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Due to the risk of occult cervical metastasis, elective neck dissection (END) is recommended in the management of patients with early oral cavity squamous cell carcinoma (OSCC) and a clinically node-negative (cN0) neck. This paper presents a systematic review and meta-analysis of studies that recorded isolated regional recurrence (RR) in the pathologically node-negative neck dissection (pN0) neck following END in order to quantify the failure rate. Pubmed and Ovid databases were systematically searched for relevant articles published between January 2009 and January 2019. Studies reporting RR following END in patients with OSCC who had no pathological evidence of lymph node metastasis were eligible for inclusion in this meta-analysis. In addition, a selection of large head and neck units were invited to submit unpublished data. Search criteria produced a list of 5448 papers, of which 18 studies met the inclusion criteria. Three institutions contributed unpublished data. This included a total of 4824 patients with median follow-up of 34 months (2.8 years). Eight datasets included patients staged T1-T4 with RR 17.3% (469/2711), 13 datasets included patients staged T1-T2 with RR 7.5% (158/2113). Overall across all 21 studies, isolated neck recurrence was identified in 627 cases giving a RR of 13.0% (627/4824) on meta-analysis. Understanding the therapeutic effectiveness of END provides context for evaluation of clinical management of the cN0 in these patients. A pathologically negative neck does not guarantee against future recurrence.

The evaluation of speech outcomes after resection and reconstruction of the oral tongue remains largely unsystematic. A cross-sectional study was performed to analyse the speech outcomes of patients who underwent curative treatment with appropriate reconstruction. Sixty-nine patients were assessed for speech intelligibility and phonetics using a validated speech intelligibility assessment tool in the local language. Volume defects were classified as class I (less than one third), II (one third to half), III (half to two-thirds), or IV (two-thirds to total glossectomy). Defect location was defined as lateral, tip, or sulcus. The χ2 test and Kruskal-Wallis test were used to test volume and location as predictors. Twenty-six patients had class I defects, 29 had class II defects, seven had class III defects, and seven had class IV defects. Twenty-two patients (31.9%) received adjuvant radiotherapy. Mean vowel, consonant, word, and paragraph intelligibility were 99.27%, 86.86%, 85.52%, and 88.72%, respectively. The incremental volume of the glossectomy defect was significantly correlated with speech intelligibility scores and phonatory alterations. In classes II and III, tip resection significantly affected interdental sounds. All patients in class III had affected alveolar and alveo-palatal sounds. The results positively corroborated the volume and location of the glossectomy defect to a classification system.

The aim of this study was to identify patterns of tumor growth as revealed on magnetic resonance imaging (MRI) and to evaluate the correlation of these patterns with histopathologic features and rates of recurrence, disease-free survival (DFS), and overall survival (OS).In a retrospective analysis of patients with tongue carcinoma, tumor advancing margins, patterns of tumor enhancement, and enhancement beyond tumor margins were studied on MRI. Histopathologic findings included differentiation, margin status, perineural invasion (PNI), and lymphovascular invasion (LVI). MRI and histopathologic features were correlated with outcomes.Ill-defined tumor margins and enhancement beyond tumor margins were associated with recurrences (P ≤ .001) regardless of perineural invasion or LVI. DFS and OS were adversely affected by ill-defined tumor margins (P ≤ .010). DFS was also affected by enhancement beyond the tumor margins (P.001). A heterogeneous pattern of enhancement showed a trend toward a decrease in DFS and OS (P = .088 and .092, respectively). Advancing tumor margins on MRI were independent predictors of overall survival. MRI characteristics exhibited significant associations with histopathologic margins, PNI, and LVI.Ill-defined advancing tumor margins, a heterogeneous pattern of enhancement, and enhancement beyond the tumor margins on MRI adversely affect outcomes and prognosis in tongue carcinoma.

Background The purpose of the study was to evaluate the oncological outcomes of salvage surgery in squamous cell carcinoma of the head and neck (SCCHN). Methods This is a retrospective analysis of all patients of SCCHN with recurrence or second primary, post-treatment, who underwent salvage surgery. The outcomes were analyzed in terms of overall survival, overall survival postsalvage surgery and disease-free survival (DFS) postsalvage surgery. Clinical and pathological predictors were considered. Results Two hundred and forty-one patients were included. The mean follow-up was 56.33 months. Five-year survival OS from date of initial diagnosis of the tumor was 61.2%. The 5-year OS survival after salvage surgery was 47.1%. Five-year DFS after salvage surgery was 28.1%. Prior chemoradiotherapy and pathological perineural invasion were independent predictors on multivariate analysis. Conclusions Survival outcomes after appropriate salvage treatment are good. Prior chemoradiotherapy and perineural invasion on salvage pathology are predictors of poorer outcomes.

