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Introduction: Mandibular reconstruction continues to challenge most head and neck reconstructive surgeons despite the tremendous advances in surgical and fixation techniques. We recently described the clavipectoral osteocutaneous flap for mandibular reconstruction. This flap encompasses the clavicle and the clavicular head of the pectoralis major with overlying skin., Objectives: The purpose of this article is to report our prospective clinical experience with the use of clavipectoral osteocutaneous flap in the reconstruction of oromandibular defects., Study Design: Prospective case series., Methods: Five patients with significant mandibular defects underwent reconstruction using the newly described clavipectoral flap. All patients had shoulder range of motion testing preoperatively and at 3 and 6 months postoperatively. Panorex and bone scans were obtained on the seventh postoperative day., Results: All five flaps survived. The transferred clavicles demonstrated good vascularity on the postoperative bone scans. The shoulder morbidity was minimal, with all patients resuming their preoperative level of activity., Conclusions: The clavipectoral flap has bone and soft tissue components that are especially suited for composite mandibular defects, but it should be used as a second-line flap owing to the short pedicle and the regular need for vein grafts.

Purpose: This study was designed to evaluate the effect of tracheostomy site suturing after decannulation on swallowing rehabilitation, the incidence of postoperative complications, the length of hospital stay, and overall cost saving in patients undergoing major head and neck cancer resections., Design: Prospective, randomized, blinded, controlled clinical trial., Methods: Seventy-five patients undergoing major head and neck cancer resections were block randomized to have their tracheostomy site sutured or not sutured at the time of decannulation. Two blinded speech-language pathologists conducted bedside swallowing assessments immediately after decannulation. Patients resumed oral feedings if they passed; otherwise, the assessment was repeated daily until they were able to resume oral feedings or required a G-tube., Outcome Measures: We monitored (1) time intervals during the admission from surgery to discharge, (2) the rate of aspiration, (3) complications, and (4) cost savings., Results: Significant differences were seen in the mean time from decannulation and commencement of swallowing (suture arm, 0.58 days; nonsuture arm, 2.7 days; p = .013). There was also a significant difference seen for the time interval from decannulation to discharge from hospital (suture arm, 5.5 days; nonsuture arm, 8.3 days; p = .045) and for overall duration of hospital stay (suture arm, 14.6 days; nonsuture arm, 19.3 days; p = .025). The cost saving per patient in the suture group averaged $11 609, which translates to a yearly saving of 742 976 dollars., Conclusion: The suturing of the tracheostomy site in head and neck cancer patients after decannulation is a safe, effective, cost-saving manoeuvre that speeds the return of the patient's normal swallowing, promoting earlier discharge from the hospital.

Hypothesis: We hypothesized that the use of reovirus as an intraoperative adjunct would improve local control of positive margins in a human squamous cell carcinoma nude mouse model., Purpose: This study was designed to (1) develop a nude mouse human squamous cell carcinoma positive margin model and (2) assess the effect of adjunct intraoperative treatment with reovirus irrigation and injection on local control of resections with positive margins., Materials and Methods: We developed a positive margin nude mouse model using the University of Michigan SCC-22B cell line. Established tumours in 39 mice were resected, leaving behind a 1 mm positive margin. The mice were then divided into five treatment groups: (1) no treatment was provided, (2) ultraviolet (UV)-inactivated reovirus was irrigated into the wound bed, (3) UV-inactivated reovirus was injected into the positive margin intratumorally and peritumorally, (4) reovirus was injected into the positive margin intratumorally and peritumorally, and (5) reovirus was irrigated into the wound bed. The mice were followed for 28 weeks and sacrificed., Results: The results of the irrigations showed that tumours recurred in all (100%) of the control groups (no treatment and UV-inactivated virus). The mice irrigated with active reovirus solution had recurrence in 3 of the 14 sites (21%). These findings were statistically significant, with p > .001. The results of the injection showed that tumours recurred in all (100%) of the control groups (no treatment and UV-inactivated virus). The mice injected with reovirus solution had recurrence in 6 of the 16 sites (38%). These findings were statistically significant, with p > .007., Conclusions: Reovirus adjunctive treatment is a novel, safe, and effective method of improving local control in the positive margin human squamous cell carcinoma mouse model.

