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Follicular dendritic cell sarcoma is a rare low-grade sarcoma of mesenchymal origin. It involves the lymph nodes more commonly and rarely extranodal sites. The most common lymph node is cervical and usually presents as a painless asymptomatic mass. More often, it is a misdiagnosis, and there is a delay in treatment. It is rarely associated with Castleman disease, myasthenia gravis. Diagnosis of this condition is by histopathology and immunochemistry. Surgery is the primary modality of treatment, and adjuvant therapy has been tried with no definite trials due to the rarity of the disease. Here, we report a case of concomitant follicular dendritic sarcoma of the right cervical lymph node and papillary carcinoma of the thyroid managed in our institute. There was a line of investigations approaching towards a diagnosis, and she underwent total thyroidectomy and right modified radical neck dissection.

The elderly patient presenting with a neck lump often raises concerns regarding a malignancy. Thyroid gland malignancies are well recognised and subtype characteristics thoroughly researched, whereas rarer types of thyroid carcinoma are reported infrequently and often behave more aggressively. An 83-year-old woman was referred from the general practitioner (GP) to otolaryngology due to a 7-month history of an unexplained enlarging left-sided neck swelling. A fine-needle aspiration revealed cytology consistent with squamous cell carcinoma (SCC). Staging imaging failed to reveal evidence of a primary foci elsewhere. The definitive diagnosis was that of a primary thyroid SCC: a rare entity with limited citations in the literature. Surgical resection has been found to comprise the optimal treatment for this disease. Recognition of the possibility of primary thyroid SCC in elderly patients presenting with a neck lump, with prompt referral to a head and neck specialist permits a timely progression to potentially curative surgical management, a more promising prognosis and reduced mortality rates.

ImportanceIn clinically localized (T1-2) oral cavity squamous cell carcinoma (OCSCC), regional lymph node metastasis is associated with a poor prognosis. Given the high propensity of subclinical nodal disease in these patients, upfront elective neck dissections (END) for patients with clinically node-negative disease are common and associated with better outcomes. Unfortunately, even with this risk-adverse treatment paradigm, disease recurrence still occurs, and our understanding of the factors that modulate this risk and alter survival have yet to be fully elucidated.ObjectiveTo investigate the prognostic value of lymph node yield (LNY), lymph node ratio (LNR), and weighted LNR (wLNR) in patients with clinically node-negative T1-2 OCSCC.Design, Setting, and ParticipantsIn this cohort study, data were collected retrospectively from 7 tertiary care academic medical centers. Overall, 523 patients with cT1-2N0 OCSCC who underwent elective neck dissections after primary surgical extirpation were identified.ExposuresLymph node yield was defined as the number of lymph nodes recovered from elective neck dissection. Lymph node ratio was defined as the ratio of positive nodes against total LNY. Weighted LNR incorporated information from both LNY and LNR into a single continuous metric.Main Outcomes and MeasuresLocoregional control (LRC) and disease-free survival (DFS) were both evaluated using nonparametric Kaplan-Meier estimators and semiparametric Cox regression.ResultsOn multivariable analysis, LNY less than or equal to 18 lymph nodes was found to be significantly associated with decreased LRC (aHR, 1.53; 95% CI, 1.04-2.24) and DFS (aHR, 1.46; 95% CI, 1.12-1.92) in patients with pN0 disease, but not those with pN-positive disease. Importantly, patients with pN0 disease with LNY less than or equal to 18 and those with pN1 diseasehad nearly identical 5-year LRC (69.7% vs 71.4%) and DFS (58.2% vs 55.7%). For patients with pN-positive disease, LNR greater than 0.06 was significantly associated with decreased LRC (aHR, 2.66; 95% CI, 1.28-5.55) and DFS (aHR, 1.65; 95% CI, 1.07-2.53). Overall, wLNR was a robust prognostic variable across all patients with cN0 disease, regardless of pathologic nodal status. Risk stratification via wLNR thresholds demonstrated greater optimism-corrected concordance compared with American Joint Committee on Cancer (AJCC) 8th edition nodal staging for both LRC (0.61 vs 0.57) and DFS (0.61 vs 0.58).Conclusions and RelevanceMovement toward more robust metrics that incorporate quantitative measures of neck dissection quality and regional disease burden, such as wLNR, could greatly augment prognostication in cT1-2N0 OCSCC by providing more reliable and accurate risk estimations.

Introduction Cadaveric dissection courses have come to a standstill since the onset of the COVID-19 pandemic. In addition to limited operative opportunities, cancellation of such courses has severely impacted surgical training, especially in a craft-based specialty such as head–neck surgery. The aim of this educational project was to: (1) study the feasibility of an in-person head–neck cadaveric dissection course during COVID-19 pandemic; and (2) validate the educational benefit of this teaching method to ear, nose and throat (ENT) trainees. Methods We developed a 2-day head–neck cadaveric dissection course for ENT trainees. The course programme covered essential head–neck open surgical procedures. Content validity (subjective feedback) was assessed using a 5-point Likert scale. Construct validity (objective usefulness) was evaluated via two pre- and post-course questionnaires, estimating knowledge of head–neck surgical anatomy and self-assessment of levels of confidence with head–neck procedures, respectively. Results A risk assessment was conducted and a protocol developed (risk was deemed to be low/tolerable). Content validity showed high satisfaction compared with a median Likert score of 3, ‘average’ (p=0.000002). For construct validity, the mean score per question improved significantly (p=0.001). Overall levels of confidence showed a trend towards improvement (p=0.08). There was significant improvement in laryngectomy (p=0.01) and level I dissection (p=0.01), with an indication of improvement in level II–V dissection (p=0.07). Conclusions We demonstrated that a cadaveric dissection course, using thorough risk assessment and protocol, could be safely conducted with high content and construct validation during these unprecedented times. This is an invaluable learning environment that needs to be encouraged despite infection control restrictions.

