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Surgery for head and neck malignancy may be complex with postoperative admission to critical care units (CCUs) often required. There are, however, increasing demands on this resource. We examined a national intensive care database to assess patterns of admission and outcomes for patients following surgery for malignancies of the oral cavity and oropharynx. An analysis was performed of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme database. Data were extracted on case mix and outcomes for patients coded as 'malignant neoplasm of the oropharynx requiring surgery' admitted to critical care between 2010 and 2019. Data included admission numbers, demographics, comorbidities, physiology scores, and outcomes including length of stay and mortality. There were 9,843 admissions for patients with malignancies of the oral cavity and oropharynx from 156 CCUs over the ten-year period. Admissions increased from 486 in 2010 to 1,381 in 2019. These admissions accounted for 0.42% of overall admissions in 2010 and 0.78% in 2019. The median age of patients was 63 years and 63.5% were male. The median length of stay in critical care was 38 hours (Interquartile range (IQR) 20.4-64.3 hours). The median length of total hospital stay was 15 days (IQR 10-23 days). Mortality in critical care was low (0.7%). Admissions to CCUs following surgery for malignancies of the oral cavity and oropharynx have increased over the last decade but remain low overall. With increasing demand for this resource, ongoing monitoring of utilisation is important., (Copyright © 2022 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

The lip-split mandibulotomy (LSMA) is an access procedure that has been used in head and neck (H&N) surgery as an aid to surgical resection of inaccessible tumours of the postertior oral cavity and oropharynx. Anecdotal evidence suggests that it has significant morbidity. Voices of concern within the H&N surgical community suggest that it has been abandoned in favour of technological advances such as robotic surgery. We report here the first (to our knowledge) registered systematic review of its kind, documenting the safety and efficiency of LSMA in H&N surgery. We performed a PRISMA-guided systematic review (PROSPERO-registered) and identified reports using a search algorithm in MEDLINE/EMBASE. LSMA-related surgical complications were recorded using the Clavien-Dindo classification. Secondary outcomes included swallowing dysfunction, facial cosmesis, and patient satisfaction recorded in health-related quality of life questionnaires (HRQoL). From 125 studies identified, 54 met the inclusion criteria (3872 patients). The LSMA mortality rate was 0%; we did not identify a single case of perioperative death. The median rate of osteoradionecrosis was 5.4%, whereas fistula formation was 5.7%. Malunion was noted in 4.9%. Other complications (surgical site infection, plate exposure) were around 5%. There was significant between-study variation with regards to swallowing assessment tools, but overall there was no significant difference in outcomes. This was also the case for the HRQoL questionairres. LSMA is a safe procedure with an acceptable rate of complications, and should definitely remain in the armamentarium of H&N surgery., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

The 8 th edition of the UICC TNM (UICC 8) staging rules for oropharyngeal squamous cell carcinoma (OPSCC) acknowledges dichotomous disease biology based on the human papillomavirus (HPV) tumour status. This retrospective study was undertaken to validate those staging rules in a single UK treatment centre. Given a recent resurgence of interest in primary surgery for OPSCC, a secondary objective was to identify subsets of patients who might benefit. Patients presenting with OPSCC between 2010 and 2017 to the South Glasgow head and neck multidisciplinary team were identified from a prospective database. Only patients managed with curative intent were included (n=272). Stage group allocation according to the UICC 8 resulted in appropriate hazard discrimination, in contradistinction to the UICC 7 staging rules. Locally advanced (cT3-4) disease had a relatively poor prognosis irrespective of HPV status. No clear benefit for primary surgery in any subgroup was demonstrated. A dichotomous disease biology based on the HPV status of tumour is confirmed in this cohort. Patients with HPV-positive T1 and T2 primary tumours have an excellent prognosis when treated with non-surgical treatment regimens. The use of surgery as the primary management for categories of patients presenting with OPSCC should be in the context of clinical trials., (Copyright © 2020. Published by Elsevier Ltd.)