Background: Tisseel (Baxter Corp. Ontario, Canada) is a fibrin-based tissue glue that has been widely used to reduce wound drainage, achieve hemostasis, and decrease surgical complications. To date, Tisseel has not been evaluated in a randomized prospective trial for use in parotid surgery., Objectives: To determine whether the use of Tisseel in parotidectomy decreases postoperative wound drainage, the duration of percutaneous drainage, the length of hospital stay, and the frequency of complications., Methods: Sixty consecutive parotidectomy patients were randomized into two groups: a group treated with 2 cc of Tisseel prior to wound closure and a control group. Postoperative wound drainage was measured for all patients by blinded hospital staff. The duration of percutaneous drainage, duration of hospital stay, and incidence of complications at the 3-week follow-up were assessed., Results: A statistically significant difference in total drainage volume (p < .02) and frequency of postoperative seroma (p < .05) was demonstrated between patients treated with Tisseel prior to wound closure and the control group., Conclusion: The use of Tisseel in parotidectomy patients prior to wound closure significantly decreases total drainage volume and the frequency of postoperative seroma.

Objective: This randomized, blinded, controlled study examines the effects of fibrin sealant (Tisseel, Laboratoire de production Baxter AG, Vienna, Austria) on wound drainage following thyroidectomy., Methods: Fifty-six consecutive patients were enrolled in the study. Patients were randomized into Tisseel and non-Tisseel treatment groups. Wound drain output was tallied in 8-hour increments by observers blinded to the treatment groups., Results: Fifty-six patients completed the study. Significant decreases in wound drainage were found in the first 8 hours in the Tisseel group. Eight hours postoperatively, wound output in the Tisseel group was reduced by 44% compared with the non-Tisseel group. A significant decrease in the total drainage over the 64-hour time period of 43% was noted between the treatment and control groups. Post-thyroidectomy wound drainage was reduced and trended to earlier drain removal. No significant changes in the length of hospital stay were noted, nor were postoperative complications encountered in either treatment group., Conclusions: Fibrin sealants offer a unique opportunity to safely decrease post-thyroidectomy wound drainage. This investigation furthers the evidence that fibrin sealants could safely enable the implementation of drain-free thyroidectomies.

Purpose: To assess the susceptibility of human squamous cell carcinoma to reovirus infection in vitro and in vivo using a murine model of cancer-contaminated wounds., Methods: The University of Michigan squamous carcinoma 22B cell line was cultured and inoculated with reovirus in vitro. The effect of the reovirus was assessed with microscopy and a standard 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H tetrazolium bromide (MTT) assay. We used the previously established cancer-contaminated wound SCID mouse model to test saline and reovirus irrigation in vivo. Fifty-five mice were used; 15 were controls, 20 had immediate irrigation, and 20 had delayed irrigation. Surgical sites were assessed for palpable tumour biweekly., Results: The microscopy and MTT assay both showed evidence of reovirus-mediated squamous cancer cell lysis. The control mice grew palpable tumours in 80% of the wounds. Immediate irrigation with saline delayed the onset of palpable tumour and demonstrated a persistent reduction in the rate of development of palpable tumours (p = .004 compared with controls). This effect disappeared when the saline irrigation was delayed, resulting in a tumour development rate that was not significantly different from that of the control. Wounds that were irrigated with reovirus, both immediately and delayed, did not produce palpable tumour (p < .0005 when compared with controls)., Conclusions: (1) The University of Michigan squamous cell carcinoma 22B cell line is susceptible to reovirus in vitro. (2) Immediate irrigation with saline resulted in a significant delay in clinically evident tumour growth and a reduction in the rate of tumour development in the SCID mouse model. (3) The reovirus irrigation resulted in a significant reduction of tumour development in both the immediate and delayed groups in the SCID mouse model. (4) The efficacy of the reovirus irrigation in the delayed group suggests that the major mechanism of action is through a selective and specific targeting of implanted cancer cells.

Objective: This study examined prospectively the functional outcomes of a cohort of patients who have undergone mandibulectomy and primary fibular free flap reconstruction, with particular emphasis on longitudinal comparison of the preoperative function with that in the postoperative and post-radiation therapy time periods., Methods: Speech and swallowing data were gathered at three evaluation times (preoperatively, pre-radiation therapy, and post-radiation therapy) for patients treated for oral cavity cancer with mandibular resection and reconstruction with a fibular free flap. Single words and sentences were recorded and analyzed for speech intelligibility. Modified barium swallows of liquid, pudding, and cookie consistencies were analyzed and graded for problems in the oral preparatory and oral phase according to the University of Chicago Center for Speech and Swallowing Disorders Oropharyngeal Mobility Data Form., Results: There was no significant difference across any of the evaluation times for single-word or sentence intelligibility. The swallowing data showed no instances of post-treatment aspiration or laryngeal penetration. There were also no significant differences in any of the swallowing parameters across treatment times., Conclusions: Osteocutaneous fibular free flaps are an excellent reconstructive option for mandibular and floor of the mouth defects.

