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Objective: To assess swallowing outcomes in patients with oropharyngeal carcinoma in relation to the Seikaly-Jha procedure for submandibular gland transfer (SJP). The SJP has recently been described as beneficial in the prevention of xerostomia induced by radiation therapy in patients with head and neck cancer., Design: Inception cohort., Setting: University-affiliated primary care center., Patients: A phase 2 clinical trial was conducted from February 1, 1999, through February 28, 2002, to evaluate SJP in patients with head and neck cancer. During that period, a consecutive sample of 51 patients who underwent surgical resection and reconstruction with a radial forearm free flap for oropharyngeal carcinoma were referred for functional assessment of swallowing after completion of adjuvant radiation therapy. At 6 months after surgery, swallowing assessments for 24 patients were available., Intervention: The cohort of 24 patients included 13 who had preservation of 1 submandibular gland (SJP group) and 11 who did not (control group)., Main Outcome Measures: Quantitative and qualitative aspects of swallowing were obtained to determine whether patients in the SJP group performed more optimally than those in the control group., Results: Baseline and stimulated salivary flow rates were significantly different between groups. Patients in the SJP group were able to move the bolus through the oral cavity and into the pharynx faster than those in the control group. In addition, patients in the SJP group swallowed less often per bolus than patients in the control group. The complete swallowing sequence was twice as long in controls., Conclusions: The SJP for submandibular gland transfer appears to be beneficial in promoting more time-efficient swallowing behaviors. This efficiency has implications for the overall well-being and nutritional status of patients with head and neck cancer.

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

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

Background: Xerostomia is a permanent and devastating sequela of head and neck irradiation, and its numerous consequences affect most aspects of the patient's life. A new method of preserving and protecting a single submandibular gland from radiation damage through the Seikaly-Jha procedure (SJP) has recently been described., Objective: To report the long-term outcomes of the SJP., Design: Inception cohort. Patients The trial was conducted between February 1, 1999, and February 1, 2002. All patients were followed up through the head and neck cancer clinic at the Cross Cancer Institute. All data were collected by a dedicated research nurse. Salivary function was evaluated at regular intervals with salivary flow studies and questionnaires., Results: Ninety-six patients were enrolled in the study, and 38 had a minimum of 2 years' follow-up. The cohort of 38 patients was composed of 2 groups: 26 patients had preservation of one submandibular gland through the SJP, while the remaining 12 did not. Salivary flow was preserved in the SJP group, in which 83% of patients reported normal amounts of saliva 2 years after radiotherapy, compared with none in the SJP group. There were no disease recurrences on the side of the transferred gland or in the submental space. There were no surgical complications attributed to the transfer procedure., Conclusions: The SJP prevented xerostomia in 83% of the study patients. The approach appears to be oncologically sound and safe.

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

Background: Shoulder dysfunction remains a frequent complication after neck dissection procedures for head and neck cancer., Methods: We conducted a pilot study to evaluate the effects of progressive resistance exercise training (PRET) on shoulder dysfunction caused by spinal accessory neurapraxia/neurectomy in patients with head and neck cancer. Twenty patients (mean age, 61 +/- 7.7 years) were randomly assigned to PRET or standard care intervention. Subjects assigned to the PRET group exercised three times per week for 12 weeks. The goal of the exercise program was to enhance scapular stability and strength of the upper extremity. The resistance-training program was progressive in terms of number of sets and repetitions performed, as well as the amount of weight lifted, depending on performance status., Results: The completion rate for the trial was 85% (17 of 20). The exercise group completed 93% of scheduled exercise sessions. Significant improvements were found in favor of the PRET group in active shoulder external rotation (p =.001), shoulder pain (p =.038), and overall score for shoulder pain and disability (p =.045)., Conclusions: The study results demonstrate a high rate of completion and adherence with our PRET program among patients with head and neck cancer. The preliminary findings, although limited, also suggest a potential therapeutic role for resistance exercise as an adjunct to standard physical therapy treatment., (Copyright 2004 Wiley Periodicals, Inc. Head Neck 26: 518-530, 2004)