Since the first description of the submental island flap 24 years ago, advances in techniques have expanded the indications for its use and improved its characteristics to make it a favourable reconstructive option for orofacial oncological defects. We describe our experience (particularly perioperatively) of its use, the complications, and the precautions adopted. We retrospectively reviewed the cases of 25 patients and focused on the operating time, use of tracheostomy, duration of postoperative inpatient stay, oropharyngeal function, and associated morbidities. Eighteen patients had defects of the tongue. Other defects were retromolar (n=2), buccal (n=1), mandibular (n=2), and maxillary (n=2). The mean (range) operating time was 250 (152-370) minutes and the mean (range) postoperative stay was 11 (4-16) days. Only four patients required a tracheostomy, and four required postoperative monitoring in the intensive care unit (ICU). The complications were partial flap loss (n=6), sialocele (n=1), and seroma (n=1). The flap has shown its merit as an option for oral reconstruction because of its reliability, versatility, and relative ease of application. To our knowledge, our case series is the largest in the United Kingdom, and we hope that in future, this humble flap will be a standard reconstructive option for small to medium oral resection defects., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Despite advances in the primary treatment of oral and oropharyngeal cancer, many patients develop local or regional recurrence, or both, and when radiotherapy has already been used, operation provides the best chance of salvage for these patients. We have looked at the outcomes of salvage procedures in a single unit, including improved survival, morbidity, and treatment-related quality of life. Patients treated with salvage procedures were identified from a prospectively-completed database. Overall and disease-free survival were analysed using Kaplan-Meier curves and logrank tests. Functional, social, and emotional outcomes were assessed using the University of Washington Quality of Life Questionnaires. Twenty-nine patients were identified, of whom 24 had free flap reconstructions, and their estimated mean overall survival was 25 months (95% CI 20.4 to 29.2). Disease-free survival was significantly worse in patients with stage IV recurrences or in whom resection margins were close or invaded. Permanent gastrostomy was required in 15/29 patients, and four/29 needed a permanent tracheostomy. Answers to questionnaires showed that a large proportion of patients had considerable problems with speech, chewing, swallowing, and appearance. The decision on whether to treat recurrent head and neck cancer is a balance between improving survival and poor functional outcomes. The extent of disease and whether clear surgical margins can be achieved should be considered when treatment is recommended., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Our aim was to evaluate the feasibility of robot-assisted neck dissection (RAND) followed by transoral robotic surgery (TORS) in treatment of cancers of the head and neck, which is expected to improve cosmesis and function. We studied 37 patients with biopsy-confirmed cNO or cN+ tumours of the oropharynx (n=22), hypopharynx (n=8), larynx (n=6), and oral cavity (n=1) who were treated by RAND then TORS from May 2010 to December 2012. Patients' characteristics and clinical details were recorded, together with operative complications and functional variables such as management of the airway and nasogastric or enterogastric feeding. All endoscopic TORS and RAND were successful, with no serious intraoperative complications or need to convert to open operation. All patients were satisfied with the cosmesis according to the answers given to a questionnaire. RAND followed by TORS in some cancers of the head and neck are feasible and showed a clear cosmetic benefit, although the longer operating time is a drawback. Studies of more patients with longer follow-up are required to evaluate long-term oncological and functional outcomes in more detail., (Copyright © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

The Patient Concerns Inventory (PCI-H&N) is a carefully designed 57-item checklist specifically for use in routine follow-up clinics for patients with head and neck cancer. Although developmental work at one hospital has been very positive, its use had not been evaluated across a wider network. The aim of this project was to evaluate use of the inventory across the Merseyside and Cheshire cancer network. Patients from 5 hospitals were included and 66 patients, 8 doctors, and 6 nurse specialists took part. Almost all patients found the inventory easy or very easy to complete and it caused no notable problems with the running of appointments. Two-thirds felt that all or most of the items mentioned were talked about in the consultations and no patient felt that the consultation had been made worse. Two-thirds felt that it had helped them communicate with the doctor, while some felt that communication was already excellent and beyond improvement. Only a small minority (12%) thought that it could or definitely would lead to disappointment because needs might not be met. Most patients definitely wanted to continue using the inventory and only 5% definitely did not. Most of the doctors and specialist nurses saw its potential benefit in clinical practice. However, some practical, administrative, and educational aspects need to be addressed before it can be used more widely. It is likely that the inventory will be incorporated into practice at each clinic and locality in different ways., (Copyright © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

A broad patient-completed screening tool in routine clinical practice in head and neck oncology has merit, but clinicians should be aware that its simplicity could lead to some patients and the detail of their problems being missed. The purpose of this study was to compare the University of Washington Quality of Life (UWQoL) swallowing domain with the MD Anderson Dysphagia Inventory (MDADI) in relation to the need for interventions for swallowing around one year after treatment. The group comprised 112 consecutively referred patients to speech and language therapy between January 2007 and August 2009 after primary operation for previously untreated oral and oropharyngeal squamous cell carcinoma (SCC). A total of 78 patients completed questionnaires (median time of assessment 11.7 months, IQR 6.1-12.2). There were significant (p<0.001) and moderately strong correlations (rs=0.51-0.62) between the UWQoL swallowing domain score and MDADI subscales and total scores, and also with individual MDADI questions: taking a great deal of effort (rs=0.71); being upset (rs=0.61); and not going out (rs=0.62) were the strongest in regard to swallowing. Use of a gastrostomy tube was associated with worse UWQoL and MDADI scores. In conclusion, patients who score 100 on the UWQoL do not require swallowing to be evaluated further. Those who score 70 could benefit from the detailed MDADI to help to clarify the specific problem and the impact it has before being referred to speech and language therapy. Those who score less than 70 should be brought to the attention of speech and language therapists to confirm that appropriate support and intervention are in place., (Copyright © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