Objective: This study examines prospectively the functional outcomes of a cohort of patients who had undergone hemiglossectomy and reconstruction with a bilobed radial forearm free flap (RFFF) for oral tongue squamous cell carcinoma., Methods: Speech and swallowing data were compiled for patients treated for oral tongue cancer with hemiglossectomy and and reconstruction with a bilobed RFFF. The three evaluation periods were preoperative, postoperatively, and postradiation therapy., Results: Eleven patients were included in the study. A significant difference between preoperative and postoperative single-word intelligibility scores was observed. There was no significant difference across any of the evaluation times for sentence intelligibility. Swallowing analysis revealed fewer instances of laryngeal penetration with liquids postoperatively. No significant differences were found in laryngeal penetration with either the pudding or cookie consistencies across any of the evaluation times. There was no incidence of aspiration at any of the evaluation times. There were no significant differences in the number of problems with the oral or oral preparatory phases across any of the evaluation times. The neurotization status of the RFFF had no significant effect on any of the observed speech or swallowing parameters., Conclusions: The bilobed RFFF provides functional speech and excellent swallowing outcomes in the reconstruction of hemiglossectomy defects.

Objective: This prospective randomized trial was designed to compare intranasal endoscopic sphenopalatine artery ligation (ESAL) with conventional nasal packing in the treatment of recurrent epistaxis., Methods: Patients were registered in the study databank following referral for epistaxis control to the otolaryngology service at the University of Alberta. All patients were initially packed using Merocel (Xomed Surgical Products, Jacksonville, FL) nasal dressings bilaterally. Patients were enrolled in the study following failure of Merocel packings. Informed consent was obtained in accordance with the Health Research Ethics Board. The patients were then managed with Vaseline nasal packs or ESAL. Patient demographics, treatment characteristics, number of hospitalization days, and rates of recurrence were recorded prospectively. The total cost of treatment for each patient was calculated., Results: Nineteen patients were enrolled in the study. There was a significant reduction in cost and length of hospitalization of the patients undergoing ESAL compared with the conventional nasal packings. ESAL was also 89% effective in controlling the bleeding and had minimal sequelae or complications. The overall calculated cost of patients undergoing ESAL was dollars 5133 compared with dollars 12213 in the conservative group, resulting in an average saving of dollars 7080 per patient. There was overwhelming patient satisfaction with ESAL compared with nasal packings., Conclusion: ESAL is an excellent, well-tolerated, and cost-effective method of treating recurrent epistaxis.

Introduction: Laryngeal cancer treatment has become more complex and diversified in past decades. Many different methods of treatment have evolved, and most have been able to restore the patient's function and maintain some form of functional speech. This study was designed to evaluate the voice and speech characteristics of patients who have undergone different treatments for laryngeal cancer and to compare those characteristics with those of age- and sex-matched normal laryngeal speakers., Methods: Twenty-two male subjects participated in the study. Five men were treated with radiation therapy, 6 men had supracricoid partial laryngectomy, 6 men had undergone total laryngectomy with tracheoesophageal puncture, and 5 men were normal laryngeal speakers. Acoustic, aeromechanical, and perceptual assessments of speech were collected., Results: Significant age effects were found for maximum phonation times. As age increased, maximum phonation time decreased (p < .005). Significant differences were found between groups for the following dependent variables: percentage of voiceless phonation, maximum phonation time, laryngeal airway resistance, subglottal pressure, oral flow, and word intelligibility. Trends in the data for differences between groups were noted for the following acoustic variables: noise-to-harmonics ratio, jitter, and shimmer., Conclusions: All patients developed or maintained a source of voicing after treatment and could use speech functionally, as demonstrated by normal sentence intelligibility. The radiation treatment group had voices that differed the least from the control group, whereas the opposite was true for the surgical groups, especially for those with total laryngectomy.

