Telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER): A pilot study for patients treated with surgery for oral cavity carcinoma

BACKGROUND

To address the rehabilitative barriers to frequency and precision of care, we conducted a pilot study of a biofeedback electropalatography (EPG) device paired with telemedicine for patients who underwent primary surgery +/- adjuvant radiation for oral cavity carcinoma. We hypothesized that lingual optimization followed by telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER) would further improve speech and swallowing outcomes after "standard-of-care" SOC rehabilitation.

METHOD

Pilot prospective 8-week (TEBER) program following 8 weeks of (SOC) rehabilitation.

RESULTS

Twenty-seven patients were included and 11 completed the protocol. When examining the benefit of TEBER independent of standard of care, "range-of-liquids" improved by +0.36 [95% CI, 0.02-0.70, p = 0.05] and "range-of-solids" improved by +0.73 [95% CI, 0.12-1.34, p = 0.03]. There was a positive trend toward better oral cavity obliteration; residual volume decreased by -1.2 [95% CI, -2.45 to 0.053, p = 0.06], and "nutritional-mode" increased by +0.55 [95% CI, -0.15 to 1.24, p = 0.08].

CONCLUSION

This pilot suggests that TEBER bolsters oral rehabilitation after 8 weeks of SOC lingual range of motion.

Functional outcomes of soft palate reconstruction after oncologic surgery: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to analyze functional outcomes of soft palate reconstruction after oncologic surgery.

METHODS

This study was conducted in conformity with the PRISMA statement. A single arm meta-analysis was performed for feeding tube dependence (FTD) (primary outcome), velopharyngeal insufficiency (VPI) and hypernasality (HN) (secondary outcomes) incidences.

RESULTS

A total of 510 patients (males: 77.75%, n = 353/454) with a median age of 58 years (n = 480/510; 95% CI 57.0-61.0) who underwent soft palate surgical resection with primary reconstruction were included. Overall, the cumulative FTD rate was 1.55% (n = 28/510; 95% CI 0.24-3.96%), the VPI rate was 22.18% (n = 119/379; 95% CI 12.99-33.02%), and the HN rate was 33.01% (n = 88/234; 95% CI 19.03-46.61%).

CONCLUSIONS

Soft palate reconstruction results in a low incidence of FTD, and most patients resume a full oral diet. Both obturators, primary closure, local and free flaps seem good reconstructive options. Nevertheless, more specific postoperative functional deficiencies like VPI and HN owns higher incidences, potentially affecting the quality of the swallowing and speaking function and the patient's quality of life.

Oropharyngeal reconstruction after transoral robotic surgery

PURPOSE OF REVIEW

Transoral robotic surgery (TORS) has experienced an evolution in recent years. This technique has proved to be a safe and effective method for extirpation of select oropharyngeal tumors. Advances in technology as well as improved surgeon experience allow for the resection of larger, more complex cancers. Although healing by secondary intention remains the current standard for limited oropharyngeal defects, larger resections demand reconstruction with vascularized tissue to minimize morbidity and optimize functional outcomes. The objective of this review is to evaluate recent literature regarding oropharyngeal reconstruction after TORS.

RECENT FINDINGS

A variety of reconstructive options to manage oropharyngeal defects exist. Several reconstructive algorithms have been suggested; however, careful consideration must be used to select the most ideal flap type. Locoregional flaps have shown excellent functional outcomes with limited morbidity. An increase in free flap reconstruction has been demonstrated, particularly among patients with larger TORS defects and following chemoradiation therapy. Despite limited data, robotic-assisted flap inset and microvascular anastomosis has recently shown promise.

SUMMARY

Reconstruction and flap selection following TORS should be tailored to the patient and unique oropharyngeal defect. Functional outcomes are promising with low complication rates among these patients.

Use of the double-paddle anterolateral thigh flap for locally advanced tongue carcinoma requiring second site reconstruction

BACKGROUND

Advanced oral tongue carcinoma can present with extension beyond the oral cavity. Operative defects after resection may involve multiple anatomical sites and significantly impact speech and swallowing. Dependence on long-term enteral feeding is not uncommon for these patients. The anterolateral thigh (ALT) flap is one of the most reliable and flexible flaps used in the reconstruction of total and subtotal tongue defects. The double-paddle flap modification may be a more suitable option for complex oral tongue defects after advanced tumor ablation.