In this prospective study we analysed the oncological and functional results of transoral robotic surgery (TORS) to find out if it was suitable as a minimally invasive treatment for oropharyngeal cancer. Between April 2008 and September 2011, 39 patients with oropharyngeal cancer were treated by TORS. We assessed overall and disease-free survival by the Kaplan-Meier test, and we used videopharyngography and the functional outcome swallowing scale (FOSS) to evaluate swallowing. We used nasometry to estimate hypernasality, and acoustic waveform analysis to evaluate the voice. Thirty-seven patients (95%) had histologically clear margins of resection. Overall survival at 2 years was 96% and disease-free survival 92%. An oral diet was tolerable after a mean of 6 (range 1-18) days. No serious swallowing difficulties were seen on the videopharyngogram. Thirty-six of 38 patients could swallow well (97%) with FOSS scores ranging from 0 to 2 (1 patient had a poor score but was able to take an oral diet after postural training). Voices were maintained close to the normal range on the acoustic waveform analysis. The oncological and functional results of TORS were quite acceptable for the treatment of oropharyngeal cancer. TORS is a valid treatment for selected patients with oropharyngeal cancer., (Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.)

The aim of this study was to evaluate the impact of expression of epidermal growth factor receptor (EGFR), mesenchymal-epithelial transition factor (c-Met), and insulin-like growth factor receptor 1 (IGF-1R) protein on response to treatment and survival in patients with oral and oropharyngeal squamous cell carcinoma (SCC). EGFR, c-Met, and IGF-1R immunohistochemical (IHC) scores were generated based on the incidence and intensity of expression of the biomarkers evaluated in paraffin-embedded sections of biopsy specimens taken before treatment from 113 patients given neoadjuvant chemoradiotherapy followed by resection for primary locally advanced oral and oropharyngeal SCC. Correlations were assessed between the IHC of the biomarkers and the patients' clinicopathological variables using Spearman's rank test. Cox's regression models were used to evaluate the impact of EGFR, c-Met, and IGF-1R, expression on survival. Almost all the patients showed expression of EGFR, c-Met, and IGF-1R (99%, 100%, and 100%, respectively). None of the biomarkers examined predicted response to neoadjuvant chemoradiotherapy or were associated with survival. In multivariate analysis, age (p=0.05), alcohol consumption (p=0.03), and pathological size/extent of the primary tumour after neoadjuvant treatment (ypT) status (p=0.009) were significantly associated with recurrence-free survival. Age (p=0.02) and alcohol consumption (p=0.02) were independently associated with overall survival. Although none of the biomarkers evaluated could be used as prognostic indicators, their common expression suggested a strong rationale for targeting EGFR, c-Met, and IGF-1R in the treatment of oral and oropharyngeal SCC., (Copyright © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Facial disfigurement can be a consequence of treatment for oral or oropharyngeal cancer. Patients' concerns about appearance and the impact this has on quality of life are very important, but are often not recognised in a busy outpatient clinic. We aimed to assess concerns about appearance using the University of Washington Quality of Life questionnaire version 4 (UW-QoL) and the Patient Concerns Inventory (PCI), a self-administered questionnaire that allows patients to choose what they would like to discuss in their consultation. Prospective data were collected from 204 patients who attended routine follow-up clinics from August 2007 to mid-July 2009. Fifty-seven percent were male, 68% had cancer of the oral cavity, 78% had clinical T1-T2 tumours, 19% had node positive tumours, 44% had had radiotherapy since diagnosis, and 48% had had free-flap reconstructive surgery. They all completed the questionnaires using touch-screen computer technology at 454 clinic appointments. Appearance was raised on the inventory at 9% (42/454) of clinics, and at 10% (47/454) it was indicated as a serious problem on the UW-QoL questionnaire. Concerns about appearance were raised on the inventory or were shown to be a serious problem on the UW-QoL in 14% (64/454) of patients. The main factors associated with those who reported concerns about appearance were age (younger patients), sex (female), T stage (III and IV), and site (oropharynx). Patients who choose concerns about appearance for discussion on the UW-QoL questionnaire and not on the PCI risk being missed if only the PCI is completed. Both tools compliment the screening of patients who have problems with facial disfigurement; failure to identify them can have serious clinical and psychosocial implications., (Copyright © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

