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Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a malignancy of increasing prevalence. The oncologic community is currently evaluating the safety and efficacy of de-intensifying treatment without compromising oncologic outcomes. Paramount to these treatment algorithms is primary surgery through transoral approaches. This article reviews the literature and concepts pertaining to transoral surgery and describes the two most common techniques, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS)., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

In addition to medical therapy studies and translational basic projects, surgically oriented studies are also regularly presented at the ASCO Annual Meeting. At the virtual conference in 2021, an US group presented a well-designed study on the de-escalation of adjuvant therapy after transoral robotic surgery of HPV-positive oropharyngeal cancer. Furthermore, the results of an Italian group on induction therapy for resectable sinunasal carcinomas were presented. An ongoing multicenter study on the surgical treatment of early-stage oral cavity cancer will investigate the impact of sentinel lymph node biopsy compared to elective neck dissection. In addition to these presentations, the following review article summarizes other studies in which surgical therapy was part of the investigational workflow., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: In the context of tumor surgery, the median mandibulotomy as an access route to the oral cavity and oropharynx provides an excellent overview of the surgical site. However, it is not regarded entirely unproblematic with regard to early and later complications that may arise., Objective: The results and complications of the median mandibulotomy will be presented based on data collected from our own patient collective., Materials and Methods: A total of 21 patients who had undergone a median mandibulotomy as part of tumor surgery at the Department of Otorhinolaryngology of the SRH Zentralklinikum Suhl were examined over a period from 01 January 2010 to 31 December 2020. The patient files were retrospectively evaluated., Results: A stair-step median mandibulotomy was performed in all 21 patients. Reconstruction was performed using a 2.8 mm thick angled mandibular plate and bicortical locking screws. The mean follow-up period was 29.8 months. In all, 7 patients (33%) had a recurrence at the time of surgery; 5 patients (24%) had already undergone pre-radiation. Furthermore, 18 patients (85.7%) received adjuvant radiotherapy. We found plate loosening or extrusion in 0 of 21 cases. A salivary fistula (4.7%) was observed in 1 patient. Trismus was found in 4 (19%) cases during follow-up. Osteoradionecrosis was found in 2 (9.5%) of 21 cases. Cosmetic deficits were not observed., Conclusion: Our results show that the stair-step median mandibulotomy in combination with a 2.8 mm thick reconstruction plate and bicortical locking screws leads to a stable and safe reconstruction even with pre-irradiated situations. Plate loosening or extrusion did not occur., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Resection margins in patients with oropharyngeal squamous cell carcinoma (OPSCC) are a predictive marker for overall survival (OS) and recurrence-free interval (RFI). Adjuvant therapy is influenced by TNM status, extracapsular extension (ECE), and resection margin status (R) of the primary tumor. The R status can be directly influenced by the head and neck surgeon. The aim of the current study was to evaluate the impact of R status on treatment decisions, RFI, and OS., Materials and Methods: All patients with OPSCC who underwent surgery (with/without adjuvant therapy) between 2001 and 2011 were enrolled. Clinical data, survival parameters, histologic data such as ECE, resection margin status, and tumor size were retrospectively collected and analyzed., Results: A total of 208 patients were enrolled. Survival parameters showed that patients with microscopically clear (R0) resection margins had an RFI/OS of 89/87 months. These values decreased in patients with R1 (65/65 months), R2 (38/33 months), and Rx (unclear) resections (59/45 months; p =  0.036/p = 0.001). In patients with ECE and R1 resection, but also in those with R0 resections achieved by follow-up resection and those with Rx resections, adjuvant therapy was escalated., Conclusion: Unclear resection status reduces OS and RFI in patients with OPSCC. Therefore, in surgical therapy, clear resection status in the first pass should be strived for to avoid escalation of adjuvant therapy due to an unclear R status.

Introduction: The primary goal of surgical resection of oropharyngeal carcinoma (OPSCC) is an R0 resection. The extension of the primary tumor is decisive for selection of access route, which should be as circumscribed as possible but as radical as necessary. To date, there are no prospective comparative studies that compared functional outcome in terms of surgical access route., Materials and Methods: A selective literature search was carried out for the period from 01/01/2000 to 12/31/2019 to assess the functional result after different surgical approaches in the treatment of OPSCC. The search strategy aimed to identify publications that investigated the functional result of transoral approaches, robot-assisted transoral resections (TORS), and surgical resection using pharyngotomies or transmandibular approaches., Results: Various measures were identified which enable subjective and objective assessment of swallowing and speaking restrictions. For all surgical access routes, studies were identified that examined the functional aspects of the respective access, but there are no direct comparisons between the individual approaches., Conclusion: There are various surgical approaches available for resection of OPSCC, each of which has been examined in various studies with regard to its oncological and functional results.