To investigate the prognostic factors to developing parotid and neck metastasis in locally advanced and relapsed Cutaneous Squamous Cell Carcinoma (CSCC) of the head and neck region.Single-center retrospective cohort study enrolling consecutive patients with advanced CSCC from 2009 to 2019. Seventy-four cases were identified. Study variables demographic data, clinical skin tumor stage, neck stage, parotid stage (P stage), surgical treatment features, and parotid, regional, and distant metastases. Survival measures: Overall Survival (OS) and Disease-Specific Survival (DSS).The study group included 72.9% men (median age, 67 years); 67.5% showed T2/T3 tumors, 90.5% comorbidities, 20.2% immunosuppressed, with median follow-up: 35.8 months. The most frequent skin primary were auricular and eyelid regions, 75% underwent primary resection with flap reconstruction. Parotid metastasis was present in 50%, 32.4% showing parotid extracapsular spread, multivariate analysis found OR = 37.6 of positive parotid metastasis evolving into positive neck metastasis, p = 0.001. Occult neck metastasis, neck metastasis, and neck extracapsular spread were observed in 13.5%, 51.3%, and 37.8%, respectively. Kaplan-Meier survival: Clinical T4 versus T1, p = 0.028, P1 stage: 30% and 5% survival at 5 and 10 years, P3 stage: 0%, p = 0.016; OS and DSS showed negative survival for the parotid metastasis group, p = 0.0283.Our outcomes support a surgically aggressive approach for locally advanced and relapsed CSCC, with partial parotidectomy for P0, total parotidectomy for P1-3, selective I-III neck dissection for all patients and adjuvant radiochemotherapy to appropriately treat these patients with advanced CSCC of the head and neck region.II b - Retrospective Cohort Study - Oxford Centre for Evidence-Based Medicine (OCEBM).

Introduction Surgery is one of the most frequently used options in the treatment of head and neck squamous cell carcinoma. In surgical patients, the use of arterial lactate to assess hypoxemia and severe inflammatory states is well-founded. However, there are few studies on its use in patients with head and neck squamous cell carcinoma. The aim of this study was to investigate whether the serum arterial lactate level on the 1st postoperative day would be a predictor of postoperative complications in head and neck squamous cell carcinoma surgeries. Methods This is a prospective cohort, which evaluated 44 adult patients of both genders, with HNSCC, who underwent surgery associated with monobloc neck dissection as an initial treatment. Patients were divided into two groups, according to the presence or absence of postoperative complications: with complication (Clavien-Dindo II-V) and without complications (Clavien-Dindo 0-I). Student’s t-test and its variants were used to compare continuous data. Pearson’s or Spearman’s test was used to correlate the data and p values 1.7 mmoL/L was identified, with a sensitivity of 65.38% and specificity of 66.67%. Conclusion Arterial lactate measured on the first postoperative day is a good predictor of postoperative complications in patients with head and neck squamous cell carcinoma. Resumo Introdução A cirurgia é uma das opções mais usadas no tratamento do carcinoma epidermoide de cabeça e pescoço. Nos pacientes cirúrgicos, o uso do lactato arterial para avaliação de hipoxemia e de quadros inflamatórios graves é bem fundamentado. Entretanto, existem poucos estudos sobre o seu uso em pacientes com carcinoma epidermoide de cabeça e pescoço. O objetivo deste estudo foi investigar se o lactato arterial sérico no 1° dia de pós‐operatório seria um preditor de complicações pós‐operatórias nas cirurgias do carcinoma epidermoide de cabeça e pescoço. Método Trata‐se de uma coorte prospectiva, que avaliou 44 pacientes adultos, de ambos os gêneros, com carcinoma epidermoide de cabeça e pescoço, submetidos a cirurgia associada ao esvaziamento cervical em monobloco como tratamento inicial. Os pacientes foram divididos em dois grupos, segundo a presença ou não de complicações pós‐operatórias: complicados (Clavien‐Dindo II a V) e sem complicações (Clavien‐Dindo 0-I). Na comparação dos dados contínuos, foi usado o teste t de Student e as suas variantes. Na correlação dos dados, usou‐se o teste de Pearson ou Spearman. Valores de p inferiores a 0,05 (p < 0,05) foram considerados estatisticamente significativos. Resultados Dos pacientes, 59% (n = 26/44) desenvolveram complicações pós‐operatórias. O lactato sérico foi significantemente maior no grupo com complicações em relação aos pacientes sem complicações, respectivamente 2,15 mmoL/L (1,10-3,90) e 1,59 mmoL/L (0,70-3,44); p = 0,03. A acurácia prognóstica do lactato arterial foi de 69% (95% IC 54%-82%; p = 0,03), estimada pela curva ROC. Foi identificado um cut‐off> 1,7 mmoL/L, com sensibilidade de 65,38% e especificidade de 66,67%. Conclusão O lactato arterial do primeiro dia de pós‐operatório é um bom preditor de complicações pós‐operatórias nos pacientes com carcinoma epidermoide de cabeça e pescoço.

The extent of neck dissection for tongue SCC is unclear owing to the potential presence of occult level IV metastasis. We aim to assess the incidence of occult level IV nodal metastasis for tongue SCC patients treated in our centre over a 20 year period.A retrospective analysis of data collected from 1999 to 2019 was performed. Patients diagnosed with oral tongue SCC treated primarily with surgery and a neck dissection fulfilled the inclusion criteria.A total of 124 patients were included in our study. Sixty-one patients were N0 with no occult level IV metastasis. About 17.3% of clinically node positive patients had level IV metastasis. Length of hospital stay and complication rates were comparable for patients who received levels I-III and I-IV neck dissections.Occult level IV metastasis in N0 tongue SCC patients are exceedingly rare, we would therefore suggest consideration for a level I-III neck dissection. In patients who are clinically node positive, a level I-IV neck dissection would be recommended.