We aimed to assess bleeding complications after increasing the thromboprophylactic dose of dalteparin from 2500 to 5000 units 12h preoperatively in line with guidance on risk stratification and appropriate pharmacological thromboprophylaxis. We evaluated two groups of patients for confounding factors and bleeding, a prospective consecutive high dose group (n=29), and a retrospective low dose group (n=30) who had had ablative and microvascular reconstructive surgery for oral or oropharyngeal cancer. The bleeding index over 5 days (range 40-60) was used as an objective measure of perioperative bleeding. The null hypothesis was that there was no difference in the bleeding index between the two groups. We found no significant difference in the mean bleeding index between the two groups (p=0.56) (mean (SD) bleeding index in the high dose group 45.3 (26.1), and 48.7 (18.1) in the low dose group). The 95% confidence interval (CI) was -1.51 lower to 0.83 higher in the high dose group. Five patients (2 (7%) in the high dose, and 3 (10%) in the low dose group) were returned to theatre with bleeding complications. There was a trend to a higher failure rate of free flaps in the high dose group (4 (13%) complete, and 1 partial failure compared with 1 (3%) complete and 1 partial failure in the low dose group). There were no symptomatic thromboembolic events in either group. An increased dose of dalteparin did not seem to increase conventional surgical bleeding complications, which was consistent with the null hypothesis at evidence level 2b, but a larger sample is needed to explore its impact on venous thromboembolic events and on the failure of microvascular free flaps., (Copyright © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

There is a lack of consistency among published reports in the definition of what constitutes close resection margins (1-5mm) in the surgical treatment of oral and oropharyngeal squamous cell carcinoma (SCC). Our aim was to define what would constitute close resection margins in predicting local recurrence and disease-specific survival. The study comprised 192 previously untreated patients with oral and oropharyngeal SCC who were recruited at the Southern General Hospital, Glasgow, from 2001 to 2007 with a minimum follow-up of 2 years. Resection was the primary treatment and the surgical margins were recorded for all patients. Statistical analyses were aided by the Statistical Package for the Social Sciences, version 15.0, and MedCalc software. The status of the surgical margins was evaluated using a receiver operating characteristic (ROC) curve to define the cut-off point. Cox's proportional hazard model was used to establish predictive factors for local recurrence and disease-specific survival. Of 192 patients, 23 (12%) had involved margins (<1.0mm), 107 (56%) had close margins (1.0-2.0mm (16.1%); 2.1-3.0mm (12%); 3.1-4.0mm (10.4%); 4.1-5.0mm (17.2%), and 62 (32.3%) had clear margins (>5mm). No predictive cut-off point was found that related close surgical margins to local recurrence. However, there was a significant adverse association between surgical margins ≤1.6mm and disease-specific survival. In recommending postoperative adjuvant treatment for oral and oropharyngeal SCC, we suggest that surgical margins within 2mm should be considered as the cut-off. However, other clinical and pathological prognostic factors should also be taken into consideration when recommending further treatment., (Copyright © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Lugol's iodine is currently under investigation as a technique to detect dysplasia, carcinoma in situ and invasive carcinoma at resection margins, plus further afield. Lugol's iodine is inexpensive and easy to use. We present two cases where the technique revealed abnormal mucosa (one carcinoma, one squamous cell carcinoma in situ) at distant sites from the tumour being treated within oral cavity and oropharynx., (Copyright © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

To assess the reliability of the reverse facial-submental artery island flap for reconstruction of oropharyngeal defects after resection of intermediate stage and advanced carcinomas, we studied 13 patients with stage III and IV squamous cell carcinoma (SCC) of the oropharynx. They had all had their tumours excised followed by reconstruction of the oropharyngeal defect using a facial-submental artery island flap. There was no major failure of a flap, but two minor ones. The marginal mandibular branch of the facial nerve remained intact and undamaged. All donor sites healed well and scars were well-hidden. The functional results of speech and swallowing after 10-28 months' follow-up were satisfactory. One patient developed lung metastases. The facial-submental artery island flap is a simple, reliable flap that can be used for reconstructing oropharyngeal defects after resection of medium and advanced carcinomas of the oropharynx., (Copyright © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

A previous audit conducted in the West of Scotland (WoS) suggested that anatomical factors accounted for a substantial proportion of invaded surgical margins after resection of an oral or oropharyngeal squamous cell carcinoma (SCC). Since then a number of technical improvements have taken place, the most important of which has been advanced digital imaging that has enabled better surgical planning. In this study we compare the incidence of involved surgical margins in a recent group with those found in the earlier audit. The earlier (WoS) group comprised a consecutive series of patient operated on for a primary SCC of the oral cavity or oropharynx between November 1999 and November 2001 (n=296). The later series comprised 178 patients operated on for oral or oropharyngeal SCC at the Southern General Hospital (SGH), Glasgow, between 2006 and 2009. A total of 245 patients in the WoS cohort had information available on the invasion of the margins of whom 68 (28%) had an invaded margin. Of 177 patients in the SGH group, 9 (5%) had an invaded margin (p=0.001). An anatomical approach to the resection of oral and oropharyngeal SCC is appropriate, as it results in a rate of invaded margins of less than 10% irrespective of size and site of the primary lesion., (Copyright © 2010. Published by Elsevier Ltd.)

