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Purpose of review Perforator flaps are increasingly being used to reconstruct head and neck defects. They offer several advantages over nonperforator-based flaps with lower donor site morbidity and a versatile range of reconstructive options. The anterolateral thigh flap is well established in the head and neck and is a good example of a reliable perforator free flap. With the increasing use of both free and regional perforator-based flaps, it is timely to review their anatomy, clinical applications, and role in head and neck reconstruction. We also discuss increasingly popular perforator flaps such as the submental flap for the head and neck. Recent findings The anterolateral thigh flap is now commonly used to reconstruct a wide variety of head and neck defects. The submental flap fills a niche role for reconstruction of intraoral defects. Summary Perforator flaps are now mainstream reconstructive options in the head and neck surgeon's armamentarium.

Objectives: Distant metastases from thyroid cancer are uncommon and have a variable prognosis. We present a series of patients with distant metastases to determine which patients are at risk of developing distant disease and to examine the significant prognostic variables. Study Design: Retrospective chart review of 30 patients with distant metastases compared with 633 controls from the Mount Sinai Thyroid Cancer Database and literature review. Methods: The prevalence of distant metastases was 4.5%, and median follow-up of survivors was 12.7 years. Histologic type was Hurthle cell carcinoma in 3, follicular in 3, papillary in 19, and 5 patients had focal anaplasia either in the primary site or regional metastases. Predictors for distant metastases, locoregional control, and survival were analyzed. Results: Cumulative survival for patients with distant metastases was 49.5% at 10 years and 12.9% at 20 years. Site of metastases was lung in 26, bone in 11 and brain in 1 patient, with 8 patients having multiple sites. The median time to diagnosis of distant metastases was 3 months. Variables that predicted for development of distant disease were male sex, age, size, extrathyroidal extension, regional metastases, and elevated thyroglobulin. Survival in patients without distant disease was significantly better than those with distant metastases (P < .001). Variables that predicted poor outcome in patients with distant metastases on analysis were age greater than 45 years (P = .003) and histologic type of thyroid cancer (P = .009). Conclusion: Although patients with thyroid cancer and distant metastases may live prolonged periods with disease, it does significantly impact on patient survival. Age remains an important variable in both predicting for development of distant metastases and also influences long-term survival in patients with existing distant metastases.

Objectives: Familial non-medullary thyroid cancer (FNMTC) is a newly recognized disease entity and can be distinguished from the more common sporadic non-medullary thyroid cancer. The purpose of this study was to determine some of the potential distinguishing features of FNMTC. Study Design: Retrospective association study and matched-case control study. Methods: Five hundred forty-three cases of well-differentiated follicular origin thyroid cancers were identified and collected in a database. Among this population, 24 cases of FNMTC were identified. A case of FNMTC was defined as a patient with the following two criteria: a well-differentiated follicular origin thyroid cancer and at least one first-degree relative with a well-differentiated epithelial origin thyroid cancer. The unmatched sporadic and FNMTC groups were compared using t test, Phi test, Cramer V test, and Pearson and Spearman correlation tests. Twenty-four FNMTC cases were matched to 24 sporadic cases based on age, gender, stage of disease at presentation, and tumor size. Clinicopathologic features, management, and outcome were analyzed statistically using a matched-proportional z test. Disease-free survival and disease-specific survival were analyzed using log-rank test and the Kaplan-Meier function. A P-value less than .05 was considered statistically significant. Results: There was no significant difference in ionizing radiation exposure, disease multifocality, surgical management, or recurrence between the sporadic and FNMTC patients. Although FNMTC patients tend to have improved disease-free survival and disease-specific survival, the difference was not significant at the 5% level. Conclusion: Although FNMTC is characterized by strong family history, these patients do not tend to have worse prognosis.