Oropharyngeal tumors can cause severe dysfunctions, which are often worsened by surgical and/or radiotherapy. The severity and type of dysfunction depends on the extent and localization of the resection. In general, entire organ resections lead to greater impairment than partial resections, whereas extended partial resection often equates to total resection. Plastic reconstructive surgery can help to preserve and reconstruct specific functions. Herein, the various surgical techniques with different flaps and tissue grafts are described, and the indications are presented depending on the dysfunctions, the defect location, and the extent of resection (partial versus total).

Background: Surgery of the soft palate in patients with oropharyngeal cancer can result in functional deficiencies of swallowing and speech. Reconstruction of the resected structures can contribute to regaining sufficient functionality after therapy., Objective: The current study used frequency analysis to evaluate the change in speech characteristics after resection and reconstruction of the soft palate during post-therapeutic follow-up., Materials and Methods: In 18 patients with oropharyngeal carcinoma and involvement of the soft palate, resection and reconstruction by free radial forearm graft (FRFG) and adjuvant chemoradiotherapy was conducted. The spoken German numbers "eins", "zwei", "drei", "vier", "fünf" were recorded during follow-up and objectively assessed by frequency analysis. Additionally, food intake status and the necessity of a tracheostomy were evaluated., Results: The maximum peak frequencies of the numbers analysed increased from 150-300 Hz before up to 1000 Hz after therapy. Two years post therapy, the peak frequencies again declined to levels comparable to those before tumour therapy. One year after therapy, complete oral nutrition was possible in two thirds of patients and the tracheostomy was closed in 80%., Conclusion: Reconstruction of the soft palate by FRFG during the course of oropharyngeal cancer treatment allows function to be regained with respect to speech and swallowing. In the majority of patients, it is possible to reach a level of function comparable to the state before tumour treatment.

The incidence of human papillomavirus (HPV)-positive oropharyngeal carcinomas is increasing worldwide. Due to a markedly different response to treatment compared to HPV-negative oropharyngeal carcinomas, determining the ideal therapeutic approach can be challenging. Particularly in never-smokers, HPV-positive oropharyngeal carcinomas respond well to primary radiation therapy; at the same time recent studies indicate comparable survival after primary surgery. For stage I tumors according to TNM‑8, retrospective analyses show very good oncologic outcomes after surgery alone, and no added benefit of adjuvant radio- or chemotherapy. Results of prospective treatment deintensification trials are expected in the coming years. Minimally invasive transoral surgical approaches for selected oropharyngeal cancers can improve preservation of postoperative function and quality of life. For both HPV-positive and HPV-negative oropharyngeal carcinomas, salvage surgery is the treatment of choice for resectable recurrent locoregional disease and resectable distant metastases.

Surgical therapy, regardless of the procedure, remains of great importance for today's treatment of oropharyngeal carcinomas, despite advances in radiation and immunotherapy. The individual treatment plan should be defined in discussion with the patient and in an interdisciplinary tumor conference, taking into account the likelihood of achieving of tumor-free resection margins and an acceptable postoperative quality of life. With regard to conventional and possibly also open surgical procedures, a good overview of the surgical site-particularly in the case of more extensive carcinomas and challenging patient anatomy-and simplified reconstructability of the defect region are decisive aspects. Endoscopically, microsurgically, or even robot-assisted minimally invasive procedures have the advantage of precise and gentle removal of tumor tissue with improved maintenance of function. Overall, selection of the appropriate surgical procedure remains an individual decision based on tumor size, the facilities at the tumor center, and the surgeon's experience. The extent of surgical intervention, also with regard to simultaneous neck dissection, depends on tumor stage. In the case of oropharyngeal carcinomas, there will be an increasing distinction between human papillomavirus (HPV)-negative and HPV-positive tumors in the future; however, the therapeutic strategy is currently identical. Upcoming clinical trials will show whether treatment de-escalation is appropriate depending on HPV infection status.

Anatomically, the oropharynx can be divided into four subsites: the soft palate, pharyngeal wall, base of tongue, and the tonsillar complex. Surgical access to these tumours is often challenging due to the anatomic localization. For this reason, such tumours were traditionally managed with open surgical techniques, usually involving a mandibulotomy, to provide better visualization and access to the oropharynx, followed by free-flap reconstruction of the oropharyngeal defect. However, the invasiveness of this approach could lead to significant morbidity, including speech, swallowing, and airway dysfunction, in addition to poor cosmetic outcomes. In response, less invasive approaches (Mercante et al. 2013) have been developed including minimally invasive surgical approaches (chiefly transoral surgery) as well as non-surgical methods, primarily radiotherapy, and chemotherapy (Mercante et al. 2013).

