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Introduction: Microvascular free tissue transfer is a technique for reconstruction of large defects in head and neck surgery. Failure due to microvascular thrombosis can lead to microvascular damage or flap loss. Recombinant tissue-type plasminogen activator (Alteplase) is still an off-label use but it can help to rescue free flaps when embedded in a salvage algorithm., Presentation of Case: A 39-year-old patient with received a tumor resection and reconstruction by a radial forearm flap of the left palate. Postoperatively a venous flap thrombosis occurred and immediate surgical revision was done. Initially eperfusion of the flap could not be achieved even after mechanical removal of the thrombus. Then a thrombolysis with Alteplase, which was applied directly into the radial artery, was done. The flap was salvaged and is now completely integrated into the mucosa. Flap salvage procedure was performed according to our free flap salvage algorithm., Discussion: Thrombolysis with Alteplase for free flap salvage is not a common method. Pedicle thrombosis cannot be predicted. Important procedures during surgical intervention when thrombosis occurs are careful reopening, removal of thrombus, flushing with heparin. Since these procedures failed, surgeons decided to employ Alteplase to optimally rescue the flap., Conclusion: The present case shows that pharmacological thrombolysis with Alteplase is an effective ultima ratio in free flap salvage with venous thrombosis, although it is still considered offlabel use. Early detection of flap failure and a clear salvage algorithm are important for successful surgical revisions., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: After that the establishment of transoral robotic surgery (TORS) for head and neck cancer has been adopted in North America, it has also recently been adopted in Europe. In these parts, transoral laser microsurgery (TLM) is widely applied. The aim of the study was to identify the absolute number of operations amenable to TORS at a TORS initiating institution on the basis of all former TLM cases., Patients and Methods: All laser surgery procedures from May 2004 to April 2013 (108 months) were initially retrospectively registered; after that, all stage pT1 and pT2 squamous cell carcinomas of the oropharynx, hypopharynx, and larynx were selected., Results: Over a period of nine years out of all TLM cases, there were 45 cases of pT1 and pT2 orohypopharyngeal and supraglottic squamous cell carcinomas, which could have been considered for TORS surgery. With the inclusion of a nowadays-typical TORS indication such as tonsil cancer, 142 cases would have been amendable to TORS., Conclusions: The indication for TORS would have been made in five of the TLM cases per year. Institutions initiating TORS, which own an intensive TLM experience, are encouraged to TORS indications in more than solely typical TLM indications. By indicating TORS instead of handheld surgery, a higher caseload of more than 15 cases per year can be achieved for TORS indications.

Objective: To compare efficacy, in terms of disease control/survival in advanced hypopharyngeal and laryngeal lesions, according to treatment strategy (primary surgery, PS or primary chemoradiotherapy, CRT) and invasion pattern (cartilage, CAI or soft tissue involvement, STI)., Methods: Records from 463 patients with T3 and T4a carcinoma with CAI (n=221) or STI (n=242) treated at a university clinic over 18 years were retrospectively reviewed., Results: Disease-specific survival (DSS) for the CAI group was 70.1% (PS) and 38.4% (CRT), and 76.6% and 46% for the STI group, respectively. Overall survival (OS) for STI was 56.4% (PS) and 30.6% (CRT), and for CAI 51.1% (PS) and 28.5% (CRT) respectively. Positive resection margins and regional neck metastases reduced survival. T3 lesions treated non-operatively still had significantly improved survival versus T4a by >20%., Conclusion: Surgery remains an indispensable part of treatment in local advanced hypopharyngeal and laryngeal cancer with high survival results. It should be part of a concept that includes adjuvant (C)RT. For T3 lesions, primary CRT is also acceptable and CAI is not a contraindication for primary CRT. Regional disease is a strong prognostic factor. In spite of adjuvant treatment, DSS deteriorates by about 20% in cases with positive resection margins., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Management of advanced laryngeal cancer is complex and ideal strategy is yet to be defined. This study evaluates the experience of a single head and neck oncologic centre in the management of T4 laryngeal cancer., Methods: Retrospective assessment of cases primarily treated for T4a squamous cell carcinoma of the larynx, between 1980 and 2007, at a tertiary referral center., Results: A total of 384 cases were studied. Five-year disease specific survival was 56.2% and local control 87.4%. Regional and distal control estimates were 90.3% and 88.3% respectively. Prognosis was significantly superior for cases treated with primary surgery compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease worsened prognosis., Conclusion: This study suggests that primary surgery remains a key element in the treatment of advanced laryngeal cancer. The need for well-designed, prospective, randomised studies in order to further evaluate the remaining role of primary surgery in the modern management of locally advanced laryngeal lesions is emphasized.