Objectives/Hypothesis: The objective was to compare the rate and site of recurrences in patients with well-differentiated thyroid carcinoma who underwent a central compartment dissection, a posterolateral neck dissection, or a combination of both procedures. Study Design: Retrospective chart review. Methods: The charts of 522 consecutive patients with well-differentiated thyroid carcinoma were reviewed, and 74 patients who had undergone a neck dissection were identified. The rates of recurrence in three sites were noted: the central compartment nodes (levels VI, superior mediastinum), posterolateral compartment neck nodes (levels II-V), and distant sites. These rates were compared in patients who underwent a central compartment dissection (level VI, superior mediastinum) and in patients who underwent a posterolateral neck dissection (levels II-V). Results: Six patients underwent only a central compartment dissection, 47 patients had only a posterolateral neck dissection, and 21 patients had both a central compartment and a posterolateral neck dissection. In these three groups there were zero, two, and two central compartment node recurrences; two, nine, and seven posterolateral neck recurrences; and zero, two, and three distant recurrences, respectively. There were no significant differences in the rate of recurrence in any of the three sites examined between any of the three treatment groups (Fisher's Exact test, all P values > .20). Conclusion: In patients with well-differentiated thyroid carcinoma, dissection of only the central or posterolateral compartments of the neck with clinical or radiographic evidence of disease is advocated.

Background: Patients with advanced cancers of the larynx and hypopharynx have been treated with total laryngectomy at the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney in the past. Increasingly, these patients are being managed with organ-sparing protocols using chemo­therapy and radiotherapy. The aim of the present study was to review complication, recurrence and survival rates following total laryngectomy. Methods: Patients who had total laryngectomy for squamous carcinomas of the larynx or hypopharynx between 1987 and 1998 and whose clinicopathological data had been prospectively accessioned onto the computerized database of the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, were reviewed. Patients whose laryngectomy was a salvage procedure for failed previous treatment were included. Results: A total of 147 patients met the inclusion criteria for the study, including 128 men and 19 women with a median age of 63 years. Primary cancers involved the larynx in 90 patients and hypopharynx in 57. There were 30 patients who had recurrent (n = 24) or persistent disease (n = 6) after previous treatment with radiotherapy (26 larynx cases and four hypopharynx cases). Pharyngo-cutaneous fistulas occurred in 26 cases (17.7%) and, using multivariate analysis, the incidence did not correlate with T stage, previous treatment or concomitant neck dissection. Local control rates were 86% for the larynx and 77% for the hypo­pharynx groups and neck control was 84% and 75%, respectively. Five-year survival for the larynx cancer group was 67% and this was significantly influenced by T stage and clinical and pathological N stage. Survival in the hypopharynx group was 37% at 5 years and this did not significantly correlate with T or N stage. There was a non-significant trend to improved survival among previously treated patients whose laryngectomy was a salvage procedure. Conclusion: Patients with cancer of the larynx had a significantly better survival following total laryngectomy than patients with hypopharyngeal cancer. Those whose laryngectomy was carried out as a salvage procedure following failed previous treatment did not have a worse outcome than previously untreated patients.

Objectives:Elucidate the incidence of cisplatin-induced ototoxicity in patients treated for head and neck cancer.Methods:This was an institutional review board approved retrospective study of patients treated with cisplatin for cancer at a tertiary referral hospital. The charts of patients of any age that had undergone cisplatin therapy from 1995 to the present were reviewed. We then narrowed this group down to those who had a diagnosis of cancer of the head and neck (hypopharyngeal, laryngeal, nasopharyngeal, oropharyngeal, scalp/face skin cancer, temporal, thyroid) and had pre- and posttreatment audiologic testing.Results:There were 1565 patients that had undergone therapy with cisplatin from 1995 to 2014. Of those, 203 patients had pre- and posttreament audiologic testing. Twenty patients had diagnosis of cancer involving the head and neck. The cochlear radiation doses were also collected from these patients. Preliminary results demonstrate that patients with head and neck cancer that were treated with...