Trismus is a serious problem for some patients after oral and oropharyngeal cancer, and it has a detrimental impact on quality of life and function. We know of few published papers that include preoperative assessment in reports on the longitudinal outcomes of mouth opening after oral and oropharyngeal surgery. We prospectively measured mouth opening in patients who had primary surgery for oral and oropharyngeal cancer from baseline to six months to find out the characteristics at baseline and at discharge of those who develop trismus at six months. Ninety-eight patients were eligible between February 2007 and March 2008, and 64 (65%) were recruited into the study. The range of mouth opening was measured on three occasions: before operation, on the ward before discharge from hospital, and at follow-up six months after operation. Using a criterion of 35 mm or less as an indication of trismus, 30% (19/63) had trismus before operation, 65% (37/57) at hospital discharge, and 54% (26/48) at six month follow-up. Patients at high risk of trismus were those with T stage 3 or 4 cancers who required free flap reconstruction and adjuvant radiotherapy; radiotherapy was the most significant factor at six months. Trismus at discharge was a prediction of trismus at six months. Interventions such as spatulas or a passive jaw mobiliser should be targeted at patients at high risk early in the postoperative phase. The efficacy of such interventions needs further research., (Copyright © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

We prospectively studied patients from the west of Scotland who presented with a primary cancer of the oral cavity or oropharynx over a period of 24 months from November 1999, and report long-term outcomes and prognostic factors. A total of 481 patients had squamous cell carcinoma (SCC), 5-year disease-specific survival (DSS) was 50%, and overall survival (OS) was 35%. One hundred were not suitable for treatment with curative intent, and factors other than stage were important in this decision. Of those treated with curative intent, 249 had SCC of the oral cavity (5-year DSS 67%; OS 42%), and 132 had SCC of the oropharynx (5-year DSS 62%; OS 42%). Multivariate analysis showed that pathological nodal stage (p=0.051, 95% CI 0.998-1.955), and perineural invasion (p=0.001, 95% CI 0.186-0.666) were prognostic indicators. Improved results using intensive treatment protocols that have been seen in trials are not likely to translate directly into a general population of patients with head and neck cancer. Algorithms that allow several pathological prognostic indicators to be incorporated into decisions about adjuvant treatment should be used., (Copyright © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

We evaluated the use of Lugol's iodine in achieving surgical margins free from dysplasia, carcinoma in situ, and invasive carcinoma by an observational study of two series of 50 consecutive patients having resection of oral and oropharyngeal squamous cell carcinoma (SCC) between November 2004 and March 2007. The standard group had resection of the primary tumour with a macroscopic 1cm margin and removal of adjacent visibly abnormal mucosa. The Lugol's iodine group had identical treatment with resection of any adjacent mucosa that did not stain after the application of Lugol's iodine (where this was feasible). In the standard group 16 patients (32%) had dysplasia, carcinoma in situ, or invasive SCC at a surgical margin. In the Lugol's iodine group two patients (4%) had dysplasia or carcinoma in situ; none had invasive SCC. Lugol's iodine is a simple, inexpensive, and apparently effective means of reducing the likelihood of unsatisfactory surgical margins in the resection of oral and oropharyngeal SCC.

This study aimed to identify all Staphylococcus aureus (MRSA) cases on a Regional Maxillofacial ward, to estimate incidence and to ascertain who were most at risk. The study also explored clinical and demographic factors associated with MRSA in a subset of consecutive patients managed by primary surgery for previously untreated oral and oropharyngeal squamous cell carcinoma (OOSCC) over the same time period. Patients admitted from 1st April 2001 to 31st March 2006 to the Regional Maxillofacial Unit ward, Liverpool were identified by a retrospective review of the hospital MRSA database and there were 10109 patient admissions. MRSA (1.1%) occurred in 115 patient episodes involving 97 patients. There were 84 patients having a single episode and 13 more than one. There were no cases of mortality due to MRSA. Of the MFU patients 73 were oncology and 7 trauma. In the oncology group the commonest primary sites were wound (41) and sputum (11). Of new patients admitted for definitive treatment for OOSCC, 14% had MRSA and the two main risk factors were stage of cancer (P<0.001) and free flap (P<0.001). The risk of MRSA infection on our maxillofacial ward is low though MRSA infection is more prevalent among oncology patients particularly those requiring free tissue transfer. Careful adherence to infection prevention and control precautions is essential and practical methods to reduce MRSA need further evaluation.