Background: Patient satisfaction with a maxillary obturator has been studied in relation to extent of surgical defect, sociodemographic characteristics, scores on mental health inventories, and psychosocial adjustment to illness scales. However, review of the literature reveals limited study of the relationship between patient satisfaction with an obturator and clinical speech outcome measures. The purpose of this study is to relate patient satisfaction scores obtained by questionnaire with those obtained by means of clinical speech measurements., Methods: Acoustical, aeromechanical, and perceptual measurements of speech were collected for 20 patients after receiving a definitive obturator. Patient satisfaction with their obturator was later measured with the Obturator Functioning Scale (OFS)., Results: Results reveal that poorer aeromechanical speech results were associated with patient-reported avoidance of social events, whereas lower speech intelligibility outcomes were related to overall poorer perception of speech function on the OFS. Several background patient characteristics were significantly related to several responses on the OFS and to the aeromechanical assessment outcomes., Conclusions: Results from instrumental assessments of speech seem to be informative regarding not only speech outcome but also a patient's satisfaction with the obturator. Consideration of background patient characteristics is important when interpreting both clinically obtained and patient-perceived outcomes., (Copyright 2003 Wiley Periodicals, Inc.)

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

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

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

Background and Purpose: Xerostomia is a significant morbidity of radiation treatment in the management of head and neck cancers. We hypothesized that the surgical transfer of one submandibular salivary gland to the submental space, where it can be shielded from radiation treatment (XRT), would prevent xerostomia., Materials and Methods: We conducted a prospective Phase II clinical trial and the patients were followed clinically with salivary flow studies and the University of Washington Quality of Life questionnaire., Results: We report the results on 76 evaluable patients. The salivary gland transfer was done in 60 patients. Nine patients (of 60) did not have postoperative XRT and in eight patients (of 60) the transferred gland was not shielded from XRT due to proximity of disease. The median follow up is 14 months. Of the 43 patients with the salivary gland transfer and post-operative XRT with protection of the transferred gland, 81% have none or minimal xerostomia, and 19% developed moderate to severe xerostomia. Three patients (6.9%) developed local recurrence, five patients (11.6%) developed distant metastases and five patients (11.6%) have died. There were no complications attributed to the surgical procedure., Conclusion: Surgical transfer of a submandibular salivary gland to the submental space preserves its function and prevents the development of radiation induced xerostomia.

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

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

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

Purpose: Speech outcome measurements are valuable in guiding treatment and determining the effectiveness of rehabilitation with a maxillary obturator prosthesis in individuals with palatal resection. Although speech outcome data exist in the literature for such patients, relatively few reports have used clinical tools designed to measure the acoustic, physiologic, and perceptual bases of speech. This investigation reports these measures for individuals rehabilitated with a maxillary obturator., Materials and Methods: Speech measurements were collected prospectively at three clinical visit times (preoperative, postresection without an obturator, and with a definitive obturator) for 12 patients assigned to three groups based on the extent of their resection (< half the hard palate, > or = half the hard palate, hard and soft palates). Acoustic data were obtained with the Nasometer, aeromechanical data were collected with the PERCI-SARS, and perceptual ratings of speech intelligibility were obtained through listener analysis., Results: Significant differences existed among the three treatments for all dependent variables and revealed that speech without an obturator is significantly different from the preoperative state, while speech with an obturator does not differ significantly from preoperative function. Individuals with soft palate involvement exhibited significantly poorer nasalance values than individuals with involvement of the hard palate only., Conclusion: Rehabilitation with a maxillary obturator is successful in restoring preoperative speech function. Rehabilitation of individuals with involvement of the soft palate may be more challenging.

Background: The finite resources available for health care and the proliferation of managed care in the United States have forced the head and neck surgeon to critically evaluate the cost of tumor treatment., Objective: To determine whether the cost of treating patients with head and neck tumors would be reduced if the patients were to spend a portion of what would otherwise be acute care hospital days in a hospital-based skilled nursing facility (HB/SNF)., Design: Retrospective cost-benefit analysis., Setting: Tertiary referral center., Patients: Twenty-four consecutive hospital admissions for definitive surgical treatment of head and neck tumors were retrospectively reviewed. The postoperative day on which the patient theoretically could have been transferred to the HB/SNF was determined. The charges and cost of each patient's actual hospital stay were compared with the theoretical counterparts had the patient been transferred to the HB/SNF on the determined day., Main Outcome Measure: Cost savings., Results: The total hospital stay for the 24 patients was 524 days. One hundred eighty-two of those days could have been spent in the HB/SNF. The total charge and cost savings with the use of an HB/SNF were $201,045 and $84,238, respectively (15% of the total charge and cost). This represents an average charge and cost savings of $8377 and $3510, respectively, per patient. The difference was statistically significant (P<.005)., Conclusion: An HB/SNF could reduce the cost of head and neck tumor treatment without compromising patient care.