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) continues to rise worldwide at a dramatic pace, buoyed by the predominance of human papilloma virus (HPV) driven disease (Panwar et al. 2014). While the outcomes of patients with HPV-positive OPSCC are dramatically improved compared to HPV-negative OPSCC, treatment failures do occur. The result is an inevitable rise in the incidence of recurrent OPSCC. Since the majority of incident OPSCC cases are treated with some form of radiation therapy (primary or adjuvant), surgery remains the backbone of treatment for recurrent OPSCC. This section will focus on options for surgical management of recurrent OPSCC.

Background: The number of elderly patients with head and neck cancer is increasing. However, there are few valid data on postoperative course after head and neck cancer surgery in elderly patients. The aim of this study was to evaluate the oncological outcome of elderly patients after surgical treatment for oro- and hypopharyngeal cancer., Material and Methods: The clinical data of 81 patients, separated into two age groups (62 < 65 years vs. 19 ≥ 65 years), were retrospectively analysed. The cohort comprised T1 and T2 oro- and hypopharyngeal cancer patients, who had undergone primary treatment with transoral laser surgery and neck dissection. Overall and disease-free survival times of the patients were analysed. Additionally, comorbidities and perioperative complications were compared between the two age groups. Median follow-up time was 5.9 years., Results: Comparison of different clinical and histopathological data revealed no significant differences between the age groups. The Kaplan-Meier method revealed no significant difference in disease-free survival between the age groups (p = 0.52). Age had no effect on disease-free survival in uni- or multivariate analysis (p = 0.53 vs. 0.94). Surgery-related complications were observed in 13 patients (16 %), 11 cases of which concerned the younger group of patients., Conclusion: Transoral laser surgery and neck dissection can lead to satisfactory oncological and surgical outcomes in elderly patients with oro- and hypopharyngeal cancer.

Oropharyngeal cancer surgery often does not allow primary wound closure; furthermore, surgery of tumors in the base of the tongue, the soft palate and the lateral pharyngeal wall often lead to swallowing disorders and nasal twang which severely impair quality of life. Secondary scarring may also result in fixation of the tongue or stenosis of the pharynx. Therefor reconstructive techniques with free or pedicled flaps are essential to reduce functional impairment. In addition, after trauma or due to malformations, reconstructive surgery using flap techniques is sometimes indicated.

Oropharyngeal squamous cell carcinoma (OSCC) is associated with oncogenic human papillomavirus (HPV) infection in 30-40% of all cases in Germany. The use of PCR and / or in situ hybridisation to detect HPV in tumour tissue is used in combination with p16 immunohistochemistry to reliably distinguish HPV-related and HPV-unrelated OSCC. The distinct biological behaviour of the HPV-related subset of OSCC results in a more favourable prognosis. This might be the result of a greater response to chemotherapy and radiotherapy as seen in recent studies. Ongoing and future clinical trials will stratify for HPV status. If the results of these prospective, randomized trials are consistent with the preliminary results of recent studies, HPV status will be of enormous clinical relevance in the future.

The anterolateral thigh flap (ATL) has become a standard procedure in reconstructive microsurgery. In this study the results with the ALT for reconstruction in the head and neck area after tumor resection in 33 patients were retrospectively analyzed. Patients included 28 men and 5 women aged 47-70 years who suffered from intraoral and extraoral tumors. Satisfactory soft tissue coverage could be achieved in all patients and no flaps were lost. The ALT is a versatile free flap enabling reliable soft tissue reconstruction of complex defects in the head and neck region. Flap dissection and preparation of the recipient area can usually be performed simultaneously. Additional advantages include the long and strong caliber vascular pedicle, the low donor site morbidity and the different possibilities of tissue composition, making the ALT a workhorse flap in modern reconstructive microsurgery.

The oropharynx is an interface between the airway and the digestive tract. Clinical evaluation and endoscopy suffice for the diagnosis of a variety of lesions, but tumors require cross-sectional imaging to assess local infiltration depth and lymphatic spread. This article discusses different lesions of the oropharynx with respect to imaging characteristics of CT and MRI, with a focus on resectability issues and decision-making.