Background Development of a second primary squamous cell carcinoma in the skin of a flap used for pharyngeal reconstruction is rare. Methods A case of squamous cell carcinoma is presented arising in a deltopectoral flap used to reconstruct the hypopharynx 27 years after total laryngectomy. Three previous reports found on review of the literature are summarized. Results A second primary squamous cell carcinoma may arise in the skin of a myocutaneous flap in the absence of any obvious risk factors. Conclusion We suspect that long-term exposure of the skin of the flap lining the pharynx to saliva may have been a significant factor in the development of this malignancy. Long-term follow up and awareness of this complication is required for patients with soft tissue reconstruction of the oral cavity and pharynx. © 2002 John Wiley & Sons, Inc. Head Neck 24: 87–90, 2002.

Objectives:1) Assess the incidence of oropharyngeal squamous cell carcinoma (OPCa) in patients

Objectives:1) Assess self-reported risk factors and knowledge gaps regarding head and neck cancer (HNC) risk factors in a multi-ethnic urban versus suburban population. 2) Improve education regarding behavioral risk factors for HNC, including regarding the transmission of human papillomavirus (HPV).Methods:The current sample includes a total of 118 individuals who presented for free HNC screenings across urban and suburban sites. Ninety-eight consented to complete behavioral risk questionnaires assessing for knowledge regarding HNC, ancestry, smoking/tobacco use, alcohol use, and sexual history.Results:Mean age was 56.63 years old (SD = 14.22, range 23 to 85), 60.2% female, predominantly African American (53.1%), Caucasian (42.7%), and other (4.1%). Those residing in an urban environment were more likely to be African American χ2(1, N = 98)=23.334, P < 0.001, have a history of treatment for some other cancer χ2(1, N=98)=6.063, P = 0.01, be a current smoker χ2(2, N=98)=5.885, P = 0.05, report more cumulati...

Objective: To present a 4-year experience with the American College of Surgeons (ACS) National Surgical Quality and Improvement Program (NSQIP) in Otolaryngology, Head and Neck Surgery, to highlight successes, and to demonstrate areas that provide opportunities for quality improvement.Method: The Henry Ford Health System (HFHS) database was utilized to analyze NSQIP outcomes and quality measures obtained for the Department of Otolaryngology–Head and Neck Surgery. This had been an ongoing project in our department over the last 4 years.Results: Overall mortality (0.34%) continues to be equal to the national average (0.34%). The overall wound infection rate (23.38%) has improved but is still slightly higher than the national average (17.4%). Initially, the wound infection rate was a significant high outlier (16.67%). The incidence of infection has improved to 0.00% (3rd Q, 2011). Individual categorical gains have been made in unplanned intubations, pneumonia rates, and off the ventilator rates within 48 hou...

Objective: To describe 2 contrasting surgical approaches in the treatment of patients with a lingual thyroid.Method: Case series from 2006 to 2008. Condition studied: lingual thyroid. Subjects and setting: Patients requiring surgery for lingual thyroid in a community hospital. Outcome measurements: recurrence, complications.Results: A 33-year-old woman had a small lingual thyroid. Although she had no symptoms she was planning to become pregnant and it was felt that the lingual thyroid would increase in size with pregnancy and could result in airway obstruction. She therefore underwent transoral laser resection of the entire lingual thyroid. A 36-year-old woman had a large combined lingual and sublingual thyroid. She was unable to sleep lying down. She had previously undergone transoral debulking. She underwent a transcervical transhyoid partial pharyngectomy with resection of the entire lingual and sublingual thyroid. Both patients had no recurrence with mean follow-up of 9 months. There were no complicat...

Evaluate current accepted risk factors for well-differentiated thyroid carcinoma, and develop a predictive model to determine one's risk of malignancy given a thyroid nodule.Retrospective analysis of 600 patients.Patients with benign thyroid nodular disease and with well-differentiated thyroid cancer were randomly selected. Patient, clinical, and investigational data were compared by means of univariate and multivariate regression analyses.Age, regional lymphadenopathy, ipsilateral vocal cord palsy, solid and/or calcified nodules, and an aspiration biopsy being malignant or suspicious predicted for cancer (P0.05). Regional lymphadenopathy and vocal cord palsy are perfect predictors of malignancy. Multivariate analysis indicated age, solid and/or calcified nodules, and all fine-needle aspiration biopsy results to be significant in assessing risk (P0.05).Taking individual risk factors in isolation is not always reliable. Using a predictive model, one can anticipate a patient's risk of malignancy when the diagnosis is unclear.