ObjectivesPharyngocutaneous fistulae are dreaded complications following total laryngectomy. This paper presents our experience using 3–5 ml gastrografin to detect pharyngeal leaks following total laryngectomy, and compares post-operative videofluoroscopy with clinical follow-up findings in the detection of pharyngocutaneous fistulae.MethodsA retrospective case–control study was conducted of total laryngectomy patients. The control group (n = 85) was assessed clinically for development of pharyngocutaneous fistulae, while the study group (n = 52) underwent small-volume (3–5 ml) post-operative gastrografin videofluoroscopy.ResultsIn the control group, 24 of 85 patients (28 per cent) developed pharyngocutaneous fistulae, with 6 requiring surgical correction. In the study group, 24 of 52 patients (46 per cent) had videofluoroscopy-detected pharyngeal leaks; 4 patients (8 per cent) developed pharyngocutaneous fistulae, but all cases resolved following non-surgical management. Patients who underwent videofluoroscopy had a significantly lower risk of developing pharyngocutaneous fistulae; sensitivity and specificity in the detection of pharyngocutaneous fistulae were 58 per cent and 100 per cent respectively.ConclusionSmall-volume gastrografin videofluoroscopy reliably identified small pharyngeal leaks. Routine use in total laryngectomy combined with withholding feeds in cases of early leaks may prevent the development of pharyngocutaneous fistulae.

Reconstruction of long tracheal defects still proves to be a challenge. Free fasciocutaneous flaps with cartilaginous struts or an allotransplant trachea have been reported but not been widely performed. This article reports with the experience of using a tracheal allotransplant in such a defect.A 43-year-old lady presented with adenoid cystic carcinoma involving the entire trachea from subglottic area up to the carina, leading to a life-threatening airway occlusion. After preliminary stenting, allotransplant trachea obtained from a brain-dead individual was revascularized in the forearm of the patient after mechanical decellularization to reduce the immune load and fulfil the need for immunosuppression in the background of active cancer. Subsequently, the trachea and larynx were resected. The vascularized neotrachea was transferred successfully into the neck. The patient did well initially but succumbed to a fatal hemorrhage due to innominate vein aneurysmal rupture on the 22nd day after the transplant.The technical details of resection, fabrication of the neotrachea, its transfer, and the lessons learnt in this tracheal allotransplant are described.

Radial forearm free flap (RAFF) is the workhorse flap for oral cavity reconstruction. In the context of oncological reconstruction with radial forearm flap, the patient-reported outcomes of donor site morbidity amongst Indian patients have not been reported previously. Cultural and racial differences prevent extrapolation of morbidity data from Western literature. We aimed to evaluate subjectively the subjective long-term functional and aesthetic outcomes of the RAFF donor site. Patients who underwent RAFF reconstruction for intra-oral defects between 2014 and 2016 were included. Two questionnaires (Cosmesis and Sensibility and Forearm Disability) were administered. Fifty-two patients who completed a 2-year follow-up were identified. Thirty-five patients (67%) had complaints regarding the donor site. With regard to cosmesis and sensibility, hand numbness was seen in 21 (40.4%) patients. With regard to forearm disability, a problem in lifting heavy weights was seen in 22 (42.3%) patients. Only three patients in the entire cohort had complaints regarding the cosmesis of the forearm scar. Overall disability score was low (7.83). With regard to donor site morbidity, numbness and difficulty in lifting weights was the most common complaint. There is good acceptance of the donor site and scar with minimum morbidity. These findings are useful for the preoperative counselling of the patients. This is the first Indian study evaluating the long-term subjective outcomes of the radial forearm donor site. We believe the RAFF is still the most preferred flap for oral reconstruction.