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

Objective: Radiation-induced xerostomia is a significant morbidity of radiation therapy in the management of patients with head and neck cancers. We have recently reported a method of transfer of one submandibular gland to the submental space in a small pilot series of eligible surgical patients. The submental space was shielded during postoperative radiation therapy. The transferred gland continued to function after the completion of radiation therapy and none of the patients developed xerostomia. The purpose of this article is to present the technique of submandibular gland transfer in detail and to evaluate the postoperative survival and function of the transferred submandibular glands., Design: Prospective clinical trial., Methods: The submandibular gland was transferred on eligible patients as part of their surgical intervention. The patients were followed clinically, with salivary flow and radioisotope studies., Results: We performed the surgical transfer of the submandibular salivary gland in 24 of 25 patients placed on the protocol. All the glands survived transfer and functioned well postoperatively as demonstrated on the salivary flow and the radioisotope studies. The surgical transfer was relatively simple and added 45 minutes to the surgical procedure. There were no complications attributed to the submandibular gland transfer., Conclusions: We have successfully demonstrated that the submandibular gland can be surgically transferred to the submental space with its function preserved. The gland seems to continue functioning even after radiation therapy with the appropriate shielding. This surgical transfer procedure has the potential to change the way we currently manage patients with head and neck cancer.

Background: Extramedullary hematopoiesis (EMH) is known to occur in myeloproliferative disorders and hemoglobinopathies and is usually seen in the spleen and liver., Methods: We report the first case of EMH causing subglottic stenosis in a woman with postpolycythemia myeloid metaplasia (PPMM). A tracheotomy was performed to maintain the airway and local radiotherapy was given., Results: Two months after the radiotherapy was completed laryngoscopy showed an unobstructed airway with no evidence of disease, and the patient was successfully decanulated. Magnetic resonance imaging 8 months after radiotherapy confirmed the absence of local disease., Conclusion: Consideration should be given to EMH as a possible cause of airway obstruction in the differential diagnosis of a patient with a history of PPMM., (Copyright 2000 Wiley & Son, Inc.)

Background: Xerostomia is a significant morbidity of radiation therapy in the management of head and neck cancers. We hypothesized that the surgical transfer of one submandibular salivary gland to submental space, outside the proposed radiation field, prior to starting radiation treatment, would prevent xerostomia., Methods: We are conducting a prospective clinical trial where the submandibular gland is transferred as part of the surgical intervention. The patients are followed clinically, with salivary flow studies and University of Washington quality of life questionnaire., Results: We report early results of 16 patients who have undergone this procedure. Seven patients have finished and 2 patients are currently undergoing radiation treatment. In 2 patients, no postoperative radiation treatment was indicated. Two patients are waiting to start radiation treatment and 2 patients refused treatment after surgery. The surgical transfer was abandoned in 1 patient. All of the transferred salivary glands were positioned outside the proposed radiation fields and were functional. The patients did not complain of any xerostomia and developed only minimal oral mucositis. There were no surgical complications., Conclusions: Surgical transfer of a submandibular salivary gland to the submental space (outside the radiation field) preserves its function and prevents the development of radiation-induced xerostomia.

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

Objective: The presence of pulmonary metastases significantly alters the treatment of patients with head and neck cancers. Currently, a chest radiograph (CXR) is used as a screening examination, although a chest CT (CCT) can detect smaller lesions. The aim of this study was to evaluate the benefit of CCT as a screening tool in patients with newly diagnosed advanced head and neck cancers., Method: New patients with stage III and IV head and neck squamous cell carcinomas were enrolled in this prospective study from August 1994 to December 1995. Twenty-five patients underwent CXR ($71) and CCT ($597) within 2 weeks of diagnosis of the index cancer., Results: In 20 patients neither the CXR nor the CCT showed any evidence of pulmonary malignancy. Two patients had normal CXRs but possible metastases on CCT. Both the pulmonary lesions resolved on follow-up evaluation. Two patients had suspicious lesions on CXR, 1 of whom had a normal CCT. The second patient underwent CT-guided biopsy which was negative for malignancy. Both the CXR and CCT of the final patient, who had a bronchogenic carcinoma, were suspicious., Conclusion: In 2 patients CCT detected suspicious lesions missed on CXR, although neither revealed malignancy. Three patients with suspicious CXRs would have had CCTs anyway. Thus 22 of 25 CCTs done at the additional cost of $13,314 did not add to the sensitivity of the screening for pulmonary metastasis or second lung primary.