The aim of this systematic review and meta-analysis was to analyse the literature on the infrahyoid myocutaneous flap (IHMCF) and evaluate its clinical outcomes. The MEDLINE, Embase, Web of Science, Cochrane Library, and Scopus databases were searched (inception to December 31, 2021). Meta-analyses were then conducted to estimate the overall rates of partial flap loss, total flap loss, salivary fistula, and surgical revision. The 21 studies that met the inclusion criteria included 768 patients undergoing head and neck reconstruction with 773 IHMCF. The oral cavity (77.7%) and oropharynx (13.0%) were the most reconstructed sites. The meta-analyses estimated a pooled partial flap loss rate of 10.4% (99% confidence interval (CI) 5.4-16.7%), total loss rate of 1.8% (99% CI 0.8-3.2%), salivary fistula rate of 3.0% (99% CI 1.3-5.3%), and surgical revision rate of 1.9% (99% CI 0.7-3.7%). Fast flap harvesting and low donor site morbidity were other flap features. Previous thyroid surgery or neck dissection and advanced lymph nodal stage were considered contraindications to IHMCF reconstruction by most authors, while prior neck radiotherapy was reported as a relative contraindication. This pedicled cervical flap is a versatile and reliable reconstructive option for medium-sized head and neck defects. Careful preoperative assessment of the neck condition allows for its safe use.

This study aimed to evaluate the incidence and risk factors of occult metastasis to superficial level VI, defined as the space anterior to the strap muscles, including the lymph nodes between the sternocleidomastoid and sternohyoid muscles and suprasternal space lymph nodes.We studied 129 patients with papillary thyroid carcinoma who underwent thyroidectomy and neck dissection, including superficial level VI dissection.Of the 129 patients, 62 (48%) had lymph nodes in the harvested specimens of superficial level VI, and the mean number of lymph nodes retrieved was 1.9 ± 1.2. Occult metastasis to superficial level VI occurred in four patients (3.1%). No significant risk factors of superficial level VI occult metastasis were noted in multivariate analysis.Occult metastasis to superficial level VI was rare in patients with papillary thyroid carcinoma. Therefore, prophylactic dissection of superficial level VI may not be necessary for primary papillary thyroid carcinoma.

Patients undergoing sentinel node biopsy (SLNB) for early oral squamous cell carcinoma (OSCC) who harbour occult metastases (pN+ve) may be at greater risk of mortality due to prolonged overall treatment times than those identified as pN+ve on elective neck dissection (ELND). A retrospective comparative survival analysis was therefore undertaken to test this hypothesis. Patients were identified from the South Glasgow multidisciplinary team (MDT) database. Group 1 comprised 38 patients identified as pN+ve, or who were false negative, on sentinel lymph node biopsy (SLNB). Group 2 comprised 146 patients staged pN+ve on ELND. The groups were compared with the Kaplan Meier method and Cox proportional hazards model. In addition, a matched-pair analysis was performed. A unique and specifically designed algorithm was deployed to optimise the pairings. No difference in disease-specific or overall survival was found between the groups. Patients undergoing SLNB as the initial neck staging modality in early OSCC and are identified as pN+ve do not appear to be at a survival disadvantage compared with those staged with ELND.

Cervical traumatic neuromas (CTNs) are a non-neoplastic hyperplasia of damaged nerves and may be misinterpreted as metastatic lymph nodes during cervical ultrasound of patients with thyroid cancer after lateral neck dissection, resulting in unnecessary and painful fin-needle aspiration biopsy. The anatomy of the cervical plexus is challenging, and the correct identification and recognition of its neural roots and branches on ultrasound are key to the correct CTN diagnosis. This review outlines the US technique used to characterize CTNs in 10 standardized steps and describes the sonographic features of the cervical plexus, to assist the radiologist in the recognition of CTNs and their differentiation from lymph node metastases.

The purpose of this study was to explore the impact of the lymph node ratio on prognosis in papillary thyroid cancer patients with lymph node metastasis.Data from papillary thyroid cancer patients with positive nodes who were initially treated at our institution during 2015-2016 were analysed. Univariate and multivariate Cox proportional hazard models were adopted to predict prognostic factors. A receiver operating characteristic (ROC) curve was used to find the best cut-off value of the lymph node ratio (LNR). Kaplan-Meier curves were used to show the relationship between the LNR in the lateral neck and recurrence-free survival.The median follow-up time was 64.6 months, and recurrence occurred in 16 of 662 patients (2.27%). Univariate analysis showed that male sex, primary tumour size (gt;17 mm), visible extrathyroidal extension, LNR in the central neck (gt;0.5), LNR in the lateral neck (gt;0.10), and visible extranodal extension were significantly correlated with recurrence-free survival (RFS) (p lt; 0.05). Multivariate analysis using the Cox proportional hazards model showed that the LNR in the lateral neck was an independent risk factor for RFS (p = 0.039; HR 14.76).The LNR in the lateral neck was an independent risk factor for recurrence-free survival. For patients with a high lymph node ratio in the lateral neck, more frequent follow-up might be needed.

A 30-year-old man presented with swelling in the lower left ear. Close examination led to a diagnosis of parotid gland cancer, T4N0M0 Stage IVA, so total resection of the left parotid gland and left neck dissection were performed. Pathological examination led to a diagnosis of high-grade malignant-type mucoepidermoid, and chemoradiotherapy was performed as postoperative treatment. Fourteen days after completion of chemoradiotherapy, the patient was admitted to the hospital with headache and lack of appetite. Echocardiography showed a pericardial effusion and complete collapse of the right ventricle; cardiac tamponade was diagnosed, and pericardiocentesis was performed. The pericardial effusion was bloody, and a metastatic lesion was suspected, but cytological examination showed class IIIa. On day 33 of the illness, respiratory distress and hypotension were observed. A clot was seen covering the lower wall of the heart, and dilatation of the lower wall was significantly impaired. Pericardiotomy was performed on day 36. Pathological examination diagnosed cardiac metastasis of mucoepidermoid carcinoma of the parotid gland. Although only 4 cases of parotid cancer have been reported as primary lesions of metastatic heart tumors, this case represents the world's first description of isolated parenchymal metastasis of mucoepidermoid carcinoma of the parotid gland diagnosed by pericardial biopsy.