We reviewed 68 cases of oral and oropharyngeal cancer that were managed without the routine use of intensive care units (ICU), to establish success rates for flaps, complications including nosocomial infections, cancellations, and length of stay. More than 98% of flaps survived and over half the patients had no complications. Low rates of perioperative infection were recorded with a median length of stay of 12 days (range 2-63), and there were no cancellations. We conclude that the routine use of a specialist head and neck ward is more appropriate than ICU for selected cases; it fulfils current guidelines for cancer services, and is an effective use of resources.

The aim of this study was to assess the timing of outpatient review appointments in relation to tumour recurrence. A retrospective review of 278 consecutive previously untreated patients with oral and oropharyngeal squamous cell carcinoma (SCC) between 1995 and 1999 was performed. Information on the time of recurrence, site, presentation, treatment and outcome was collected. There were 54 (19%) patients who developed recurrent disease. Recurrence occurred at a median time of 8 months after the initial operation and most (49/54) within 2 years. Thirty-five patients (65%) presented with a new lump (7 local, 22 regional and 5 locoregional). Our policy is to review patients once a month for the first year and every other month for the second year. Patients were seen less frequently than expected, and one in five patients attended half or less than half as frequently as intended in the first year. Although 20 patients were aware of new symptoms from their recurrent disease fewer than half (9) brought their appointment forward. This study has emphasised the need for close clinical follow-up of patients previously treated for oral/oropharyngeal SCC if recurrent tumours are to be discovered and treated at the earliest opportunity.

Disfigurement after operations for oral and oropharyngeal cancer is an important issue. Our aim was to review the casenotes of patients who reported distress in the appearance domain of the University of Washington Quality of Life Scale (UWQOL) and to find out what help they were given. Of 278 patients with previously untreated oral and oropharyngeal squamous cell carcinoma treated between 1995 and 1999, 114 (41%) were concerned about their appearance. Factors that correlated with these concerns included tumours more than 2cm in size, T2 or worse stage, free tissue reconstruction, segmental mandibular resection, and neck dissection. In only 7 of the 114 was there any mention of the patient's appearance in the clinic notes, of whom 4 were given help (2 scar revisions and 2 oral rehabilitations). This study suggests that patients' concerns about disfigurement are poorly recognised in routine clinical practice and supports the principle of using the UWQOL scale to discuss problems of appearance with patients.

The general surgeon, Wilfred Trotter (1872-1939), earned a reputation for his advances in head and neck surgery and his important contribution to the founding concepts of bio-sociology. He pioneered an operation for resection of tumours of the oropharynx, which he published in 1920. He also recognised the importance of total excision of tumours regardless of anatomical boundaries. At a time when antibiotics were not available, Trotter advocated extraction of all teeth before operations and relied on elective tracheostomy to secure the airway and to reduce infection, of both the lungs and tissues of the neck. He persevered with surgery at a time when the introduction of radiotherapy was completely altering the management of head and neck cancers. Unfortunately he did not publish his results, but nevertheless, made an important contribution to the subject of pharyngeal cancer.

Aims: To define the reproducibility of the position of omohyoid muscle., Setting: A regional Maxillofacial surgical oncological service., Material and Patients: Thirty dissections of cadavers and consecutive series of 88 patients who had had neck dissections, either prophylactic or therapeutic, as part of their oncological management., Method: Measurement of the upper border of omohyoid muscle relative to the clavicle and the internal jugular vein (mm)., Results: The position of omohyoid muscle in relation to the clavicle and internal jugular vein varied considerably and by inference the nodal yield at level IV is also likely to vary., Conclusion: The wide variability of the position of omohyoid muscle is likely to have implications for the surgical management of oral and oropharyngeal cancer.

The purpose of this study was to investigate the use of oral rehabilitation in a group of patients who had primary resection of oral and oropharyngeal squamous cell carcinoma. Of 132 consecutive patients operated on for previously untreated disease between January 1995 and June 1997, 130 were recruited. The University of Washington Quality of Life questionnaire was completed on the day before operation at 6 and 12 months, and at last review. A larger similar dataset was used to predict survival. Twenty-eight patients (22%) were seen by the oral rehabilitation team. The median (IQR) time from operation to start of treatment was 12 months (6-21). The median (IQR) time from beginning to end of rehabilitation was 14 months (5-49). Patients with larger tumours (P=0.06) and patients who were edentulous with dentures in the maxilla (P=0.07) were most likely to be seen for oral rehabilitation.