Objectives: No-reflow is failure of perfusion in free tissue transfer despite adequate arterial inflow. The objectives of this study were to construct a theory of interactive mechanisms of the no-reflow phenomenon and to determine whether preischemic vascular washout could increase flap ischemia tolerance., Study Design: The evidence for the role of various mechanisms in the development of no-reflow is reviewed, and an integrated network proposed. A rat-groin free flap model is used to test preischemic vascular washout with normal saline, heparinized normal saline, lactated Ringer's solution, Tis-U-Sol, and Viaspan., Methods: The mean ischemia tolerance of this flap without any therapeutic intervention was first determined, using 22 animals. An additional 50 animals were used to compare with the control group the ischemia tolerance of flaps washed out with the above fluids before their ischemic period., Results: The critical ischemia time 50 (time after which half of the flaps are expected to survive and half, die) of the untreated flap is 23.4 hours in this model (P<.05). Flaps washed out with normal saline or lactated Ringer's solution have significantly worse ischemia tolerance (P<.0001). Flaps washed out with Tis-U-Sol or Viaspan behave similarly to the control group (P>.57). Flaps receiving preischemic washout with heparinized normal saline (4,000 units/L) had a significantly better outcome than the control group (P<.027)., Conclusions: Preischemic washout with normal saline, lactated Ringer's solution, or heparinized Tis-U-Sol is detrimental for flap survival after ischemia, Tis-U-Sol- and Viaspan-treated flaps do have ischemia tolerance similar to the control group, and flaps washed out with heparinized normal saline have a survival advantage in this model.

Epstein-Barr virus (EBV) has been shown to be a likely etiologic agent in nasopharyngeal carcinogenesis. Human papillomaviruses (HPVs) have previously been identified in numerous upper aerodigestive tract carcinomas. This pilot study was undertaken to investigate the prevalence of combined EBV and HPV infection in 17 patients with nasopharyngeal carcinoma (NPCA) using polymerase chain reaction (PCR). The primary goal was to determine if the presence of HPV could be correlated with molecular, histologic, or clinical parameters. There were seven patients with undifferentiated NPCA (World Health Organization [WHO] type III) and 10 patients with squamous cell carcinoma (WHO type I). All 17 patients had stage IV disease at presentation. EBV was identified in 15 patients (88.2%), and HPV subtypes were identified in samples from nine patients (52.9%). All HPV-positive cases were also EBV positive. Western blot analysis of six samples showed a high level of expression of c-myc and cdc2 kinase and a low level of p53 protein in NPCAs that contained both HPV and EBV (n = 3). Increased expression of c-myc and cdc2 kinase was seen in the cases that contained EBV only, but to a lesser extent (n = 2). These findings indicate an effect of the virus on cellular proliferation and differentiation. Similarly, an elevated level of Rb protein was found only in the HPV-containing NPCAs. Moderate differentiation (keratinization) occurred in four of eight HPV-negative and none of the nine HPV-positive NPCAs. (All HPV-positive cases were poorly differentiated or undifferentiated.) This difference is statistically significant for this sample size (P < 0.03). There was a trend for the group that was HPV positive to have WHO III histology and for the HPV-negative group to have WHO I. The presence of HPV could not be correlated with any clinical parameters in this small group of patients with advanced disease; however, these data suggest that coexistence of EBV and HPV infection may be a factor in the pathogenesis of NPCA and may have an effect on regulation of cellular proliferation and differentiation.