Therapy of oropharyngeal squamous cell cancer traditionally has been radiation-based, with surgery mainly in reserve. With increasing depth of local infiltration and volume of regional metastases the role of surgery in safeguarding curative chances increases. However, after failed chemoradiation of oropharynx cancer, few patients are cured by salvage surgery. Thus, primary surgery with postoperative radiotherapy may be contemplated if circumtances are favorable. The oropharynx can be approached by transoral, transmandibular or transcervical routes. Primary surgery is increasingly valuable when resultant morbidity is decreased as in the case of more elaborated transoral approaches. Classical approaches also have improved with increasing use of midline mandibulotomy, marginal mandibulectomy, reconstructive surgery, selective neck dissection (ND), and rehabilitation. Elective ND is restricted to levels I or II to III or IV, therapeutic ND is comprehensive (classic or modified radical depending on capsular integrity), and salvage ND is individualized. Surgery, most often followed by radiotherapy, in selected cases of oropharynx cancer is an interesting alternative to chemoradiation, and in advanced disease a facultative but essential part of multimodal therapy.

Introduction: Transoral laser microsurgery of locally advanced carcinomas of the lateral pharynx often results in exposure of major vessels of the neck and is accompanied by a substantial risk of intra- and postoperative bleeding. We therefore only perform these operations after external protection of neck vessels, if necessary combined with flap reconstruction., Patients and Methods: Between October 2001 and December 2004, 11 locally advanced squamous cell carcinomas of the lateral oropharynx that reached the major vessels of the neck were treated as follows: after ipsilateral neck dissection with temporary protection of the jugular vein and carotid arteries, the neck remained open while transoral laser surgery of the primary tumor was performed. Pharyngeal defects were subsequently closed by either primary suture or a platysma myofascial flap. All patients underwent adjuvant radiotherapy., Results: All primary tumors were completely resected. None of the patients required tracheotomy or placement of a percutaneous endoscopic gastrostomy tube. The mean duration of nasogastric feeding tubes was 12.7 days. In one case, the routine radiological contrast study revealed a blind cervical fistula 10 days after surgery. This healed spontaneously within 7 days. One mild postoperative hemorrhage had to be stopped by endoscopic coagulation under general anesthesia. During a mean follow-up of 19.4 months, none of the patients developed a local and/or regional recurrence., Conclusion: The surgical procedure described ensures sufficient protection of neck vessels during and after the transoral resection of advanced carcinomas of the pharynx. It successfully combines the advantages of minimally invasive laser microsurgery with those of flap reconstruction known from traditional surgery.

Background: The purpose of this study was to evaluate the impact of patient characteristics and surgical interventions on quality of life (QoL) after primary surgery and postoperative irradiation in patients with oropharyngeal carcinoma., Patients and Methods: Between January 1997 and February 2002, 169 patients with carcinoma of the oropharynx were treated with curative intent. In September 2002, a total of 88 disease-free survivors were identified and included in this study. A retrospective chart review was performed and patient responses to the SF-36 Health Survey, EORTC QLQ-C30 and EORTC QLQ-H&N35 questionnaires were evaluated. The questionnaires were completed by 34 patients (39% response rate)., Results: All patients were treated with primary surgery followed by postoperative irradiation. The median follow-up was 2.3 years (range 0.5-4.9 years). Using Bonferroni-Holm adjustment for alpha, gender was found to be an important factor in QoL. Females scored significantly worse than males in all three questionnaires. We could not identify other factors influencing QoL., Conclusion: The impact of gender on QoL must be considered as very significant.

Background: Modern treatment concepts for patients suffering from oral and oropharyngeal cancer include more and more adjuvant therapeutic options. Local chemotherapy offers the possibility to apply an extremely high drug concentration at the tumor site while minimizing possible side effects by systemic neutralization at the same time., Patients and Methods: A total of 289 patients with histologically proven carcinoma of the oral cavity and the oropharynx underwent neoadjuvant intra-arterial chemotherapy with high-dosage cisplatin within a multimodal therapeutic setting. Concerning the TNM classification, more than 70% of the patients were classified as stages III and IV. The mean age at the time of intervention was 60 years, and 71% of the patients were male., Results: After the first cycle 19.3% of the patients presented with complete remission (grade I); 35.4% and 41.5% showed partial remissions (grade II) or stable disease (grade III), respectively. The mean observation time after treatment was 28 months (median: 24.2 months). Of the 137 patients who completed the full multimodal therapeutic scheme, 11% developed local recurrence, and 12.4% developed lymph node or distant metastasis. At the time of evaluation, 72.5% of these patients were still alive., Conclusion: Intra-arterial chemotherapy is a safe and highly effective procedure that should be considered as an important option in multimodal therapeutic concepts for oral and oropharyngeal cancer.