Objective: The main advantage of primary oromandibular reconstruction using free vascularized bone-containing flaps is improved oral function from (1) the maintenance of mandibular and soft tissue architecture and (2) dental rehabilitation through osseointegrated implants. Bone dimensions, volume, quality, and the ability of the bone to withstand masticatory forces are important factors in achieving successful osseointegration. Previous studies have objectively examined the dimensions of bones used in oromandibular reconstruction, but few have addressed their biomechanical properties. The purpose of this study was to compare the dimensional and biomechanical properties of the bones commonly used in oromandibular reconstruction with those of the mandible., Methods: Eleven formalin-fixed cadavers were used. The mandibles, fibulae, iliac crests, scapulae, clavicles, second metatarsals, radii, and anterior ribs were harvested. Measurements of the dimensions of the bones were made with calipers at multiple sites. Three-point break strength and screw pulling force tests were then performed on all of the bones., Results: The fibulae, iliac crests, and clavicles had dimensions that best matched those of the mandible. The three-point break strength and screw pulling force tests were consistently the highest for the mandibles and fibulae, followed by the clavicles, scapulae, iliac crests, metatarsals, radii, and ribs, in that order., Conclusions: The fibula is the bone that best matches the properties of the mandible.

Introduction: Frontal sinus obliteration continues to be the gold standard for frontal disease control and is often employed as a last resort of treatment after more conservative therapies fail. Different methods of sinus mapping have been previously reported and include (1) 6-foot Caldwell radiography, (2) sinus probing, and (3) sinus transillumination. Image-guided technology was recently introduced to clinical practice, but its utility in frontal sinus mapping has not been evaluated., Objective: To assess the accuracy and safety of the previously reported methods of frontal sinus mapping and compare them with image-guided mapping., Study Design: Five cadaveric heads were used. The four mapping methods were applied to each head along five different axes of the frontal bone: 0, 45, 90, 135, and 180 degrees. The true frontal sinus margin was ascertained. Measurements were made from the true sinus limits to the margin points estimated by the four frontal sinus mapping methods., Results: The image-guided mapping method provided was the most accurate when compared with the other mapping methods (p < .01). The image-guided mapping method was also the least likely to overshoot the real margin compared with the other mapping methods (p < .001). The template method was the least accurate and least safe method., Conclusions: Image-guided mapping is the most accurate and safest method of mapping the frontal sinus margins.

Microvascular free tissue transfer has become an integral component of head and neck reconstructive surgery and historically has a greater than 95% success rate. Hematomas have long been known to cause skin flap necrosis by a variety of mechanisms including direct pressure necrosis, cellular damage secondary to the effects of free radicals, and inflammation. Compression from a hematoma is known to cause free flap compromise. To our knowledge, however, there have been no studies documenting the effect of a noncompressive hematoma surrounding the vascular pedicle on free flap viabiliry. This animal study was designed to assess the effects of a noncompressive hematoma on free flap survival. A right groin cutaneous free flap was created in 32 male Spraque Dawley rats. The rats were then divided into three groups: (1) 10 rats had no fluid added to the anastomotic compartment; (2) 11 rats had 0.5 cc of blood, taken from the femoral artery at the time it was cut, instilled in the anastomotic compartment via the 18-gauge angiocath; and (3) 11 rats had 0.5 cc of pentastarch instilled in the anastomotic compartment via the 18-gauge angiocath. There was 100% free flap survival in all three groups. All vessels examined at the time of sacrifice revealed intact anastomoses and no evidence of luminal clots. This study strongly suggests that in the cutaneous groin free flap model, a perianastomotic noncompressive hematoma has no effect on free flap survival.

Xerostomia is the most common negative sequela after radiotherapy for head and neck cancer and results from destruction of normal salivary gland tissue by radiation. We hypothesized that transferring a single submandibular gland outside the radiation field to the submental region may preserve its function, thus preventing xerostomia and its consequences. This anatomic study was designed to evaluate different methods of submandibular gland transfer to the submental region. Eight submandibular glands were dissected in four fresh human cadavers. The anatomy and blood supply of the region were documented. Each gland was transferred to the submental region by either free microvascular transfer or based on retrograde flow through the distal facial vessels. Both methods of transfer resulted in complete relocation of the submandibular gland into the submental region.