Background: Temporary balloon test occlusion (BTO) might be performed prior to procedures in which occlusion of the internal carotid artery (ICA) might be necessary. We tested the hypothesis that parametric color coding (PCC) of angiographic series (digital subtraction angiography (DSA)) along with the assessment of cerebral blood volume (CBV) in the angiography suite would simplify and enhance the identification of candidates who are most likely to tolerate occlusion., Materials and Methods: Fifteen patients underwent angiographic series (DSA) and perfusion imaging before and during BTO. Pre- and postocclusion DSA acquisitions were evaluated for venous delay by conventional methods ("eye balling") and by PCC measurements. Comparison of CBV values between the left and right hemisphere in 6 defined regions was performed., Results: Values of venous delay by eye balling and PCC showed a high correlation (r = 0.87, p < 0.01). Bland-Altman plot indicated slightly lower values (-0.05 s) by the PCC method. One of the 15 patients developed an asymmetrical CBV map with an increase in CBV of more than one standard deviation in 3 of the 6 regions of interest (ROIs). Acquisition of angiographic series and perfusion imaging did not prolong the test occlusion time., Conclusion: PCC and CBV mapping are feasible during BTO. The use of PCC seems to simplify the ability to measure changes in venous filling delay. Perfusion imaging may show an increase in CBV in patients reaching the limits of cerebral autoregulation. These patients may be at risk for delayed infarction, even though they seem to tolerate temporary occlusion, and could be unsuitable candidates for permanent ICA occlusion.

Conclusion: In pT2 floor of mouth cancer (FOMC), a standardized neck dissection (ND) should be carried out, due to the high risk of occult metastases. In cases of pT1 carcinomas with a clinically negative neck using high imaging standards and expertise a tight 'wait and watch' strategy can be used., Objective: To report on the oncologic results with primary surgical treatment of pT1/pT2 FOMC and to examine the benefit of elective ND in cN0., Methods: This was a retrospective study design including 216 patients who were treated between 1980 and 2010 for pT1/2 FOMC. The 5-year disease-specific survival (DSS), local and (loco)regional control based on the T and N classification and depth of infiltration were investigated., Results: DSS was 79.5% and (loco)regional control was 89.8%. DSS in patients staged pN0 was significantly higher, at 84.6%, than in those staged pN+, at 60%. ND was performed in 165 patients, and adjuvant therapy was administered in 124 patients. Ninety patients (41.7%) were staged cN0, and 53.3% of them underwent elective ND. The risk of occult metastases was 4.8% in pT1 and 28.6% in pT2. A depth of infiltration of ≥ 5 mm showed a markedly higher relative frequency of occult neck metastases and pN+ status.