Over time, the primary treatment modality of oropharyngeal squamous cell cancers (OPSCC) is intensity-modulated radiation therapy (IMRT), eventually associated with chemotherapy (CHT). This treatment modality is preferred for reduced impact on the quality of life rather than aggressive open surgical approaches. The advent of TransOral Robotic Surgery (TORS) has rediscovered the role of surgery in the treatment of OPSCC. Although the primary chemoradiation therapy (CRT) and transoral robotic surgery (TORS) are competing for similar oncologic results, CRT may result in significant functional complaints such as severe dysphagia and feeding tube dependence and, on the other hand, TORS might result in surgical defects depending on the size of the resection and anatomic location. Nevertheless, TORS may intercept the locoregionally advanced population through pathologic downstaging as well as the potential for improvement in oncologic outcomes. The available reconstructive options allow an expanding role of this minimally invasive surgery, even in locally advanced tumours. Finally, the surgical management of OPSCC with TORS identifies areas of opportunity in shortening the overall treatment package time compared to traditional surgery.

Sialocele and salivary fistula are recognised complications of parotid surgery and have been reported to be more common with less extensive parotidectomy. We investigated the efficacy of tissue sealant(Cunniffe et al., 2019)The study comprised a retrospective review of a prospectively maintained parotidectomy database at a single tertiary Head and Neck referral centre between 2009 and 2020. Cases undergoing concomitant neck dissection or major skin resection were excluded. Patients were divided into Group 1 (without tissue sealant), and Group 2 (with tissue sealant). Patients were also divided based on extent of surgery 1) Extracapsular dissection/Partial superficial parotidectomy 2) Superficial/total parotidectomy.Of 202 included patients, there were 146 in Group 1 (143 with drain), and 56 in Group 2 (7 with drain). Compared to Group 1, Group 2 had a significantly shorter LOS (mean 1.4 ± 0.98 versus 3.1 ± 1.29 days, p 0.05) and estimated cost (€1386 versus €2736). There was no significant difference in the complication rates (15.8% Group 1 versus 10.7% Group 2, p = 0.50). Group 1 showed a higher incidence of complications in patients undergoing less extensive parotidectomy (19/70 versus 4/76, p = 0.02), whereas in Group 2, the difference was not significant (5/30 versus 1/26, p = 0.20).The use of tissue sealant as an alternative to surgical drains after parotidectomy facilitates reduced LOS and cost savings without increase in morbidity.

Background Endoscopic thyroidectomy offers excellent cosmetic outcomes, but requires a period of time for surgeons to become proficient. We examined the learning curve for the first 100 cases experienced by a single surgeon using a video-assisted neck surgery (VANS) subclavian approach. Methods We retrospectively studied 100 patients (99 women, 1 man; mean age, 36.2 years) with both benign and malignant thyroid diseases treated between 2016 and 2020. Results Preoperative diagnosis was papillary thyroid carcinoma (PTC) in 36 cases and other (non-PTC) in 64 cases. All patients underwent lobectomy, with unilateral central node dissection added for patients with PTC. Mean operative time was 125 min for non-PTC cases and 129 min for PTC cases (p = 0.43), with blood loss of 33.8 ml and 7.6 ml, respectively (p = 0.01). Recurrent laryngeal nerve paralysis (RNP) was observed in 12 patients (12%) and hemorrhage in 2 patients (2%). Comparing the first 30 cases with the last 70 cases, no significant differences in operative time or blood loss were evident, although tumor size of non-PTC cases was significantly greater among later cases (32.4 mm vs. 39.5 mm, p = 0.039). RNP was significantly decreased in later cases (26.7% vs. 5.7%, p = 0.003). Multivariate analysis revealed tumor size as a significant risk factor for increased blood loss, and increased experience correlated significantly with the decrease in RNP. Conclusions In VANS, a certain surgical level was reached after experiencing 30 cases.

Recent years there have been witnessed considerable advances in endoscopic selective lateral neck dissection (LND). However, dissection of lymph nodes at level IV and level VI via the chest approach is inherently challenging. In this study, we used combined trans-oral and chest approach for endoscopic thyroidectomy in patients with cT1-2N1bM0 papillary thyroid carcinoma (PTC).Clinical characteristics and surgical outcomes of ten patients with cT1-2N1bM0 PTC who underwent endoscopic thyroidectomy via combination of trans-oral and chest approach between September 2020 and September 2021 were retrospectively reviewed.All 10 patients successfully underwent total thyroidectomy and selective LND via chest approach, while central neck dissection (CND) and supplementary dissection of lymph nodes at level IV were performed via the trans-oral approach. The mean number of positive/retrieved level II, III-IV, and VI lymph nodes were 0.6 ± 1.0/9.8 ± 5.0, 4.6 ± 2.8/23.1 ± 4.7, and 4.9 ± 3.4/10.3 ± 4.6, respectively. Four patients developed transient hypoparathyroidism which spontaneously resolved within 1 month. Five patients developed numbness of lateral neck and ear and one patient experienced limb lift restriction. No other complications or tumor recurrence occurred during follow-up.It is feasible to perform total thyroidectomy, CND, and selective LND via combined trans-oral and chest approach, and satisfactory short-term outcomes were observed in this cohort. This approach may offer one more option for cT1-2N1bM0 PTC patients, especially those in whom metastatic lymph nodes at level IV or level VI are detected by preoperative examination.

Papillary thyroid carcinomas (PTC) arising from the isthmus have aggressive clinical and pathological features, especially regarding the Delphian lymph node (DLN), which are associated with poor overall and disease-specific survival of patients with head and neck cancer. In the present study, we evaluated clinicopathological characteristics in 195 DLN-positive isthmus PTCs (14.9%) and their lymph node metastatic pattern in 1305 isthmus PTC patients in our hospital between January 2016 and July 2019. Furthermore, a multivariate analysis was conducted to investigate independent risk factors for isthmus PTC with a positive DLN. The results showed that a positive DLN was significantly related to tumour size, extrathyroid extension, median number of DLN, and metastasis to the central, bilateral central, lateral, and pretracheal lymph nodes. Meanwhile, patients with DLN-positive PTC had a significantly increased incidence of suspected preoperative lymph node status than patients with DLN-negative PTC. Multivariate logistic regression of DLN metastasis in PTC located in the isthmus showed that tumour size, extrathyroid extension, and metastasis to the central, bilateral central, lateral, and pretracheal lymph nodes, were independent risk factors.

