgery. We have developed an approach using free tissue transfer in an effort to improve tissue vascularity, reinforce the pharyngeal suture line, and minimize complications in this difficult patient population. The purpose of this study was to outline our technique and determine the effectiveness of this new approach., Methods: We conducted a retrospective review of a prospective cohort and compared it with a historical group (surgical patients of Radiation Therapy Oncology Group (RTOG)-91-11 trial). Eligibility criteria for this study included patients undergoing salvage total laryngectomy following failed attempts at organ preservation with either high-dose radiotherapy or concurrent chemo/radiation therapy regimen. Patients were excluded if the surgical defect required a skin paddle for pharyngeal closure. The prospective cohort consisted of 14 consecutive patients (10 males, 4 females; mean age, 58 years) who underwent free tissue reinforcement of the pharyngeal suture line following total laryngectomy. The historical comparison group consisted of 27 patients in the concomitant chemoradiotherapy arm of the RTOG-91-11 trial who met the same eligibility criteria (26 males, 1 female; mean age, 57 years) but did not undergo free tissue transfer or other form of suture line reinforcement. Minimum follow-up in both groups was 12 months., Results: The overall pharyngocutaneous fistula rate was similar between groups-4/14 (29%) in the flap group, compared with 8/27 (30%) in the RTOG-91-11 group. There were no major wound complications in the flap group, compared with 4 (4/27, 14.8%) in the RTOG-91-11 group. There were no major fistulas in the flap group, compared with 3/27 (11.1%) in the RTOG-91-11 group. The rate of pharyngeal stricture requiring dilation was 6/14 (42%) in the flap group, compared with 7/27 (25.9%) in the RTOG-91-11 group. In our patients, the rate of tracheoesophageal speech was 14/14 (100%), and complete oral intake was achieved in 13/14 (93%) patients. Voice-Related Quality of Life Measure (V-RQOL) and Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) scores suggest that speech and swallowing functions are reasonable following free flap reinforcement., Conclusions: Free vascularized tissue reinforcement of primary pharyngeal closure in salvage laryngectomy following failed organ preservation is effective in preventing major wound complications but did not reduce the overall fistula rate. Fistulas that developed following this technique were relatively small, did not result in exposed major vessels, and were effectively treated with outpatient wound care rather than readmission to the hospital or return to operating room. Speech and swallowing results following this technique were comparable to those following total laryngectomy alone., ((c) 2007 Wiley Periodicals, Inc.)

Objective: To evaluate facial impairment and disability with respect to quality of life in patients with facial paresis after vestibular schwannoma surgery., Design: Cross-sectional observational study., Setting: Academic, tertiary care hospital., Patients: All consecutive patients during a 5-year period who underwent vestibular schwannoma surgery., Main Outcome Measures: The validated, patient-graded Facial Clinimetric Evaluation (FaCE) scale questionnaire was administered to all study patients. Main outcome measures included total and social function FaCE scores. Subgroup analysis was performed on patient factors (age and sex), surgical factors (tumor size and time since operation), and House-Brackmann grade., Results: A total of 56 FaCE questionnaires were returned (85% response rate): 28 patients (50%) had normal facial function (House-Brackmann grade I), and 28 patients (50%) had abnormal facial function (House-Brackmann grades II-VI). There were no demographic differences between the normal and abnormal groups. The normal group had a total FaCE score of 96.2 compared with 67.1 in the abnormal group (P<.05). Subgroup analysis of patients with facial paresis revealed that age, sex, time since operation, tumor size, and House-Brackmann grade were not statistically significant factors predicting the FaCE social function score (P<.05)., Conclusions: Facial paresis is an important complication of vestibular schwannoma surgery and will impair a patient's quality of life. The level of impairment may not be predicted by a patient's age, sex, tumor size, time since operation, or severity of facial paresis.