Objectives To study the determinants of locoregional control (LRC) on stage I/II oral squamous cell carcinoma (OSCC) classified by AJCC 8th edition. Methods Retrospective analysis from 296 patients of pT1-2N0 oral OSCC treated with surgery (wide local excision and selective neck dissection). Those receiving adjuvant therapy were excluded. Multivariate analysis was performed for impact of adverse pathological features (APFs) on LRC. Results In stage I, LRC was impacted by perineural invasion (PNI) (HR 7.72, p = 0.010, 95% CI 1.64–36.26) and moderate/poor differentiation (MD/PD) (HR 3.04, p = 0.049, 95% CI 0.99–9.25). In stage II, LRC was impacted by depth of invasion (DOI) (HR 1.59, p = 0.014, 95% CI 1.099–2.32), PNI (HR = 2.86, p = 0.005, 95% CI 1.36–5.98). Combined MD/PD and PNI were associated with worse LRC than either feature individually (HR = 4.12, p Conclusion PNI and differentiation accurately predict LRC in AJCC 8th edition classified stage I/II OSCC. PNI was a stronger predictor of locoregional failure than DOI in stage II disease. By incorporating these parameters, we can improve precision in staging of early OSCC and identify potential candidates for treatment escalation to improve outcomes.

Purpose of review Marginal mandibular nerve palsy (MMNP) is often an understated complication after neck dissection. This article reviews literature regarding anatomic landmarks that help define marginal mandibular nerve (MMN) during neck dissection, oncologic safety of surgical maneuvers, implications of MMNP, and reconstructive options. Recent findings A thorough knowledge of anatomy of the nerve can aid in its preservation. Course, branching pattern and communications of MMN are extremely variable. The Hayes Martin method classically described to preserve the nerve may not be oncologically safe in patients with prefacial nodal involvement. MMNP significantly affects quality of life after neck dissection. Cause, timing, and degree of neural damage play an important role in determining diagnostic and therapeutic options to correct the deformity resulting from MMNP. Owing to treatment-related factors, functionality of local structures may be compromised, which limits available reconstructive options for the surgeon. This should favor a shift of management option toward more conservative procedures in patients treated for head and neck cancer. Summary When oncologically safe, the MMN must always be preserved. The patient perceived deformity resulting from MMNP is significantly higher than clinician-detected rate. In select patients who are affected by significant smile asymmetry, multiple dynamic and static corrective procedures can be offered.

According to the eighth edition of the AJCC Cancer Staging Manual (AJCC8), a depth of invasion (DOI)10mm is classified as pT3, representing a locally advanced tumour requiring postoperative radiotherapy (PORT). When node-negative, however, evidence regarding whether PORT improves loco-regional control or survival is unclear. To clarify this, two cohorts of patients were studied: (1) patients classified as pT3N0 by the seventh edition of the AJCC manual (AJCC7), with DOI10mm and a tumour diameter4cm (17 patients who received PORT), and (2) patients classified as pT1N0 and pT2N0 by AJCC7, with DOI10mm and a tumour diameter4cm (55 patients who did not receive PORT). Loco-regional control and survival were analysed. PORT was found not to impact overall survival or disease-free survival. It was also found not to impact local, regional, or distant recurrence. Although the two subsets of patients considered here (DOI10mm with tumour diameter below or above 4cm) were previously distinct, they are both considered pT3 in AJCC8. Data from this study indicate that the routine administration of PORT to patients with a DOI10mm may not be warranted in the absence of other risk features such as nodal disease or close margins.

Osteoradionecrosis (ORN) is a painful and debilitating serious late complication following treatment for head and neck cancer (HNC) often requiring surgical resection of the jaw and complex multidisciplinary management. An important aggravating factor for mandibular ORN is surgical trauma, commonly dental extractions or implant placement following head and neck radiotherapy. The evidence on the treatment protocols ranges from conservative management to more radical surgical strategies including the use of hyperbaric oxygen therapy. The available evidence on the preventive approaches for ORN includes prophylactic dental care prior to radiotherapy, the use of hyperbaric oxygen (HBO) treatment and prophylactic antibiotics for post-radiotherapy extractions. However, the efficacy of hyperbaric oxygen therapy has been questioned recently signifying poor understanding of the pathophysiology of the condition and therapies targeting the fibroatrophic process have become a focus of ORN treatment. Implementing recent IMRT radiation techniques has also shown evidence to reduce the incidence of ORN. This review provides an insight into the variations in definition and classification of the ORN, the controversies in its pathophysiology and the advances in the prevention and management.