The central retinal artery (CRA) is the main vessel for inner retinal oxygen and nutrition supply. While the intraocular branches lack autonomic innervation, the innervation pattern of the extra-ocular part of this vessel along its course within the optic nerve is poorly investigated. This part however is essential for maintenance of retinal blood supply, in physiological and pathological conditions. Therefore, the aim of this study was the characterization of the autonomic innervation of the preocular CRA in humans with morphological methods. Meeting the Declaration of Helsinki, eyes of body or cornea donors were processed for single or double immunohistochemistry against tyrosine hydroxilase (TH), dopamine-β-hydroxylase (DBH), choline acetyl-transferase (ChAT), vesicular acetylcholine transporter (VAChT), neuronal nitric oxide synthase (nNOS), calcitonin gene-related peptide (CGRP), substance P (SP), vasoactive intestinal polypeptide (VIP), and cytochemistry for NADPH-diaphorase (NADPH-d). For documentation, light-, fluorescence-, and confocal laser-scanning microscopy were used. TH and DBH immunoreactive nerve fibres were detected in the CRA vessel wall, although a distinct perivascular plexus was missing. Further, nerve fibres immunoreactive for ChAT and VAChT were found, while CGRP, SP, and VIP were not detected. NADPH-d staining revealed scattered nerve fibres in the adventitia of the CRA and in close vicinity; however, nNOS-immunostaining could not confirm this finding. The CRA receives adrenergic and cholinergic innervations, indicating sympathetic and parasympathetic components, respectively. Remarkably, a peptidergic primary afferent innervation was missing. Since clinical results suggest an autoregulation of intraretinal vessels, further studies are needed to clarify the impact of CRA innervation for retinal perfusion., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Conclusion: This study showed that elective neck dissection (ND) resulted in reduced regional recurrences in a selected group of surgically treated patients with pT1-2 carcinomas but did not show any benefit for disease-specific survival (DSS). Furthermore, the importance of pN classification was also verified for this patient group., Objectives: The aim of this study was to determine whether the use of elective ND in patients with early head and neck carcinomas and cN0 neck that have undergone a transoral removal of the primary tumor can reduce the incidence of regional recurrence and improve survival., Methods: Between 1980 and 2010, 224 patients that underwent transoral resection of a pT1-2 carcinoma and had a cN0 neck were included in the study; 101 patients received an elective ND and 123 did not., Results: The group that underwent elective ND showed a tendency toward better regional control (RC) (96.0% vs 90.3%, p = 0.07) but similar DSS (85.7% vs 85.4%, p = 0.984). Cases with pN0 classification had a better overall survival (74.6% vs 46.9%, p = 0.07), DSS (88.4% vs 53.6%, p = 0.44), and RC (98.6% vs 62.5%, p < 0.001) compared with pN+ patients.

Objectives/hypothesis: The aim of this study was to assess the efficacy of primary surgical treatment in the management of T3 glottic carcinomas., Study Design: Retrospective clinical study., Methods: A retrospective evaluation of the records for all patients treated with primary surgery for T3 glottic carcinomas at a tertiary referral center between 1980 and 2005 was carried out. Data for the 5-year disease-specific survival (DSS) were assessed, as well as local control rates in relation to vocal cord immobility, N classification, choice of surgical modality, and adjuvant therapy. Patients who underwent partial laryngectomy were also evaluated in relation to organ preservation and the rate of permanent tracheotomies., Results: The 5-year DSS in the 120 patients was 78.3%. Positive neck disease was shown to be a significant negative prognostic factor. Organ preservation was achieved in 90.1% of the patients who underwent partial laryngectomy and in 50% of the overall patient group. The occult metastasis rate was 14%., Conclusions: Primary surgical treatment is an effective modality against T3 glottic carcinomas. Partial laryngectomy is a reliable method in carefully selected cases. Low complication rates can be expected., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Purpose: Various protocols exist to prevent thrombosis after free flap surgery in the head and neck. This study reviews the outcome and incidence of perioperative complications in patients undergoing head and neck reconstruction, simply using subcutaneous low-molecular-weight heparin., Materials and Methods: A total of 137 free tissue transfers performed between 2007 and 2010 were reviewed. All patients received a general thrombosis prophylaxis with subcutaneous low-molecular-weight enoxaparin. No aspirin, dextran, or additional antithrombotic medication was administered., Results: Overall flap survival was 97.1%. A total of 3 complete and 1 partial flap loss occurred, all due to venous thrombosis. Five cases of venous congestion were successfully revised., Conclusion: The free flap survival rate using simple subcutaneous heparin seems to be equivalent to other management regimens. Therefore, we suggest that no additional antithrombotic treatment is needed for patients who undergo head and neck reconstruction with free tissue transfer., (Copyright © 2012 Elsevier Inc. All rights reserved.)