OBJECTIVE To investigate the outcomes of patients with mucoepidermoid carcinoma of the palate undergoing pedicled facial-submental artery island flap (FSIF) reconstruction following resection. PATIENTS AND METHODS 41 patients with early stage disease and 9 patients with advanced-stage disease underwent radical excision and neck dissection. 37 IIb, 4 class IIa and 9 IIIb maxillary defects were reconstructed with FSIF, folded FSIF or folded FSIF with titanium mesh respectively. The skin paddles were 3 × 8 to 5 × 15 cm and 3 × 8 to 5 × 14 cm, respectively. 5 patients with high grade disease were treated with cobalt 60 adjuvant radiotherapy after operation. RESULTS One flap failure occurred, yielding a success rate of 98.0% in the reconstruction of palate II and III defects with FSIF or titanium mesh. The patients were seen for follow-up for 16-60 months postoperative. 76.0% patients alive with no disease (AND); 14.0% patients alive with disease (AD) and 10.0% died of disease (DD). Rates of AND, AD and DD differed significantly according to histopathologic grade and TNM stage (P

Objective Sentinel lymph node biopsy (SLNB) has been proved to be as efficient as selective neck dissection (SND) for the treatment of occult metastases in T1-T2cN0 oral squamous cell carcinoma (OSCC). The aim of our study was to assess and compare the cost of these two surgical procedures. Patients and methods This retrospective cost analysis includes consecutive patients treated between 2012 and 2017 in two French hospitals either by SLNB or SND. Hospital cost (hospital stay for initial surgery and re-hospitalizations over a period of 60 days after the initial surgery), the length of hospital stay for the initial surgery and the perioperative management were described and compared between the two techniques. The propensity score regression adjustment method was used to address selection bias. Results Ninety-four patients underwent SLNB procedure and seventy-seven patients underwent SND. The length of hospital stay for initial surgery was lower in SLNB group: 5.8 days (SD: 3.8) versus 9.2 days (SD: 5) in the SND group. Hospital costs were lower in SLNB group: €7 489 (standard deviation: €3 691) versus €8 886 (standard deviation: €4 381) but this difference was not significant after propensity score regression adjustment. The rate of complication, the delay of full oral feeding and postoperative drainage were lower in SLNB group. Conclusion SLNB in T1-T2cN0 OSCC is less invasive than SND with fewer complications, a shorter length of hospital stay and favorable perioperative management. This study shows that this technique could be also less expensive than SND.

The objective of this study was to investigate the correlation between magnetic resonance imaging (MRI) characteristics of cervical lymph nodes and the pathologically confirmed status of cervical lymph node metastasis (LNM) in oral squamous cell carcinoma (OSCC) and to provide imaging evaluation parameters for the clinical diagnosis of cervical lymph node status in OSCC.In a retrospective analysis, 79 patients who were first pathologically diagnosed with OSCC were included. The MRI-derived imaging parameters of the cervical lymph nodes were evaluated and the pathological status of lymph nodes in neck dissection specimens was reviewed. The relationship between the imaging parameters and cervical LNM was analyzed.The MRI-derived imaging parameters of 4419 lymph nodes were evaluated, and the pathological status of 2463 lymph nodes was reviewed. The MRI-derived shortest axial diameter (SAD) and unclear boundary of the cervical lymph node were significantly related to LNM. The cutoff value of SAD that enabled identification of LNM was 3.6 mm, and it was 4.2 and 4.1 mm for the prediction of overall survival and disease-specific survival, respectively.The MRI-derived parameters SAD and unclear boundary of the cervical lymph node correlated with LNM in OSCC. MRI-derived SAD larger than 3 mm warrants simultaneous neck dissection at initial surgery.

Background Parapharyngeal lymph node metastasis is very rare in patients with thyroid carcinoma. In this study, we elucidated on the clinical features, diagnosis, surgical treatment, and outcomes for patients with parapharyngeal lymph node metastases from thyroid carcinoma. Methods Patients with thyroid carcinoma who had been subjected to surgery through the transcervical approach at our institution between April 1999 and January 2019 were retrospectively enrolled in this study. Results Parapharyngeal lymph node metastases were successfully resected through the transcervical approach in all the 97 patients. There were 32 treatment-naive patients, while 65 patients had a history of treatment before parapharyngeal lymph node metastases. All 97 cases of parapharyngeal lymph node metastases were detected by enhanced CT scans. Lateral neck lymph nodes metastases were confirmed in 96 patients. Unexpected postoperative neurological side effects were reported in 11 (11%) patients, including dysphagia in 5 (5%) patients, Horner’s syndrome in 2 (2%) patients, glossal deviation in 3 (3%) patients, and asymmetrical mouth in 1 (1%) patient. During the follow-up period, 6 of the 97 patients exhibited parapharyngeal lymph node recurrence (recurrence rate 6.2%). The incidence of distant metastases was 44.3% (43 out of 97). The 5- and 10-year disease-specific survival was 93.4% and 88.9%, respectively. Conclusion Parapharyngeal lymph node metastases should be considered in patients with widespread cervical lymph node metastases. Enhanced CT scan is one of the best methods for diagnosing such metastases. Surgical resection through the transcervical approach is an effective and safe option for patients with parapharyngeal lymph node metastases from thyroid carcinoma. Moreover, parapharyngeal lymph node metastasis is associated with distant metastases that may lead to poor prognosis.