Objective: To present a decision paradigm for facial defect reconstruction, and test the ability of this paradigm to improve resident performance., Design: A decision paradigm for reconstruction of facial skin defects is proposed and explained, with patient examples. The paradigm's usefulness is then tested with residents., Setting: Otolaryngology residency training program at a tertiary hospital., Study Participants: Otolaryngology residents., Interventions: Twelve residents took a pretest wherein they were presented with drawings of skin defects and asked to choose the "best" (most aesthetically pleasing) type of reconstruction from a closed set. This paradigm was presented to these residents, and their posttest consisted of choosing again with the same defects and closed set of choices., Main Outcome Measures: Cosmetic outcomes of reconstructive decisions on the pretest and posttest were rated on a scale of 0 to 5 (with 0 indicating poor; 5, excellent)., Results: There was a significant improvement in reconstructive choices between the pretest and posttest (P<.001, Student t test)., Conclusion: This paradigm can be easily modified to accommodate different surgical approaches preferred by individual surgeons and is thus useful in almost any reconstructive teaching situation.

Microvascular free tissue transfer has revolutionized head and neck reconstruction and currently is considered the most successful and reliable method of primary oromandibular reconstruction. This study was designed to assess the feasibility of full thickness free vascularized transfer of the clavicle based on the clavicular branch of the thoracoacromial artery and the soft tissue component associated with the thoracoacromial axis. Forty dissections of the pectoral region were performed on 26 cadavers. The anatomic relations of the region and the thoracoacromial arterial and venous systems were documented in detail. Selective ink injections of the thoracoacromial arterial branches were also performed on fresh cadavers. The clavicle was supplied mainly by the clavicular artery (medial three quarters), with minor contribution from the deltoid artery (lateral quarter). An average of 16.1 cm (range of 12 to 20 cm) was obtained with total clavicular harvest and the clavicle had sufficient width and height to support dental implants. Two soft tissue donor sites were associated with the thoracoacromial artery: the sternocostal head of the pectoralis major muscle, with the overlying skin supplied by the pectoral artery, and the clavicular head of the pectoralis major muscle, with the overlying skin supplied by the deltoid and clavicular arteries. Sensory innervation of the upper chest was supplied through the supraclavicular nerves, whereas the lateral pectoral nerve supplied motor innervation to both heads of the pectoralis major muscle. The anatomy of the clavipectoral donor site and the first case of full thickness free clavicular transfer for mandibular reconstruction in the English literature are presented. The donor site is an excellent source of well vascularized, thin, pliable, hairless, potentially innervated (motor and sensory) soft tissue, along with up to 20 cm of clavicular bone. The surgical anatomy is familiar to the head and neck surgeon. The harvesting does not require repositioning of the patient and is amenable to a two-team, simultaneous approach. The functional and cosmetic donor site morbidity is minimal even with clavicular harvest. The major disadvantage of this flap is the relatively short pedicle. The authors conclude that the thoracoacromial system provides a free flap with osseous and soft tissue components that are well suited for oromandibular reconstruction.

Objectives: To determine the satisfaction of patients with their current method of alaryngeal communication. To focus primarily on the patients' perception of their own speech., Design: A retrospective review of patients who underwent total laryngectomy for malignancy identified 4 groups of patients. A survey using a mailed questionnaire was used to compare groups., Setting: Tertiary care university hospital, University of Texas Medical Branch at Galveston., Patients: Forty-seven patients underwent total laryngectomy for cancer and survived. Thirty-one of the 47 patients responded to the survey. Patients were divided into 4 groups by their current method of communication: (1) tablet writers; (2) esophageal speech; (3) electrolarynx; and (4) tracheoesophageal speech., Main Outcome Measures: Satisfaction with communication, satisfaction with speech quality, ability to communicate over telephone, limitation of interaction with others, and satisfaction with quality of life., Results: Patients in group 4 were significantly more satisfied with their speech (P < .001), perceived their speech to be of better quality (P < .001), had improved ability to communicate over the telephone (P < .001), and had less limitation of their interactions with others (P < .004). Patients in group 4 also rated their overall quality of life higher (P = .23)., Conclusion: Although many studies in the past have demonstrated the objective superiority of tracheoesophageal speech compared with other methods of alaryngeal communication, most studies have focused on the intelligibility of speech judged by listeners. This study demonstrates that patients who use tracheoesophageal speech rate their own speech significantly higher than patients who use other methods and most likely have an overall superior quality of life.