Background: Patients with supraglottic laryngectomy often complain about persisting dysphagia because the resection includes the most important protective mechanisms of the airway. The additional resection of parts of the tongue base or the lateral hypopharyngeal wall leads to increasing aspiration problems., Patients and Results: Reconstruction of the supraglottic region with a free radial forearm flap and septal cartilage in extended oro-hypopharyngeal and laryngeal carcinomas was carried out in seven patients from 1997 to 2002. In one patient, the reconstruction was performed in a second stage procedure after extended endoscopic laser resection. In four patients, the temporary tracheostomy was closed, and in five total oral feeding was possible., Conclusions: Preliminary results show that a functional reconstruction of the supraglottic region with a free radial forearm flap and septal cartilage to reconstruct the epiglottis helps to avoid chronic aspiration and to preserve the larynx.

Background: The often documented prognostic influence of the depth of invasion of oral and and oropharyngeal squamous cell carcinomas should be examined using more advanced lymphogenic metastasized tumours. This should be compared with the established prognostic factors T stage and capsular rupture of the lymph node metastases., Methods: Five-year postoperative follow-ups of 66 patients treated consecutively were studied retrospectively., Results: There was no significant relationship for the depth of invasion of the primary tumour. Survival rate was significantly related only to the T stage., Conclusion: In the presence of lymph node metastases and in particular of capsular rupture, T stage and depth of tumour invasion lose their prognostic value. The prognostic value of features of the primary tumor such as size and depth of invasion is limited to early non-metastasized oral and and oropharyngeal squamous cell carcinomas.

Alveolar soft part sarcoma is a malignant soft part tumor the etiology of which has not yet been clarified. Histopathological examinations show an alveolar or pseudoglandular pattern. PAS-positive, diastase resistant intraplasmic inclusion bodies are characteristic for this tumor which occurs in the head and neck region; mainly the tongue and the orbita. Primary therapy includes total resection which can later be combined with radiotherapy or chemotherapy. The present study involves a 17 year old patient. We totally removed the tumor and then used radiotherapy. The postoperative examinations over 3 years showed neither local recurrence nor distant metastases.

Background: Total pharyngeal reconstruction after salvage pharyngolarynectomy in recurrent tumors after primary surgery or radiation therapy may be performed by ENT surgeons in the oncologic field., Patients: We report on six patients that underwent salvage pharyngolaryngectomy and total pharyngeal reconstruction., Methods: In three cases pharyngeal reconstruction was performed as a two-stage procedure with deltopectoral flaps. One of these patients died before the completion of reconstruction. In three other patients the reconstruction was performed with a tubed pectoralis major myocutaneous flap including one patient after a failed reconstruction with a jejunum segment. or fistula prevention we applied silicon stents in three patients and self-expanding Nitinol stents in three other patients., Results: Of five successfully reconstructed patients two fed orally, one fed combined orally and via PEG and two fed via PEG., Conclusions: Summarizing our experiences the use of silicon tubes and nitinol stents has proved its worth. Experiences with a larger number of patients must be collected in the future.

Malignant fibrous histiocytoma is a rare sarcoma. This is the report of a radiation-induced histiocytoma of the right tonsillar region. Because of squamous cell carcinoma of the left tonsil, a 64-year-old woman was treated with primary surgery and postoperative radiotherapy. Six years later, a histiocytoma was diagnosed histologically within the former field of radiation. This second primary tumor was resected radically. Clinical, radiological, and histological findings are presented, and the importance of this very rare malignant tumor, especially when it is radiation-induced, is discussed.

Introduction: Resections of extensive tumours, recurrences and radiodermatitides at the neck cause complex defects. Free bowel transplantation enables one-stage reconstruction., Patients and Methods: In 35 out of 57 interdisciplinarily treated patients, small-bowel transplantation was performed for reconstruction. Thirty patients received cylinder grafts, five jejunal patch plastics. In four patients neoglottis formations according to Ehrenberger were performed. To cover soft tissue defects, two patients received scapular free flaps, eight patients a jejunal segment, incised at the anti-mesenteric side, the mucosa stripped and covered by a split skin graft., Results and Conclusions: Thirty-four grafts were viable. One patient received a successful re-transplantation. One postoperative fistula at the hypo-pharyngojejunostomy was closed by a separated jejunal segment which was primarily used as monitor, two others by pectoral flaps. Separation of a jejunal graft into two or three segments enables restoration of swallowing, voice and covering soft tissue in a one-stage procedure. The whole reconstruction necessitates only one arterial and one venous microanastomosis at the neck.