Background: The clearance of surgical margins at the primary site is widely thought to influence the subsequent course of the disease in patients operated on for oral and oropharyngeal carcinoma. In some reports the adverse impact of close or involved margins was not negated by postoperative radiotherapy. These findings, in addition to descriptive histopathological studies, have led some authors to recommend margins of more than a macroscopic clearance of 1cm at certain subsites. We have therefore examined the relation between the condition of surgical margins and local recurrence and disease-specific survival., Methods: Identical treatment protocols were used to treat two independent groups of patients (Sydney, Australia, n=237; Lanarkshire, n=95) who presented with previously untreated carcinoma of the mouth or oropharynx. All patients were operated on with the primary objective of achieving a macroscopic clearance of 1cm. Postoperative radiotherapy was used according to a protocol. Data about patients were entered into comprehensive computerised databases prospectively. Known clinical and pathological prognostic indicators, in addition to the condition of surgical margins, were analysed to find out if they were predictive of local recurrence and disease-specific survival using the Cox proportional hazard model., Results: Local recurrence was predicted by the presence of perineural invasion at the primary site in both groups. Disease-specific survival was predicted by the presence and extent of regional lymph node metastases in both groups. The condition of surgical margins (clear, close, or involved) did not predict local recurrence, or disease-specific survival on multivariate analysis., Conclusions: A macroscopic margin of 1cm seems adequate in the surgical management of oral and oropharyngeal carcinoma. For most patients who have close or involved margins the biology of the disease influences the subsequent course irrespective of the width of clearance of tumour.

We undertook a retrospective study of the outcome of radial forearm, gastro-omental, and jejunal free tissue transfer for oral and oropharyngeal reconstruction in 30 patients (10 in each group). No significant differences were found between the type of free flap and the clinical outcome. More long-term difficulties were experienced with swallowing than with speech. The selection of free flap did not correlate with speech function (P=0.44), swallowing (P=0.68), or management of saliva (P=0.59). No significant difference was found between the patients' outcome and the site of resection of the tumour. There were more complications after gastro-omental flaps and this may influence the choice of reconstruction.

The aim of this study was to record clinical function using an 11-item clinical examination and identify the main postoperative functional deficits. Of 132 consecutive patients undergoing surgery for previously untreated disease between January 1995 and June 1997, 130 were recruited in the study. An 11-domain clinical examination was made on the day before operation, and at 6 and 12 months afterwards. This examination assessed lip competence, tongue movement, oral mucosa, dental state, mouth opening, speech, drooling, diet, appearance, oral sensation and shoulder movement. Preoperatively there were deficits in natural dentition, consistency of diet and tongue protrusion. Postoperatively functional scores fell particularly for tongue movements, mouth opening, mucosa, dentition, speech, diet, appearance, lip sensation and tongue sensation. At 1 year, dental status, sensation and oral mucosa were particularly defective. Patients with large tumours, free tissue transfer, or adjuvant radiotherapy had the worst levels of function.A simple clinical examination provides a rapid assessment of function that can be used in conjunction with validated questionnaires to provide a more comprehensive evaluation of outcome., (Copyright 2002 The British Association of Oral and Maxillofacial Surgeons.)

Free gastro-omental flaps can be used to reconstruct defects in the oral cavity after ablative cancer surgery. The omentum can provide as much bulk as required. The generous gastro-omental pedicle allows mobility. The gastric mucosal lining has the advantage that it produces mucus, does not carry hair follicles and is not prone to troublesome desquamation. This paper reviews the surgical anatomy of free gastro-omental flaps and presents a series of eight cases in which these flaps were used for oral and oropharyngeal reconstruction., (Copyright 2002 The British Association of Oral and Maxillofacial Surgeons.)

The aim of this study was to report the cause and place of death of patients with oral cancer as recorded by death certification and their survival with regard to comorbidity and age. From the departmental head and neck oncology database, 322 patients were identified with previously untreated oral and oropharyngeal squamous cell carcinoma diagnosed between 1992 and 1997 inclusive. Three-hundred were matched with the Office for National Statistics (ONS) and copies of death certificates generated on 6 March 1999. Of the 286 patients primarily treated by operation, 203 were alive and 83 had died. In 56 (68%), oral cancer was a contributory factor to the patient's death. Patients with a medical history recorded on their admission for operation had similar survival curves compared to those having no problems recorded. Although most patients (n= 46 55%) died in hospital, only 13 (16%) died in the Regional Maxillofacial Unit. Almost half of those patients who died were not recorded as dead on the departmental oncology database. This study shows that it is useful to link with the ONS to obtain accurate data on date and place of death. The death certificate also gives a useful indication of the cause of death and this seems unrelated to preoperative comorbidity.