This study was conducted to evaluate the outcomes of re-exploration procedures done after head and neck microvascular flap reconstructions. This is a retrospective review of 109 flaps in 106 patients (three patients had two flaps each) that underwent re-exploration procedures in 1001 consecutive free flap surgeries. The outcome was analysed in terms of the type of the flaps, re-exploration rate, flap salvage rate and overall flap success rate. Free radial forearm (RFF) was the commonest flap done (354, 35.3%). One hundred nine flaps underwent re-exploration procedures in 106 patients. Out of this, 79 flaps could be salvaged, and 30 flaps failed. There were also another ten flaps, which failed without any re-exploration. The overall re-exploration rate was 10.8%. The flap salvage rate was 72.4%. The overall flap success rate was 96.1%. Nearly three-fourths of the flaps with vascular compromise can be successfully salvaged with appropriate and timely intervention.

The purpose of the present study was to translate and culturally validate the University of Washington Quality of Life Questionnaire, Version 4.1 (UW-QOL v4.1) in Malayalam, a language commonly used in the state of Kerala in India. The tool underwent translation and adaptation. The translated instrument then underwent a pretest survey in 30 patients. The intention was to identify any problems with the questionnaire when applied to the participants and make any minor changes if required. This was followed by validation in 100 patients. The reliability was tested for internal consistency with Cronbach's alpha. Concurrent validity was tested by correlating it with the concurrently administered FACT-HN questionnaire scores. Construct validity was tested using 'Known-group validity.' Pretest survey did not identify any major problems. There was a moderate to strong correlation between the PF, SEF subscales and the composite scores on UW-QOL scores and the Head and Neck Cancer subscale and the FACT-H&N Total score. QOL scores were more in early staged patients and those who underwent no reconstructive procedure. This proved the construct validity. This study validates the Malayalam version of the UW-QOL instrument. It is reliable, valid and culturally adapted.

Background Trans-oral robotic surgery (TORS) and primary radiotherapy are the two modalities used to treat early T stage oropharyngeal squamous cell carcinoma(OPSCC). Prior literature including a recent randomized controlled trial have not shown the superiority of one modality over the other. When the modalities have similar outcomes, cost-effectiveness have an important role in deciding on the appropriate treatment. There are economic evaluations comparing the two modality with contradicting conclusions. The purpose of this review is to synthesise the evidence. Methods This is a systematic review of economic evaluations on the treatment modalities for OPSCC, namely TORS versus radiotherapy. The main outcome measures were the Cost-utility results reported as the effectiveness and costs separately and as part of the Incremental Cost-Effectiveness Ratio. Results Literature search identified five articles reporting cost-utility analysis, eligible for the review. A strategy is considered to be dominant when the effectiveness achieved was more at a lower cost, compared to the comparator. At the willingness to pay (WTP) threshold of 50,000 to 100,000 USD per Quality Adjusted Life-Year (QALY), three studies showed dominance of strategies in the base case analysis (TORS in two and Primary Chemoradiotherapy in one). Two of the articles studied node negative patients, one of them favored TORS. Three articles had node positive patients and two of them favored TORS and one favored chemoradiotherapy in the base case analysis. On sensitivity analysis, adjuvant treatment was found to be the detrimental factor affecting the cost-effectiveness. Conclusions TORS can be considered a cost-effective strategy in early T stage OPSCC, if the addition of adjuvant therapy involving radiotherapy can be avoided. Literature have shown that around 70% of the early cancers would require adjuvant treatment. This implies the importance of case selection while considering TORS as the initial treatment modality.