Dysphagia is a common complaint following surgical intervention in the oral cavity and hypopharynx, often leading to prolonged postoperative recovery. Videofluoroscopy allows detailed visualization of deglutition, demonstrating the morphology as well as the functional aspects. Therefore, videofluoroscopy provides the basis for further therapeutic management. We discuss the pathology of deglutition in 19 patients recovering from tumor surgery of the oro- and hypopharynx. In most cases the results demonstrated severe impairment of both the oral and pharyngeal phase of deglutition. Our data emphasize the importance of the oral phase of deglutition for preparation and initiation of the following phases.

Reconstruction of defects after resection of advanced head and neck tumours with the pedicled myocutaneous pectoralis-major-flap is a well established method of regional plastic surgery. A 66 year old female patient with an oropharyngeal squamous cell carcinoma was treated by surgery and radiotherapy in curative intention. A few months later a local recurrence could be resected by a lateral pharyngotomy while the defect was reconstructed with a myocutaneous pectoralis-major-flap. Together with another local relapse at the pectoralis-major-flap in the oropharynx a painless tough swelling developed in the ipsilateral axilla which revealed histologically as a lymph node metastasis of a squamous cell carcinoma. Because no second malignoma as a source for this metastasis could be found, a lymphogenous spread of the oropharyngeal carcinoma along the pedicle of the flap could be the most probable explanation for this rare event. As a conclusion of this observation all patients with pedicled reconstructions after resection of head and neck cancer should not only be examined in the tributary lymph node levels of the neck but also in the axilla during oncological follow up.

It remains a controversial question whether or not the anastomosis of sensory nerves is necessary in free transplants of microvascularly reanastomosed radial forearm flaps in the oral cavity and oropharynx. Some authors perform this routinely because they expect fewer complications in a skin with a sensory nerve supply. We carried out clinical and morphological examinations in 20 patients in order to determine the sensory innervation of the transplanted tissue. All patients received free transplants of microvasculary reanastomosed radial forearm flaps during a tumor operation in the oral cavity or oropharynx. Postoperative wound healing proceeded without complications in all but three cases, but these disturbances were insufficient to explain any deficit in sensation in the operated areas. Following surgery, sensation was determined clinically by two-point discrimination. Morphological studies of 20 flap biopsies using conventional colored light microscopy demonstrated nerve fibers in 14 of the biopsies. Immunohistochemical investigations also showed the presence of small nerve fibers by proving S-100 positive Schwann cells. We could not find a correlation between the demonstration of nerve fibers and the use of radiation (or an increased radiation dosage) following surgery. These findings suggest that nerve regeneration was completed just before the 6th postoperative month, which was the earliest time recorded in this study. Perivascular (vegetative) nerves showed a delayed regeneration and could be demonstrated only 36 months after operation. Histological investigations of the transplanted tissue showed a decrease in keratin with a partial increase in parakeratosis, a loss of skin structures and nearly always chronic inflammation. Our findings verify that a sensory innervation is possible in free transplanted radial forearm flaps by the regeneration of nerves coming from the transplantation bed and/or adjacent (oral) mucosa. This leads to a sensation comparable to that of healthy mucosa. These findings also indicate that there is no need for the anastomosis of sensory nerves during transplant surgery.

Many cases of oropharyngeal and hypopharyngeal neoplasms without diffuse infiltration of the larynx or mandible cannot be treated effectively by a transoral approach. In such cases a lateral and/or median translingual pharyngotomy can permit effective surgical therapy. However, these surgical techniques require greater effort and violate uninvolved tissues, such as the lip, mandible and floor of the mouth. In contrast to this, a suprahyoid pharyngotomy can be a simple and precise approach to the oropharynx and hypopharynx, and provide the shortest distance to the pathological process. The excellent exposure given to the oropharynx and hypopharynx offers a more exacting macroscopic identification of tumor margins and minimizes possible injuries to vital neurovascular structures. The wound created can usually be closed primarily without the need for regional flaps. These factors allow a faster healing of the wound and better rehabilitation, as well as avoiding delays in postoperative radiation therapy. Over the past 6 years a suprahyoid pharyngotomy was performed in eight patients. Five patients underwent resections of an oropharyngeal cancer while three patients required resections of benign neoplasms of the tongue base. In the cases of oropharyngeal cancer, a suprahyoid pharyngotomy was performed in combination with a unilateral or bilateral neck dissection. A tracheotomy was required in six patients. Three patients underwent postoperative radiation therapy. No locoregional recurrences were found in these patients, with a median follow-up of 20.8 months.