Background Free flap reconstruction of head and neck cancer defects is complex with many factors that influence perioperative complications. The aim was to determine if there was an association between perioperative variables and postoperative outcome. Methods We evaluated 185 patients undergoing free flap reconstruction following ablation of head and neck cancer between 1999 and 2001. Demographic, laboratory, surgical and anesthetic variables were analyzed using univariate and multivariable techniques. Results Ninety-eight patients (53%) developed complications, of which 74 were considered major, giving a major morbidity rate of 40%. Predictors of major complications were increasing patient age, ASA class, and smoking. Predictors of medical complications were ASA class, smoking, age and crystalloid replacement. Predictors of surgical complications were tracheostomy, preoperative hemoglobin, and preoperative radiotherapy. Conclusion Patient age, comorbidity, smoking, preoperative hemoglobin, and perioperative fluid management are potential predictors of postoperative complications following free flap reconstruction for cancer of the head and neck. © 2007 Wiley Periodicals, Inc. Head Neck 2007

Objective To assess the predictive value of wound amylase as an indicator for pharyngocutaneous fistula development following laryngectomy for cancer. Design and Setting We conducted a prospective observational study at a tertiary referral center of 102 consecutive laryngeal or hypopharyngeal cancer patients undergoing laryngectomy with or without pharyngectomy. Intervention Data were collated on potential predictors of fistula formation compared with rate of development of clinical fistulas, all confirmed radiologically. Main Outcome Measures Rate of fistula formation was determined for the following potential predictors: extent of resection (extended laryngectomy), postoperative wound (drain) amylase, previous radiotherapy, neck dissection, preoperative and postoperative hemoglobin and albumin levels, and postoperative transfusion. Sensitivity, specificity, and positive and negative predictive values of significant predictors were ascertained. Results The only significant predictors of fistula formation were extent of resection (extended laryngectomy) and drain amylase >4000 IU/L. If both factors are combined, the sensitivity, specificity, and positive and negative predictive values for fistula development are 83, 94, 63, and 98 percent, respectively. Conclusion We advocate that patients be managed postoperatively according to the presence or absence of these given predictors to reduce occurrence of fistula formation in the high-risk group.

Nous presentons la revue des dossiers de 35 patients traites entre 1982 et 1997 pour une premiere recidive d'adenome pleomorphe de la glande parotide. Tous les patients ont ete traites chirurgicalement; aucun patient ne recevant de radiotherapie pour cette tumeur benigne. Nous avons obtenu un controle loco-regional de 77%, avec un taux de transformation maligne de 5.7%. Nos resultats suggerent que chez des patients bien choisis, la resection locale des recidives est suffisante pour controler la maladie.

We report a 38-year-old woman with a malignant catecholamine-secreting vagal paraganglioma. In the preceding year she had intermittent severe frontoparietal headaches. While she was receiving radiotherapy (35 Gy in 15 fractions) she developed palpitations, which steadily worsened over the following three years. A repeat CT scan showed no change in the size of the tumor. Urinary catecholamines were elevated and a MIBG scan showed increased uptake in the region of the vagal paraganglioma. She underwent near total resection of her tumor via a Fisch type C approach. Pathological examination showed a paraganglioma with metastasis involving a cervical lymph node. The palpitations and headaches resolved completely after surgery. This report and other published case reports suggest that catecholamine secretion from head and neck paragangliomas does not appear to respond to radiotherapy. Patients with cardiovascular symptoms from catecholamine-secreting paragangliomas are best managed surgically.