Introduction Salvage surgery is the treatment option in recurrences and second primary tumors. This paper aimed to study the options and outcomes of reconstruction and the predictors of poor reconstructive outcomes in salvage surgery for head and neck cancers. Study Design This is a retrospective study of all patients who underwent reconstructive flap surgery as part of salvage surgery for head and neck cancers between the years 2004 and 2017. Methods The initial treatment may be single modality radiotherapy or surgery or multimodality with combinations of surgery, radiotherapy, and chemotherapy. Any pathology that required surgical salvage was included. Any procedures done purely as reconstructive surgery were excluded. Predictor variables included demographical, clinical, and treatment factors. The outcome parameter was the occurrence of any flap-related complication or not. The complications and morbidity related to the procedures are reported Results Ninety-three patients underwent loco-regional flaps (LRF group), and 100 had free flaps (FF group). Pectoralis major flap was the commonest flap used in 68 patients (73.1%). Anterolateral thigh (ALT) flap was the commonest free flap and comprised 41% of the FF group. Any skin-related complication was seen in 35 patients (37.6%) and 41 (41%), respectively, in LRF and FF subsets. Any flap-related complication was seen in 16 patients (17.2%) and 29 patients (29%), respectively, in LRF and FF subsets. A summary measure “any one of the complications” was seen in 46 (49.5%) and 57 (57%), respectively, in LRF and FF subsets. Univariate and multivariate analysis for any flap-related complication identified no statistically significant predictor. Conclusions Soft tissue flaps were preferred in salvage reconstruction, though the defects had a bony component. In the microvascular free flap reconstruction era, pectoralis major flap has shifted its role from a “workhorse flap” to a “salvage flap.” About half of the patients develop some complications. Flap-related complications are also common. In salvage surgery, it is important that an appropriate flap is selected, suitable for the setting, according to the indications, neck, and patient conditions.

BACKGROUND Partial pharyngeal defect reconstruction after total laryngectomy with regional and free fasciocutaneous flaps has been described. However, mucosal flaps for such defects have not been reported. METHODS An islanded facial artery musculo-mucosal (FAMM) flap was used to reconstruct a partial pharyngeal defect after total laryngectomy. Surgical, swallowing, and speech outcomes were analyzed at 6 months postoperatively. RESULTS At 6 months, videofluoroscopy showed no post swallow residue, fistula, trachea-esophageal puncture leak, or stricture. Perceptual analysis of recorded cold speech, native language passage sample, and the intelligibility analysis was good. The patient had normal mouth opening and marginal mandibular nerve function. CONCLUSION Islanded FAMM flap is ideal for partial pharyngeal defects, which cannot be closed primarily. Speech and swallowing outcomes were good. It provided a robust and predictable blood supply and adequate reach. There was no significant donor site morbidity. The musculo-mucosal flap replaced "like-with-like" tissue.

Tongue and buccal cancer carcinomas form the major bulk of oral cancers in the Indian subcontinent [1]. Although the diagnosis of tongue and buccal mucosa cancer is straight forward, a vast majority of patients present with locally advanced lesions. Several challenges exist in the management of oral cancer [2]. Standard management of oral cancers is surgical resection of the primary lesion and cervical lymph node dissection with the addition of radiation and/or chemotherapy as adjuvant therapy depending on the histopathological report. Along with the resection of the tumour, primary reconstruction is important to minimize morbidity. The tongue and buccal mucosa play an important role in speech and swallowing and reconstruction is performed to restore acceptable form and function [3]. Also, the reconstruction should be tailored in such a way to maximize the function of the remaining musculature and mucosa.

This study aimed to develop a speech intelligibility tool in Malayalam, an Indian language, based on the perceptual analysis. The tool had components of vowel, consonant, word, passage, and overall intelligibility. After face and content validation, a sample of 30 consecutive oral cancer patients underwent preliminary testing for internal consistency, inter- and intra-rater reliability, concurrent, and known-group validity. Subsequent validation was done in 80 T1–T4 patients from two centers. The scale had a high level of internal consistency; the Cronbach’s alpha was 0.847 and good intra-rater and inter-rater agreement amongst all raters. There was a strong correlation between the Malayalam and the English passage. Pearson correlation coefficient of 0.646 proved concurrent validity. On known-group and subsequent validation, the tool showed expected differences between the treatment groups. The speech tool proved to be reliable and valid for perceptual evaluation of speech intelligibility in oral cancer patients. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13193-020-01216-1) contains supplementary material, which is available to authorized users.

In oral squamous cell carcinoma (OSCC), expression of PDL1 is controversial with expressions showing a positive and negative correlation with survival in previous studies. Additionally, it is unclear whether expression on the tumour or tumour infiltrating lymphocytes (TIL) is a better predictor of survival. We performed this study on a cohort of Indian patients with OSCC to determine impact of PDL1 expression on survival. Retrospective analysis of 64 patients of OSCC treated with curative intent surgery with or without adjuvant therapy was performed. Stored tissue blocks were extracted and quantitative immunohistochemistry was performed for PDL1 expression separately on the tumour and the TIL using commercially available Dako kits. Correlation of clinical and pathological variables with PDL1 expression was performed using chi-square test. Survival analysis was performed using Kaplan-Meier method and Cox proportional hazards ratio. In our cohort, PDL1 expression was low, both in tumour (92% had