Freely transplanted, microvascularly anastomosed jejunal patches can be used to cover soft tissue defects in the oral cavity or oropharynx after the resection of malignant tumors. Even a patch without complications or alteration from tumor recurrence is morphologically diverse. Therefore it is difficult to distinguish between malignant and benign alterations, and knowledge of the possible morphological spectrum and the significance of an alteration is of practical interest. Computed tomography (CT; n = 30) and magnetic resonance imaging (MRI; n = 13) were used for follow-up examinations in patients who had an operative reconstruction with a jejunal patch. Three parts of a patch were differentiated with both imaging modalities: the region of the anastomosis, the mesenterial fatty tissue and the intestinal wall. The morphology of the patches correlated with clinical findings in the following cases. The patches were identified satisfactorily by CT and MRI. The appearance of patches without complications was influenced by a variable degree of fibrosis and by persistent intestinal folds. Recurrent tumors only infiltrated the margins of the patches. Destructive alterations in the patches were always less severe than those in the original orofacial soft tissue. Postoperative follow-up examinations with CT and MRI are particularly important when tumor recurrences spread under a patch, since these tumors are invisible in the clinical examinations. CT was advantageous in demonstrating osseous alterations and showed less loss of image quality in patients for whom the implantation of multiple metallic hardware during the operation had been necessary.

Although induction chemotherapie given prior to local therapy produces encouraging initial response rates in head and neck cancer, randomized studies have failed to demonstrate an advantage in survival. All randomized studies have included only patients with far advanced stage III and IV disease. To us this is the main reason for the low rate of complete responses demonstrated (maximum, 18%). Frei et al. estimate that 40-50% complete responders are necessary before improved survival benefit will occur. To date, such complete response rates with induction chemotherapy are only attainable in resectable T2-T3, N0-N2 disease. Therefore, we started a prospective randomized trial that included only patients with earlier disease. Patients were randomized to receive either induction chemotherapy with 3 cycles of carboplatin/5-fluorouracil prior to surgery and radiotherapy (arm A, 49 patients) or standard treatment with surgery and radiotherapy (arm B, 48 patients). Patients were stratified by primary tumor site and neck disease. After a follow-up of 12-48 months, overall survival was 72% in arm A and 53% in arm B, but this difference was not significant. Considering only the results in patients with cancer of the oral cavity and tonsils, overall survival was 87% in arm A and 45% in arm B (p < 0.04). At present, the numbers of patients with cancers of the tongue base and hypopharynx are too small for a statistically significant statement. However, preliminary data indicate a better overall and disease-free survival without chemotherapy in these patients. Therefore, we now recommend induction chemotherapy in all patients with stage T2-T3 and N0-N2 carcinomas of the oral cavity and tonsils prior to surgery but not in patients with cancers of the hypopharynx and base of tongue.

As a rule carcinomas of the oral cavity and oropharynx are not diagnosed in early stages. Surgical resections of these tumors including margins of safety invariably result in large defects. At present, one-stage flap techniques are preferred for reconstruction, as exemplified by pectoralis major myocutaneous flaps and free revascularized jejunum grafts. The skin island of the myocutaneous flap is underlayed by fat tissue as a sliding surface. Temporary sutures are necessary but have the disadvantage of producing a convex configuration. This shape compromises anatomical reconstruction of the oral cavity and oropharynx. Robertson et al. in 1985 demonstrated an alternative method for a muscle-fascia flap from the pectoralis major muscle. In comparison to the temporalis muscle-fascia flap, the pectoralis muscle-fascia flap is associated with a lesser incidence of complications. Although it is still too early to conclude their definitive use, their application in some cases is now being questioned because of such factors as reduced time of anesthesia.

30 patients with malignant tumours of the cavum oris and oropharynx were examined by MRI and CT to compare their accuracy for T-staging. There was histological information in all cases. Histological studies showed an accuracy in T-staging of 81% for MRI and 77% for CT. Differentiation between stages T2/T3 and T3/T4 is possible in 80% by CT and 84% by MRI. Tumours of the cavum oris and oropharynx of T1-stage are possible only in 1 of 3 cases. The use of T2-weighted sequences allows the best frequence of tumour representation in 89%. CT shows an earlier bone involvement than MRI. In addition, the ability to produce coronal and sagittal images by MRI makes it superior to CT in judging tumour extension.