The resection of even relatively small tumours that involve the base of tongue can lead to problems with swallowing. Free tissue transfer has improved the functional results and reduced the complications of head and neck surgery. The outcome after ablative operations depends on the site and extent of the resection, and in cases where the tongue base is involved, swallowing can be severely impaired. Aspiration in a patient with swallowing difficulties is of particular concern, however, there is a range of techniques that can be introduced during videofluoroscopy to reduce or eliminate aspiration. It is during the rehabilitation phase that procedures and techniques to improve swallowing and prevent aspiration should be incorporated. The efficacy of adaptive manoeuvres needs further evaluation, and in this study we aim to assess the effectiveness of compensatory procedures and therapy techniques (chin tuck and supraglottic swallow) in eliminating aspiration. We report on a study of the swallow function of 13 patients following surgical resection of the oropharynx including the base of tongue. Postoperative assessment by videofluoroscopy was carried out at 2 weeks, 1 month, 3 months, and 6 months according to a standard protocol. Subjects were analysed in two groups depending on the degree of resection of the tongue base resection (less than 1/4,1/4 or more).Patients' swallowing disorders were related to the extent of the resection and the consistency of the bolus. Those with involvement of a quarter of the tongue base or more generally had greater impairment, and radiotherapy tended to exacerbate these problems. Compensatory procedures and therapy techniques were effective in 50% of patients who aspirated, and tended to be more effective between the one month and 6 month follow-up in patients with smaller resections., (Copyright 2000 The British Association of Oral and Maxillofacial Surgeons.)

The incidence, extent and distribution of nodal metastasis is described in 152 neck dissections from patients with an NO neck undergoing surgery for an intraoral/oropharyngeal squamous cell carcinoma. The preoperative N stage had been determined by palpation under general anaesthesia and magnetic resonance imaging. Metastasis was detected histologically in 32 (21%) of the 152 NO necks. The number of positive nodes per NO neck ranged from 1 to 6. In total, 52 positive nodes were found and 29 (56%) measured 10 mm or less in maximum dimension. Twenty-one dissections (66%) contained a single positive node and 24 (75%) showed a single positive anatomical level. Three cases showed 'skipping' of levels within the neck and one case showed 'peppering'. Seventeen (53%) of the 32 positive NO necks and 31 (60%) of the 52 positive nodes contained only 'micrometastases' (deposits < 3 mm). Microscopic extracapsular spread was evident in five NO necks including one case with extracapsular spread at multiple levels. The study concludes that preoperative staging by palpation and routine magnetic resonance imaging cannot be relied upon to detect early cervical metastatic disease, and the topographic distribution of positive nodes indicates that modified neck dissections should include level IV when the primary tumour involves the tongue.

The prognostic importance of accurate pathological staging of oral cancer patients with established lymph node metastases is well known. The present study sought to determine the incidence and clinical significance of minimal neck disease (only micrometastases) and to evaluate clinical features of the primary tumour in relation to the pathological metastatic status. Surgical resection specimens from 178 patients with oral/oropharyngeal squamous cell carcinoma were assessed by routine techniques. Micrometastases were defined as intranodal deposits measuring in total no more than 3 mm at any level of sectioning. Fourteen patients (8%) had only micrometastases and 72 (40%) had established nodal metastases. Patients with only micrometastases were younger than those with established metastases, but there were no differences in T site, T stage or sex. The outcome (2-6 years postsurgery) of patients with only micrometastases was similar to those without cervical node metastases. Hence, the main short-term significance of micrometastases seems to be in relation to clinical staging and elective management of the NO neck.

We report a retrospective study of 64 patients with primary squamous cell carcinoma of the oropharynx. The tumours were classified by the UICC (Union Internationale Contre le Cancer) system and a New Tumour Staging (NTS) system. Results showed a crude survival of 29% at 5 years. The most important prognostic factor for survival rate was the tumour (T) stage in both classifications. NTS recommendations that consider the number of sites and subsites involved yield a better correlation between survival and T stage. NTS also discriminates better between the T stages than the UICC criteria.

Free jejunal transfers have been used for intra-oral reconstruction after extensive oral carcinoma resection in Münster since 1983. Reconstruction has been carried out for tumours at different locations within the oral cavity and oro-pharynx. The indications are presented for this procedure and a description is given of the surgical technique. The follow-up experience of 27 patients over a period of 6 years is discussed with particular reference to problems encountered.

Patients with intraoral cancer present to various specialties. A series of 63 patients shows the importance of modern reconstructive surgery for patients treated by tumor excision. The reasons why a variety of techniques must be available to the patient are discussed. The advantages and disadvantages of some of these methods of reconstruction are reviewed.