BACKGROUND To validate the newly proposed American Joint Committee on Cancer (AJCC) eighth edition staging in early T1 and T2 oral cavity cancers and its effect in predicting tumour control. METHODS Retrospective analysis of treatment outcomes of 441 T1 to T2 oral squamous cell carcinoma (OSCC). Overall survival (OS), disease-specific survival (DSS), and tumour control were calculated and compared between the AJCC 7 and 8 staging systems. RESULTS The 5-year OS was 78% and 61% for T1 and T2 tumours, respetively (P

Population-based studies indicate that chemoradiation has become the most popular treatment for advanced laryngeal cancers; however, by extrapolating trial results to the general population, several issues have emerged, such as reduced overall survival, non-functional laryngeal preservation, and poor response to treatment. Although included in these trials, T4 laryngeal and hypopharyngeal cancers with cartilage invasion formed a small percentage of these patients and questions over whether they were appropriately staged remain unanswered. Literature on the use of chemoradiation in this set of patients, including the challenges, treatment considerations, and factors predicting response to treatment and outcomes, was reviewed. Current evidence indicates that all patients of T4 laryngeal and hypopharyngeal cancer are not suitable candidates for organ preservation; this modality should be offered only to select patients with good performance status and access to rehabilitative care and regular follow-up in order to achieve good results.

Objectives The purpose of this paper is to report the technique and outcomes of the use of gastro-omental free flap reconstruction in glossectomy defects. Materials and Methods This is a prospective case series of 9 patients of tongue squamous cell carcinoma, who underwent either subtotal or partial glossectomy and reconstruction with gastro–omental free flap. The flap anatomy, surgical technique and the outcomes including the swallowing and speech are presented. Results Five patients underwent partial glossectomy and 4 had sub-total glossectomy. The median age was 43 years; and the median follow up was 11.4 months. Laparoscopic harvest was done in 8 patients. There was one flap loss. Seven patients underwent postoperative radiotherapy. Functional evaluation was done in 5 patients who were disease free. Four could tolerate soft diet orally, one patient was on liquid to pureed diet. Speech was intelligible in 4. None of the patients had any complications related to laparotomy or laparoscopy. Conclusion Gastro-omental flap provided a secretory mucosal surface and was beneficial in the saliva depleted patients post radiotherapy. The laparoscopic harvest of this flap has minimized donor site morbidity. One patient had a flap loss. Two patients reported superficial ulcerations on the surface, one of them had to undergo surgical debulking to correct it while the other healed with conservative measures. Speech and swallowing outcomes of the reconstructed tongue was good, especially in patients with partial glossectomy. The reconstructed gastric mucosal flaps tolerated the adjuvant radiation well.

Background: Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction. Materials and Methods: Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction. Results: Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap (n = 29), anterolateral thigh flap (n = 8), gastric pull-up (n = 13) and free jejunal flap (n = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis (P = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour (P = 0.003). Conclusion: Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.

Background: Head-and-neck resections carry a major risk of postoperative pulmonary complications. It adds to morbidity and mortality, adversely affects recovery, and contributes to financial burden. The objective of this study is to find out the incidence of pneumonia and the utility of our institution protocol in the prevention of postoperative pneumonia (POP). Materials and Methods: Retrospective study including patients undergoing oral cavity resection at the tertiary hospital from August 2017 to July 2018. The patients were analyzed in terms of demographic profile, operative findings, and postoperative course. Diagnosis of pneumonia was established by intensivist based on symptoms and signs. Results: Incidence of pneumonia was 5.79% (15 out of 239). Average age of patients with pneumonia was 64.8 years and 60% were male. All had multiple comorbidities. Average preoperative serum albumin was 3.49. POP was seen commonly in patients who had composite resections involving alveolar arch and tongue (26.67%). Majority had reconstruction in the form of free flap (46.6%) with fibula flap being most common. Average intraoperative time was 10.5 h. The most common isolate was Pseudomonas aeruginosa (40%), followed by Klebsiella pneumonia (33.3%). About 26% were multidrug-resistant strains. Average hospital stay was found to be 30.6 days in patients of pneumonia. Conclusions: Data from our cohort indicated a much lower incidence compared to published literature. We attribute this to our routine practice of intensive care unit care in the immediate postoperative setting with a nursing care ratio of 1:1, postoperative early mobilization, frequent tracheal toileting, chest physiotherapy, early diagnosis of pneumonia, and prompt initiation of treatment.