After surgery of advanced larynx and pharynx malignancies, a main problem is reconstruction of swallowing and voice. With microvascular small bowl transplantation, we have been able to use a 30 cm segment of jejunum in a one-stage procedure to reconstruct extended defects of the oropharynx, and total by hypopharynx, as well as to create a speaking-syphon as devised by Ehrenberger. The surgical technique is described and we now report the results achieved in our first five patients. This new method enables pharyngectomized and laryngectomized patients to speak and to eat without any aspiration after about two weeks. This rapid and functionally encouraging rehabilitation means a significant improvement in a patient's quality of life and is further justification for the great effort required in using this method.

In tumor surgery of the oral cavity and oropharynx function and quality of life should be maintained and large resection margins to avoid recurrences. For these purposes the radial forearm flap has proved to be a versatile tissue transfer since it is thin and pliable and has a long vascular pedicle. From 1987 to 1991 we used the radial forearm flap in performing 70 reconstructions of the oral cavity and oropharynx after resection of squamous cell carcinomas. Forty-six patients had carcinomas of the oropharynx, while 24 patients had carcinomas of the oral cavity. The indications for these reconstructions were tumors of the oral cavity and oropharynx greater than T2 which after resection were not suitable for primary closure of the defect. Thirty-seven patients died during the follow-up period, with 36% dying within the first 2 years after operation. Fifty-five percent of these patients died of recurrences, 17% of metastases and 11% of intercurrent diseases. In 17% of cases the cause of death was unknown. The 2-year survival probability was 52% (Kaplan Meier). Our results show that reconstructions with the radial forearm flap do not improve survival rates when compared to the general survival rate in these cases despite a possibly larger resection margin allowing a more radical tumor resection. Thirty-one of the 33 patients still alive underwent following examinations. Forty-six percent of the patients with tumors of the oropharynx and 57% of the patients with tumors of the oral cavity had severe difficulties in swallowing.(ABSTRACT TRUNCATED AT 250 WORDS)

Lateral laryngeal suspension in combination with a cricopharyngeal myotomy represents a simple technique for prevention and/or treatment of chronic aspiration in patients during or after surgery for head and neck cancer. At the Department of Otolaryngology/Head and Neck Surgery of the University of Heidelberg this technique has been employed with satisfying results in 6 patients with large carcinomas of the oral cavity and pharynx. Lateral laryngeal suspension was not able to prevent--or if used secondarily--to eliminate aspiration completely in all patients. However, none of our patients experienced aspiration of saliva postoperatively. All were able to use a speech canula and some could even be fed orally.

Leiomyosarcomas arise rarely in the head and neck. We report a 41-year-old woman with an extremely rare leiomyosarcoma of the floor of the mouth extending to the oropharynx. This article stresses the value of imaging methods such as CT, MRI and ultrasound for preoperative diagnosis, and emphasises histopathological findings. The therapeutic principles and prognostic factors of leiomyosarcomas are illustrated on the basis of this case.

Either the musculocutaneous island flap (especially the pectoralis major flap) or the free jejunal transplant are used for large mucosal defects of the oro- and hypopharynx. As a jejunal transplant is more time consuming than the use of a musculocutaneous flap, its use must be justified. A review of the literature and our own experience show that the jejunal transplant should be preferred because (1) it is more versatile, (2) it can easily be handled, (3) it provides better functional results, (4) it avoids the functional and aesthetic morbidity of the donor site defect and (5) it has a lower complication rate than the pectoralis major flap.

We report 155 free jejunal transplants carried out since August 1984. The complications and the indications for the use of free intestinal transplants in the reconstruction of defects of the oral cavity and pharynx are recorded. Also we report the use of the revascularised latissimus dorsi myocutaneous flap and the fascicutaneous radial forearm flap in head and neck reconstruction.

Many microsurgical free flaps have been described to tackle various problems in the head and neck. The authors present a system of indications which has proved to be suitable as judged by the functional and cosmetic results obtained. The harvesting of these flaps requires versatile training in surgical techniques for the different anatomical areas. This system of indications comprises the free fasciocutaneous forearm flap, jejunal loops, the fasciocutaneous parascapular flap, iliac crest flaps with vascularized bone and the parascapular cutaneous, latissimus dorsi osteomyocutaneous double flap.

Reconstruction of defects after tumor ablation has been accomplished by a variety of different techniques. The platysma musculocutaneous flap for reconstruction is outlined and the surgical technique described. It provides 8 x 10 cm of flap coverage. The donor site is closed primarily without cosmetic defect. Forty of 48 patients on whom this flap was used healed without complication.