Use of sympathomimetic topical nasal decongestants to treat nasal obstruction is usually restricted to 3 to 5 days to avoid potential rebound swelling (rhinitis medicamentosa). In this study, 10 healthy volunteers used oxymetazoline (long-acting topical nasal decongestant) nightly for 4 weeks. Subjects who used antihistamines, oral or topical decongestants, or systemic steroids or who had active sinusitis were excluded from the study. Weekly history, physical examination, and anterior rhinomanometry revealed no adverse effects. Eight (80%) subjects developed nightly nasal obstruction a few hours before the evening dose; the obstruction resolved within 48 hours if no more decongestant was used. All subjects remained responsive to oxymetazoline 4 weeks and 8 weeks after the study began. This finding suggests that long-acting decongestants may be safely used for longer than the recommended 3 to 5 days without adverse effects if used once nightly.

Objectives: To determine how helical rim closure with advancement flaps affects ear length and cupping, to compare the tension of closure with wedge excision and helical rim advancement and the effects of 3 tension-decreasing surgical techniques, and to review clinical experience with this flap., Design: The laboratory study was performed on 6 fresh cadaver ears, by means of sequential excision of tissue, and closure tension was measured with a strain gauge. Results obtained in 10 patients were reviewed., Setting: University referral hospital., Patients: Ten patients with helical rim defects treated with helical rim advancement flaps., Intervention: In cadaver ears, a helical rim defect of 5 mm was enlarged sequentially to 10 mm, 15 mm, and finally 20 mm. In the patients, defects of the helical rim caused by trauma or tumor were closed by this helical rim advancement flap method., Main Outcome Measures: For the laboratory study, the outcome measures were tension of closure of the defect, ear length, and ear cupping. For the review of cases, outcome was determination of perioperative complications and the patient's and surgeon's judgment of cosmetic appearance., Results: Closure of a helical rim defect with advancement flaps caused minor shortening and moderate cupping of the ear. The tension of closure was decreased by extending the inferior incision into the earlobe, creating a Burow triangle, and shaving cartilage from the scapha. Both the Burow triangle and the scaphal shave caused mild increases in ear cupping., Conclusion: Helical rim advancement flaps provide satisfactory closure of helical rim defects up to at least 20 mm (longer in some ears) with excellent preservation of normal anatomic landmarks and a near-normal appearance of the reconstructed ear.

Pharyngocutaneous fistula is a serious complication after laryngectomy. Gastric fluid is known to cause severe laryngopharyngeal injury and poor mucosal healing. This study was designed to evaluate the effects of a gastroesophageal reflux prophylaxis regimen on the incidence of fistula after laryngectomy. Twenty-one consecutive patients were entered in the study. Patients with positive resection margins were excluded from the overall analysis. All patients had a Connell's two-layer closure of the pharynx with absorbable suture, suction drainage of the neck, postoperative tube feeding, and prophylactic antibiotics. All patients were started on an antireflux regimen postoperatively composed of continuous tube feeds, intravenous ranitidine, and intravenous metoclopramide hydrochloride. Patients were followed postoperatively with Gastrografin swallows and clinically for 8 weeks. The control group consisted of retrospectively studied patients managed identically except for the antireflux prophylaxis. The two groups were well matched for factors reported to influence the rate of pharyngocutaneous fistula formation. The control group had six fistulae (26%) and an average of 16.5 days of hospital stay. The study group had no fistulae and an average of 11.5 days of hospital stay (P = .02). This study suggests that gastroesophageal reflux may predispose to fistula formation after laryngectomy and that mechanical and pharmacological prophylaxsis decreases postoperative morbidity and length of hospital stay.

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

Forty-four patients were reviewed to determine the incidence of atelectasis following pectoralis major myocutaneous flap reconstruction of head and neck defects. Patients underwent tumor resection with subsequent pectoralis major myocutaneous flap reconstruction (flap group, n = 24) or another major head and neck procedure (control group, n = 20). Chest roentgenograms taken on the first postoperative day were scored for atelectasis by preestablished criteria. Sixty-five percent of control and 70% of flap patients demonstrated postoperative atelectasis roentgenographically. The flap patients with skin paddles larger than 40 cm2 had a 60% incidence of major atelectasis compared with 5% in control patients. The skin island area was strongly correlated with the atelectasis score in the flap group. These results suggest that atelectasis is common following pectoralis major myocutaneous flap reconstruction of head and neck defects. As well, decreased chest wall compliance after primary closure of large donor defects may contribute to the atelectasis observed.