Pseudotumors of the sternoclavicular joint are rare, poorly characterized pseudoneoplastic lesions previously reported in association with prior neck dissection and thought to result from mechanical instability of the muscles of the shoulder girdle. We report 25 examples of this distinctive process, occurring in patients without a history of neck dissection, typically sent in consultation out of concern for a primary bone or soft-tissue tumor. Cases occurred in 14 women and 11 men (median = 68 years of age) and involved the sternoclavicular joint (17 cases), sternomanubrial joint (2 cases) or other nearby locations (6 cases). The masses ranged from 0.4 to 6.4 cm in size (median = 2.2 cm). Twenty-one patients (84%) had a clinical history of osteoarthritis involving other joints. Clinical follow-up (16 patients; mean = 11.4 months; range = 2-40 months) was uniformly benign, without evidence of recurrent disease. Radiologic review showed changes of osteoarthritis, often with cystic change. Pathologic features included degenerating cartilage, fibrinoid debris, pseudocyst formation, and florid proliferation of myofibroblasts and capillaries. The differential diagnosis of sternoclavicular/sternomanubrial pseudotumors centers around cartilaginous tumors of bone, in particular chondrosarcoma. Careful clinical, radiographic, and pathologic correlations are essential in arriving at the correct diagnosis and avoiding overtreatment.

Historical studies of the anatomy of the spinal accessory nerve (SAN) have reported conflicting results regarding its relationship with the internal jugular vein (IJV). A literature review was undertaken to establish the prevalence of anatomical variations of the SAN encountered during routine neck dissection surgery, in order to increase awareness and reduce morbidity associated with iatrogenic SAN injury. The published literature was analysed by qualitative synthesis and nine articles were yielded following application of the inclusion and exclusion criteria. Incidences of the SAN lateral to the IJV and medial to the IJV ranged from 39.8% to 96.6%, and 2.6% to 57.4%, respectively. Five of the studies reported incidences of the SAN traversing the IJV, which occurred in 0.9% to 2.8% of cases. One study reported an isolated variant of the SAN dividing around the IJV, with a prevalence of 0.5%. We present a case report demonstrating the rare variant of the SAN traversing the IJV. Preoperative identification of rare anatomical association of the SAN and IJV may reduce perioperative injury to vital structures during neck dissection.

Occult cervical lymph node metastasis is a significant prognostic factor in patients with early-stage (cT1/2N0) oral squamous cell carcinoma (OSCC). The aim of this study was to investigate the potential value of the tumor-stroma ratio (TSR) as a histological predictor of occult cervical metastasis and survival in early-stage OSCC. This retrospective study included 151 patients who underwent excision of the primary lesion and elective neck dissection from 2013 to 2017. The clinicopathological features of the tumor, risk factors associated with occult neck metastasis, and prognostic factors for overall survival (OS) and disease-free survival (DFS) were studied. A significant correlation of TSR (P = 0.009) was found with occult neck metastasis in the multivariate logistic regression model. Multivariate Cox proportional hazards regression analysis showed that the TSR (P = 0.002) and perineural invasion (P = 0.011) were associated with OS. Occult neck metastasis (P = 0.032) was associated with DFS. These findings indicate that assessment of the TSR might be useful in prognostication for early-stage OSCC patients. Moreover, the TSR is effective in allowing an accurate evaluation of the risk of occult neck metastasis, and this may be easily applicable in the routine pathological diagnosis and clinical decision-making for elective neck dissection.

Transoral robotic surgery (TORS) is becoming widely used in Japan, and information on postoperative hemorrhage is needed. We treated a patient who developed a second massive postoperative hemorrhage on Day 35 post-TORS. The 69-year-old man was diagnosed with p16-positive, T1N1M0 stage I cancer of the anterior wall of the oropharynx. Curative treatment began with right neck dissection. The external carotid artery and its branches were not ligated. One month after right neck dissection, TORS was conducted. On Day 23 post-TORS, the patient was brought to the emergency room due to pharyngeal bleeding. Hemorrhage was stopped by reclosing the site with Z-shaped silk sutures. Severe hemorrhage recurred on Day 35 post-TORS. The patient went into hemorrhagic shock. Tracheostomy was immediately performed. The neck dissection wound was then opened and the external carotid artery clamped. Hemostasis was confirmed transorally, but the hemorrhage site was again sutured with Z-shaped silk sutures to stop the bleeding. The patient was discharged on Day 58 post-TORS. Even in hindsight, this hemorrhage would have been difficult to prevent with better local treatment. This means that using transcervical arterial ligation together with TORS is appropriate from the perspective of making every effort to prevent potentially fatal postoperative hemorrhage.

Black thyroid is characterized by a rare pigment change observed almost exclusively in patients taking minocycline. We present the case of a 72-year-old man diagnosed with T3N3bM0 stage IVB hypopharyngeal squamous cell carcinoma who had been taking minocycline for approximately 18 months as a treatment for prurigo chronica multiformis. Initial treatment consisted of total pharyngolaryngoesophagectomy, bilateral neck dissection, total thyroidectomy, pharyngeal reconstruction using a free jejunal autograft, and creation of a permanent tracheostoma. During surgery, black discoloration of the thyroid and trachea was observed. Postoperative histological findings confirmed the black discoloration, with deposits of dark-brown, melanin-like granules observed in the thyroid, trachea, thyroid cartilage, and cricoid cartilage. Therefore, the black discoloration of the thyroid associated with the use of minocycline can extend to the thyroid cartilage, cricoid cartilage, and trachea. This information is important for surgeons to recognize in order to prevent unnecessary resection due to misdiagnosis.

Background Parathyroidectomy for primary hyperparathyroidism (pHPT) is safely performed in the outpatient setting in the adult population. However, concern that children and adolescents have higher complication rates and are unable to recognize and communicate symptoms of hypocalcemia has limited same-day discharges in the pediatric population. Methods Nineteen patients aged 8–18 years (14.1 ± 0.7) underwent outpatient parathyroidectomy for pHPT by a single high-volume endocrine surgeon from 2002–2020. Patient demographics, disease, operations, and complications were reviewed. Results Sixteen of 19 patients were symptomatic with fatigue (62.5%), joint pain (37.5%) and nephrolithiasis (18.7%) most common. Mean preoperative Ca and PTH were 11.7 ± 0.3 mg/dL and 102.3 ± 11.8pg/mL, respectively. Ten of 19 had a single adenoma and 9 had multigland hyperplasia including one MEN1 and one MEN2A patient. We performed 11 four-gland explorations, 8 unilateral parathyroidectomies; including 9 transcervical thymectomies, 1 total thyroidectomy, and 1 bilateral central neck dissection. Mean 6-month postoperative Ca and PTH levels were 9.5 ± 0.3 mg/dL (range 7.3–10.3) and 29±5.0pg/mL (range 6.3–77), respectively. One patient developed permanent hypoparathyroidism and 1 had temporary hypocalcemia. No temporary or permanent hoarseness, unplanned same-day admission, wound complications, or Emergency Department visits occurred. Conclusion Outpatient parathyroidectomy can be safely and effectively performed in pediatric patients with primary HPT. Level of Evidence Treatment Study, Level III.