Salivary gland cancers are a complex group of tumours with variations in location, type and grade, all of which influence their biological behaviour. The understanding of salivary gland pathology has evolved at the molecular level in the last decade leading to identification of distinct entities, development of improved methods of diagnosis as well as identifying therapeutic targets for selected high-grade tumours. This article focuses on these advances and their impact on the management of primary salivary gland cancers.

The use of postoperative radiotherapy (PORT) in early stage oral cancer with adverse pathologic features (APFs) is controversial. Prognostically relevant APFs reviewed were perineural invasion, lymphovascular invasion, depth of invasion, worst pattern of invasion, and margin status. The current literature remains divided with regard to the benefit of treatment escalation in these patients; although these patients are at high risk for recurrence, the morbidity of PORT needs to be balanced against the likely benefit in disease control. A wide heterogeneity in the literature exists, likely as a result of differences in treatment protocols. We performed a literature review of the role of PORT in early-stage oral cancer with APFs. Based on the current evidence, the decision to administer adjuvant therapy needs to be made on an individual basis; patients with >1 APF are likely to benefit from PORT, and the use of risk-scoring systems may help in decision making.

Differentiated thyroid cancers (DTC) are seen with increasing incidence in clinical practice. These tumours have good prognosis and the extent of surgery can be tailored to the size and pathological characteristics of the lesion. Historically total thyroidectomy was the recommended procedure for tumours >1 cm; however, current recommendations suggest a more conservative approach. This review focuses on the evolution of the extent of surgery in differentiated thyroid cancer.

Squamous cell carcinoma oral tongue (SCCOT) in patients below 45 years is relatively uncommon in literature; however, there have been increasing trends in incidence. Previous studies showed conflicting data, with no conclusive evidence of differences in outcome compared with older patients. The aim of our study was to determine if younger patients with tongue cancer in India had different clinico-pathological characteristics, prognostic determinants or survival than their older counterparts. Retrospective analysis of 425 adult patients of SCCOT, with 114 patients

ObjectiveElderly patients have been consistently shown to receive suboptimal therapy for cancers of the head and neck. This study was performed to determine the peri-operative outcomes of these patients and compare them with those of younger patients.MethodsIn this retrospective analysis, 115 patients aged 70 years or more undergoing major surgery for head and neck cancers were matched with 115 patients aged 50–60 years, and univariate analysis was performed.ResultsElderly patients had a reduced performance status (p < 0.001) and more co-morbid illnesses (p = 0.007), but a comparable intra-operative course. They had a longer median hospital stay (p = 0.016), longer intensive care unit stay (p = 0.04), longer median tracheostomy dependence (p = 0.04) and were more often discharged with feeding tubes (p < 0.001). They also had a higher incidence of post-operative non-fatal cardiac events (p = 0.045).ConclusionElderly patients with good performance status should receive curative-intent surgery. Although hospital stay and tube dependence are longer, morbidity and mortality are comparable with younger patients.

Recently, there have been significant developments in our understanding of salivary gland pathology, and new entities, such as mammary analogue secretory carcinoma, have been described. Attempts are being made to identify effective therapeutic agents for salivary duct carcinomas by using molecular diagnostic techniques. Concepts such as high-grade transformation have been described, which not only influence macroscopic and microscopic evaluation of a specimen but, given the high incidence of metastases and morbidity, also carry significant treatment implications. Specific chromosomal translocations, which can be detected by fluorescent in situ hybridization, can augment diagnostic accuracy and carry prognostic implications. The landscape of benign salivary gland lesions is changing with better understanding of chronic sclerosing sialadenitis related to IgG4. This multiorgan inflammatory condition may primarily present as a salivary gland lesion and clinically and radiologically mimic a salivary gland malignancy. Histology and immunohistochemistry play a critical role in its accurate diagnosis. The purpose of this article is to review these changes, with an emphasis on their effect on patient management. Given their diagnostic, prognostic, and therapeutic implications, it is critical that surgeons, oncologists, pathologists, and those involved in caring for patients with salivary gland tumors are aware of these changes while considering management options.