Interposition grafts are an important and invaluable technique in free microvascular tissue transfer as they extend the vascular pedicle to allow it to reach undisturbed donor vessels away from the surgical or traumatic site. Autologous vein has been the most commonly used material for interposition grafting, but it has significant disadvantages. Nonautologous grafts are readily available and could certainly remedy most of the autologous graft disadvantages. This study was designed to (1) evaluate the patency of expanded polytetrafluoroethylene (PTFE) grafts in a simple microvascular vessel repair and (2) evaluate the survival of microvascular free flaps using PTFE arterial interposition grafts. The inferior epigastric vein or PTFE was used to reconstruct the femoral artery in 10 animals (20 sides) in a simple vessel repair model and in 20 animals in a groin free flap model. All epigastric vein grafts were patent at 1 week in the vessel repair group. Only five in the PTFE vessel repairs were patent. Nine of 10 free flaps were viable in the free flap group with epigastric vein interposition. All of the 10 free flaps with PTFE interposition failed. There was a statistically significant difference in vessel patency between PTFE grafts in the vessel repair and free flap models. Our data show that PTFE microvascular grafts are a poor substitute for vein grafts in the vessel repair and free flap animal models. We also found that simple vessel repair is not an acceptable model to study manipulations intended for free tissue transfer.

Introduction: Historically, squamous cells exfoliated from head and neck carcinoma resection have been implicated in locoregional recurrence, but there have been few studies demonstrating the presence of these cells. This study was designed to evaluate the presence of exfoliated malignant cells in surgical irrigation fluid collected during head and neck cancer resection., Methods: Thirty patients undergoing surgery for biopsy-proven squamous cell carcinoma had their surgical sites irrigated with 1,000 cc of normal saline. Surgical gloves and instruments were also washed. These samples were prepared and stained using standard squamous cell cytologic stains. All cases were reviewed by one cytopathologist., Results: Eighteen patients (60%) had positive or suspicious cytology detected in at least one of the surgical samples. In patients with T0 and T1 tumours, all surgical samples were negative. Positive or suspicious cytology was detected in the primary site and glove and instrument irrigation in 40% of patients with T2 tumours, 42% of patients with T3 tumours, and 50% of patients with T4 tumours. This was statistically significant (p < .05). Positive or suspicious cytology was detected in the neck and glove and instrument irrigation in 29% of patients with an N0 neck, 31% of patients with an N1 neck, 39% of patients with an N2 neck, and 100% of patients with an N3 neck. Five of seven patients (71%) with previous radiation therapy had positive or suspicious cytology in at least one of the surgical samples., Conclusions: Higher tumour and nodal staging and a previous history of radiation therapy are associated with an increased incidence of positive or suspicious cytology in surgical irrigation fluid. These findings have implications for surgical protocols.

Interposition vein grafting is an important technique in microvascular free tissue transfer. Studies in rats have demonstrated that the patency rate of vessels is not affected by interposition grafting when the vein grafts and receipt vessels are of similar diameter. Size discrepancy between vein grafts and recipient vessels is frequently encountered in clinical practice and may potentially be an important factor in anastomotic patency. This study was, therefore, designed to assess the effect of vein graft diameter on the patency of arterial repair and survival of a groin free flap in the rat model. Forty-nine Sprague-Dawley rats were used. The inferior epigastric and femoral veins were used to reconstruct the femoral artery in situ (12 rats, 24 anastomoses) and in groin free flaps (30 rats). The vessel patency with inferior epigastric (1:1 size match) and femoral (2:1 size match) veins was 100% in the non free flap model. In the free flap model, flap survival was 30% in the femoral (2:1 size match) vein graft group. This was significantly less than both the free flap epigastric vein graft group (90% survival) and primary anastomoses group (100% survival). The results of this study suggest that size-matched interposition vein grafts can provide a high degree of reliability, but with size mismatch vein grafts are prone to thrombus formation and subsequent free flap failure.

Infantile subglottic hemangiomas are rare congenital lesions of the larynx that are difficult to manage. Our experience with 10 cases was reviewed. All patients presented with stridor at birth, or shortly after. The minimum follow-up was 6 months, with an average of 44 months. The patients were classified and treated according to the size of the hemangioma. The treatment included expectant management, systemic steroids, CO2 laser excision, and tracheostomies. Overall, eight patients were cured, one developed subglottic stenosis, and one died due to unrelated causes. We recommend that (1) patients with small lesions (< 25% of lumen) be treated expectantly, (2) patients with moderate lesions (25-60% of lumen) be treated with systemic steroids initially, and CO2 laser excision if steroids fail, and (3) patients with large lesions (> 60% of lumen) be treated with tracheostomies initially, and staged CO2 laser excision.