Papillary thyroid carcinoma (PTC) accounts for the majority of thyroid malignancies; risk of PTC recurrence over a 30-year period is approximately 30%, of which 70% occur as nodal metastases. Patients with nodal disease who are treated with therapeutic dissection are at higher risk for recurrence, but optimal nodal yield has not been defined. We aim to determine variables predictive of nodal recurrence of PTC within the first 5 years of surgery, with a focus on lymph node ratio (LNR), to inform clinical decision-making.Retrospective chart review identified 41 patients with nodal recurrence of PTC and 284 without nodal recurrence following thyroid surgery from 2000 to 2015. Cohorts were compared with regards to clinical history, surgical findings, and tumor characteristics.The fraction of the patients who underwent therapeutic central or lateral lymph node dissection was significantly higher in the nodal recurrence cohort. Maximum tumor size, presence of extrathyroidal extension, largest lymph node focus, LNR, postoperative thyroglobulin level, and administration of postoperative radioactive iodine were significantly increased in the PTC nodal recurrence group. LNR greater than 0.3 held the highest level of significance as a binary cutoff and captured the larger proportion of patients in the nodal recurrence cohort (68.3%).This study demonstrates characteristics to help assess risk of nodal recurrence of PTC and suggests LNR of lower than 0.3 is optimal to reduce risk of recurrence. The next steps include cohort studies to validate findings and weight variable analysis to optimize the extent of surgical therapeutic dissection.4 Laryngoscope, 132:1883-1887, 2022.

To verify the feasibility of the SF-MPF for oral reconstruction, the anatomic, sonographic and histologic features of the SF-MPF were investigated and the outcome in a series of patients was evaluated. The sonographic and histologic results showed a supra-fascial arterio-venous vascular blood supply to the sub-fascial design of the MPF. The clinical course of 12 consecutive patients who underwent oral reconstruction using the SF-MPF along with ipsi- or lateral neck dissection for treatment of oral cancer showed sufficient pedicle length and reliable blood supply. The SF-MPF is a reliable and safe pedicled myocutaneous flap. Therefore, it should be considered being an additional option when a pedicled flap has to be selected.

The lymph node ratio (LNR) has been proposed as an independent prognostic factor for survival in patients with oral squamous cell carcinoma (OSCC). However, little attention has been paid to its role in the specific subsite of the floor of the mouth (FOM). The purpose of this study was to evaluate the prognostic significance of the LNR in patients with FOM SCC. A retrospective analysis of 92 patients with FOM SCC who were treated with primary curative resection and neck dissection was conducted. Overall survival (OS) and disease-free survival (DFS) were used to evaluate the prognostic significance of the LNR. Both of these parameters were significantly worse (P0.001) in patients with neck metastases. The mean LNR was 0.145 in patients with positive lymph nodes. A LNR0.145 was predictive of longer DFS, while the receiver operating characteristic curve analysis demonstrated that a LNR ≥0.175 indicated a significantly lower OS. This study confirms that metastatic cervical lymph nodes correlate with an adverse prognosis in patients with FOM SCC, and specifically, a LNR ≥0.145 is predictive. Therefore, the LNR in patients with FOM SCC may be a predictor of survival in these patients.

Background: Multiple endocrine neoplasia type 2A (MEN 2A) is mainly caused by germline RET codon C634 mutation and is characterized by Medullary Thyroid Carcinoma (MTC), pheochromocytoma (PHEO), and hyperparathyroidism (HPTH). The early diagnosis and initial normative treatment are helpful for the long-term outcome of MEN2A. Methods: Three index cases and their 29 relatives from three families with MEN2A were included in this study. Genetic screening was performed on all participants. Demographic, clinical profiles, tumor histopathologic features, and follow-up records were systematically analyzed. Results: In total, RET C634Y mutation was identified in 10 individuals (10/32, 31.3%). Among them, 5 presented with MTC symptoms, whereas the other 5 did not show apparent clinical manifestation, and all were subjected to thyroidectomy with varying neck dissection. Compared to individuals in the former, the latter benefited greatly from RET screening with significantly younger age at diagnosis of MTC and surgery (18.1 ± 13.8 years vs. 39.0 ± 14.1 years, P =0.045), and lessaggressive MTC behavior (size: 0.74 vs. 2.82 cm, P =0.026; LN+/resected: 20.0% vs. 100.0%, P =0.048) and also lower recurrence rate of MTC (20.0% vs. 100.0%, P =0.048). The PHEO was identified in 6 of the 10 carriers (60.0%), and all had undergone adrenal-sparing surgery. During the 10 years of follow-up, one (16.7%) developed recurrence of PHEO. Conclusion: Integrated RET screening, serum calcitonin, and plasma metanephrine/ normetanephrine levels can facilitate the early diagnosis and standardized MTC/PHEO surgery to improve the prognosis of MEN2A. Laparoscopic adrenal-sparing surgery prior to the bilateral total thyroidectomy is a preferred surgical approach for PHEO.