Patients with advanced cancers of the larynx and hypopharynx have been treated with total laryngectomy at the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney in the past. Increasingly, these patients are being managed with organ-sparing protocols using chemo-therapy and radiotherapy. The aim of the present study was to review complication, recurrence and survival rates following total laryngectomy.Patients who had total laryngectomy for squamous carcinomas of the larynx or hypopharynx between 1987 and 1998 and whose clinicopathological data had been prospectively accessioned onto the computerized database of the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, were reviewed. Patients whose laryngectomy was a salvage procedure for failed previous treatment were included.A total of 147 patients met the inclusion criteria for the study, including 128 men and 19 women with a median age of 63 years. Primary cancers involved the larynx in 90 patients and hypopharynx in 57. There were 30 patients who had recurrent (n = 24) or persistent disease (n = 6) after previous treatment with radiotherapy (26 larynx cases and four hypopharynx cases). Pharyngo-cutaneous fistulas occurred in 26 cases (17.7%) and, using multivariate analysis, the incidence did not correlate with T stage, previous treatment or concomitant neck dissection. Local control rates were 86% for the larynx and 77% for the hypo-pharynx groups and neck control was 84% and 75%, respectively. Five-year survival for the larynx cancer group was 67% and this was significantly influenced by T stage and clinical and pathological N stage. Survival in the hypopharynx group was 37% at 5 years and this did not significantly correlate with T or N stage. There was a non-significant trend to improved survival among previously treated patients whose laryngectomy was a salvage procedure.Patients with cancer of the larynx had a significantly better survival following total laryngectomy than patients with hypopharyngeal cancer. Those whose laryngectomy was carried out as a salvage procedure following failed previous treatment did not have a worse outcome than previously untreated patients.

Objective: To determine the relationship between stimulated serum thyroglobulin levels (taken 3 months after total thyroidectomy) and tumor stage and recurrence in patients with well-differentiated thyroid carcinoma. Study Design: Retrospective chart review in a tertiary care institution. Methods: Two hundred thirteen consecutive patients with well differentiated thyroid carcinoma treated between 1983 and 1998 were identified. Data were collected on clinicopathological variables, stimulated serum thyroglobulin levels obtained 3 months after total thyroidectomy prior to 131 I therapy and recurrence. Results: A high postoperative thyroglobulin level was significantly associated with advanced-stage disease at presentation (P = .005, Kruskall-Wallis) but not with any of the other clinicopathological variables. Patients with a thyroglobulin level greater than 20 pmol/L had a significantly increased risk of disease recurrence on univariate analysis (n = 213 [P = .0001, log rank test]), and in the Cox proportional-hazards model, both advanced tumor stage (P = .001, relative hazard, 3.4 [95% confidence interval [CI]: 2.4-4.9]) and a thyroglobulin level greater than 20 pmol/L (P = .001, relative hazard, 5.1 [95% CI: 2.0-13.1]) were significant predictors of recurrence. No other variables significantly altered the hazards model. Conclusions: Advanced tumor stage at diagnosis and a stimulated thyroglobulin level greater than 20 pmol/L taken 3 months after total thyroidectomy were independent predictors of disease recurrence. Patients with a thyroglobulin level greater than 20 pmol/L are at increased risk of recurrence and may be candidates for more intensive follow-up or additional treatment.

OBJECTIVE: To examine the relationship between lymphatic vessel density and clinical and pathological variables in patients with well-differentiated papillary thyroid carcinoma. SUBJECTS: Clinical information was retrieved on 109 previously untreated patients with well-differentiated papillary thyroid carcinoma treated with total thyroidectomy and postoperative iodine I 131 ablation. Median follow-up was 38 months. DESIGN: Archived tissue specimens were sectioned and stained with hematoxylin-eosin and anti-LYVE-1 antibody, a highly specific marker for lymphatic endothelium. The size of the tumor and its multifocality were noted and lymphatic vessel density was measured by means of Chalkley point counting. RESULTS: Numerous intratumoral lymphatics were seen in papillary thyroid carcinoma. There was a highly significant association between the presence of intratumoral lymphatics and the presence of neck node metastases (P