Reduced mobility of the mandible known as trismus is a phenomenon frequently seen in head and neck (H&N) cancer patients and patients with temporomandibular disorders [1–3]. Although numerous advancements have occurred in head and neck oncology practice during the past few decades, survival has not improved significantly. Currently, there is a need for clinical trials that focus not only on survival but also on the patient’s experience and health-related quality of life.

Aspiration is the inhalation of oropharyngeal or gastric contents into the larynx and the lower airway. Aspiration of the sterile gastric contents leads to aspiration pneumonitis, whereas aspiration of oropharyngeal contents leads to aspiration pneumonia. The pathophysiology is distinct between the two conditions. It is one of the important causes of pneumonia in the intensive care setting, in patients with oropharyngeal dysphagia secondary to neurological disorders and head-neck cancer patients. This chapter will focus on the aspiration and its management in head and neck cancer patients.

Purpose To determine the factors affecting outcomes in surgically salvaged, locoregionally recurrent squamous cell carcinoma of the tongue (SCCT). Materials and Methods In a retrospective cohort of patients who underwent successful salvage of locoregionally recurrent SCCT, we performed this observational analytical study to determine survival and its determinants. Details extracted from our database were patient characteristics (age, gender, tobacco use), treatment characteristics, and characteristics of recurrent disease (stage and adverse pathologic features [APFs] such as grade, perineural invasion, and lymphovascular invasion). Overall survival (OS) curves were plotted using the Kaplan-Meier method. A Cox proportional hazards model was used to determine the impact of patient, disease, and treatment characteristics on OS. Results Of 52 patients with locoregional recurrences of surgically treated SCCT, 25 (48.1%) underwent surgical salvage with curative intent. The median overall OS for this cohort was 26 months. Factors predictive of worse OS were previous adjuvant therapy (P = .016) and increasing APFs in recurrent tumor histology (P = .008). Lymphovascular invasion in recurrent tumor histology and patients with a disease-free interval of less than 6 months showed worse survival (P = .008 and P = .058, respectively). Conclusions Among patients with locoregional recurrence, the number who are eligible for curative-intent surgical salvage is small. Those who received previous adjuvant therapy and those with increasing APFs in recurrent tumors had poor outcomes despite attempts at surgical salvage, particularly patients with early recurrence.

Pre-operative assessment is vital to determine patient-specific risks and minimize them in order to optimize surgical outcomes. The American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) Surgical Risk Calculator is the most comprehensive surgical risk assessment tool available. We performed this study to determine the validity of ACSNSQIP calculator when used to predict surgical complications in a cohort of patients with head and neck cancer treated in an Indian tertiary care center. Retrospective data was collected for 150 patients with head and neck cancer who were operated in the Department of Head and Neck Oncology, Amrita Institute of Medical Sciences, Kochi, in the year 2016. The predicted outcome data was compared with actual documented outcome data for the variables mentioned. Brier’s score was used to estimate the predictive value of the risk assessment generated. Pearson’s r coefficient was utilized to validate the prediction of length of hospital stay. Brier’s score for the entire calculator was 0.32 (not significant). Additionally, when the score was determined for individual parameters (surgical site infection, pneumonia, etc.), none were significant. Pearson’s r value for length of stay was also not significant (p = .632). The ACSNSQIP risk assessment tool did not accurately reflect surgical outcomes in our cohort of Indian patients. Although it is the most comprehensive tool available at present, modifications that may improve accuracy are allowing for input of multiple procedure codes, risk stratifying for previous radiation or surgery, and better risk assessment for microvascular flap reconstruction.

Traditional neck dissection for oral squamous cell carcinoma (OSCC) involves removal of the submandibular salivary gland. Several studies have cited the low incidence of direct gland invasion by tumours and have recommended gland-sparing neck dissection. In this study, a detailed audit of level Ib involvement in OSCC was performed in order to assess the feasibility of submandibular gland-sparing in neck dissection; the rate of direct involvement by the primary tumours, the involvement of periglandular level Ib nodes, and their determinants were investigated. A total of 586 neck dissection specimens obtained between 2005 and 2014 from patients operated on at the study institution for floor of mouth, tongue, and buccal primaries, were evaluated for direct invasion of the gland and periglandular lymphadenopathy. Of 226 node-positive patients, 21 (9.3%) had direct gland invasion by tumour. Risk factors were tumour diameter >4cm (P=0.002) and depth of invasion >10mm (P=0.003). Determinants of periglandular lymphadenopathy were depth of invasion >10mm (P