Surgery for thyroid cancer via endoscopic approach was still controversial. Herein, we report the indications, strategies for operative techniques, as well as results for endoscopic central lymph node dissection of thyroid cancer via chest-breast approach (ETCB-CLND).A retrospective analysis was conducted on the cases of DTC, whom underwent ETCB-CLND from January 2013 to June 2020. Three hundred and twenty-three cases underwent ETCB-CLND (endoscopic group) and 267 cases underwent open surgery (open group). General characteristic, surgical results, thyroglobulin (Tg), radioactive iodine uptake (RAIU), radioactive technetium uptake (RATU), radionuclide imaging of the thyroid residual area (RITRA), and radionuclide imaging of suspicious lymph nodes metastasis (RISLNM) were analyzed and compared between the two groups.The age of the endoscopic group were lower than that of the open group. The operation time of lobectomy in endoscopic group were longer than that in open group. The gender distribution (P = 0.831), operation time of total thyroidectomy (P = 0.311), intraoperative blood loss (P = 0.672), postoperative hospital stay (P = 0.852), tumor size (P = 0.259), number of cases of lymph node metastasis (P = 0.618), number of dissected lymph nodes (P = 0.681), number of metastatic lymph nodes (P = 0.723), and complications (P = 0.749) did not differ significantly between groups, nor did the surgical range (P = 0.661), Tg at 1 month (P = 0.61) and 1 year (P = 0.67) after surgery, before (P = 0.589) and after (P = 0.593) radioiodine therapy, RAIU-2 h/24 h (P = 0.906/0.582), RATU (P = 0.532), (The rational and normative application of the endoscopic technique in central lymph node dissection of DTC is safe, feasible, and consistent with the principle of radical tumor cure for selected cases by well-trained surgeons.

Extensive lymph node metastasis (ELM) can occur in some patients with T1 papillary thyroid cancer (PTC). However, the risk factors for ELM in patients with T1 PTC have not been fully explored. In this study, we aimed to examine the association between extranodal extension (ENE) and ELM in patients with T1 PTC.We identified 645 consecutive patients who had T1 PTC initially resected at our centre. Clinical and pathological data were reviewed. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for ELM.ELM was identified in 3.9% of T1 PTC patients, and ENE was identified in 8.1% of patients. ENE was associated with male sex, large tumour size, more positive nodes, and comprehensive surgical treatment. In multivariate analysis, three variables were independently associated with ELM, including ENE (odds ratio [OR], 11.15; 95% confidence interval [CI], 4.54 to 27.30; P 0.001), age (OR, 0.96; 95% CI, 0.93 to 0.99; P = 0.022), and tumour size (OR, 1.18; 95% CI, 1.06 to 1.31; P = 0.002). Bilateral multifocality and sex were not independently associated with ELM.ENE is a strong independent predictor of ELM in patients with T1 PTC. Patients with ENE-positive nodes might need extensive neck dissection.

This article reviews the various treatment options, by primary or postoperative external radiotherapy and by brachytherapy for the p16-negative oropharyngeal squamous cell carcinoma. Dose levels, fractionation and association with systemic treatments are presented. The need for neck node dissection post local treatment is discussed, as well as specificities for the management of p16-positive tumours. Guidelines for target volume selection and delineation are thoroughly elaborated. Last, the management by radiotherapy of locoregional recurrences is discussed.

To explore the application of supraomohyoid neck dissection via retroauricular hairline incision in patients with oral cancer, thereby providing a basis for the surgical treatment of patients with oral cancer in clinical practice.A total of 68 patients with oral cancer who met the inclusion criteria and exclusion criteria were included in our hospital from August 2018 to June 2020. According to the random number table method, they were divided into the experimental group (34 cases), in which patients underwent supraomohyoid neck dissection via retroauricular hairline incision, and control group (34 cases), in which patients received neck dissection.The operation time was significantly longer and the intraoperative bleeding was significantly less in the experimental group compared with those in the control group (both P 0.05). No significant differences in postoperative drainage, number of detected lymph nodes and length of hospital stay were detected between the two groups. One month after surgery, the scores of pains, muscle strength, range of motion and daily activities were significantly higher in the experimental group than those in the control group (all P 0.05). Three months after surgery, the scores of pains, muscle strength, range of motion and daily activities were higher compared with those at one month after surgery in both groups, and these scores in the experimental group were higher than those in the control group (all P 0.05). In addition, the scores of shoulder function, language, deglutition, chew, work, entertainment, activity of daily living, facial features, pain and degree of satisfaction to the scars in the experimental group were significantly higher than those in the control group one month after surgery (all P 0.05).Supraomohyoid neck dissection via retroauricular hairline incision can reduce the amount of intraoperative bleeding in patients with oral cancer, is beneficial to the recovery of shoulder joint function, improves the patient's quality of life and the degree of satisfaction to the scars, reduces the occurrence of related complications. It has relatively high safety and is worthy of clinical application and promotion.

Background The scapular osseous free flap (SOFF) has become an important reconstructive option for complex head and neck defects. Postoperative donor site function is, however, an important consideration. The objective of this study was to prospectively investigate SOFF donor site morbidity and to relate the findings to hand dominance and neck dissection. Methods Objective assessment included bilateral measurement of shoulder, elbow, and hand range of motion (ROM), hand strength, and distal nerve function in consecutive patients with head and neck cancer SOFF reconstruction at a tertiary referral center in Sweden between 2016 and 2019. The subjective function was assessed by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Results Sixteen of 20 consecutive patients were evaluated (median follow-up 10 months [range 3–17]). Significant side differences in shoulder range of motion (ROM) (flexion, abduction, external and internal rotation) were observed for patients where the SOFF had been harvested from the same side as their dominant hand (n = 9; Ps ≤ 0.04). For patients where the SOFF was harvested from the non-dominant hand side, no significant shoulder ROM side differences were observed (n = 7; Ps ≥ 0.08). There were significant side differences in shoulder ROM for patients who underwent neck dissections (n = 12; Ps ≤ 0.03), not for the other four patients. Patients reported low but varying DASH scores (median 2.5, range 0–57). Conclusion Postoperative donor site morbidity seems to be quite acceptable after SOFF surgery. The results indicate possible benefits of choosing the non-dominant hand side for the SOFF and that a neck dissection affects postoperative shoulder outcome. Further studies are however needed.