METHODS

Case series of 31 patients with oral tongue squamous cell carcinoma that were classified as stage IV. The age of patients ranged from 32 to 63 years. We designed the double-paddle ALT flaps to reconstruct the two-site surgical defects (tongue defect and pharynx or neck skin defect). Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after the completion of adjuvant chemoradiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) using a Speech Intelligibility Score and the Functional Oral Intake Scale.

RESULTS

A total of 31 patients with surgical defects after total or subtotal tongue resection for cancer underwent double-paddle ALT flaps for reconstruction from March 2018 to December 2019. The dimension of flaps from 8 × 12 cm to 10 × 18 cm were divided into double-paddle from 8 × 5 cm to 10 × 10 cm. There was one case of pedicle thrombosis, one case of postoperative bleeding, three cases of neck infection, and six cases of salivary fistula. Our patients were seen in follow up from 6 to 36 months, with median follow-up of 23.5 months. The survival rate of ALT flap was 100%. All of our patients achieved an oral diet by 9 months after surgery. The mean score speech intelligibility was 2.74 ± 0.68 (4-point ordinal scale). The 2-year disease-free survival rate was 61.3%.

CONCLUSIONS

The double-paddle ALT flap is a reliable flap suitable for oral defects involving multiple subsites after ablative procedures. The majority of patients demonstrated acceptable functional rehabilitation.

CLINICAL QUESTION/ LEVEL OF EVIDENCE

Therapeutic, IV.

Current perspectives on recurrent HPV-mediated oropharyngeal cancer

In the recent years, the prevalence of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) has increased significantly. Currently, nearly 80-90% of all oropharynx tumors are HPV-positive. In addition, it is now recognized that HPV-positive tumor status is associated with good prognosis and improved response to chemoradiation. However, within this setting, there are still patients with HPV-positive OPSCC who will experience recurrence. With the increasing incidence of HPV-mediated OPSCC, recurrent HPV disease is also becoming more prevalent and there is an increasing need to understand the unique presentation and treatment of recurrent HPV-mediated disease. In this review, we will discuss epidemiology of recurrent HPV-positive OPSCC, role of surgical salvage, re-irradiation, and the role of upcoming novel treatments and immunotherapy. Historically, recurrent oropharyngeal disease has been associated with poor prognosis and high morbidity. However, recent advances have transformed the landscape for salvage treatment of HPV-mediated OPSCC. Liquid biomarkers offer potential for early detection of recurrence, robotic techniques may reduce morbidity of surgical salvage, improvements in re-irradiation approaches reduce toxicities, and novel immune based therapies on the horizon are offering promising results. These advances combined with the improved prognosis of HPV-positive disease offer to transform our approach to recurrent disease of the oropharynx.

Reconstruction following transoral robotic surgery for head and neck cancer: Systematic review

We performed a systematic review to characterize reconstructive modalities and postoperative surgical outcomes following TORS resection. A search of the PubMed, SCOPUS, and EMBASE databases was conducted to identify studies describing patients undergoing reconstruction of TORS defects. Twenty-six studies met inclusion criteria, consisting of 260 patients who underwent TORS resection followed by reconstruction. Twenty-one studies reported tumor classification information, with TORS performed for 44 (23.0%) T1, 86 (45.0%) T2, 33 (17.3%) T3, and 28 (14.7%) T4 tumors. Eighteen distinct reconstructive modalities were described in the studies identified, including nine unique free flap types. The most commonly performed reconstruction was the radial forearm free flap (RFFF), accounting for 121/260 (46.5%) of reconstructions performed. Reported surgical complications included 5 pharyngocutaneous fistulae, 13 hemorrhagic complications, 24 infectious complications, and 5 free flap failures. Our findings demonstrate favorable surgical outcomes but minimal quantitative functional data to compare reconstructive options following TORS.

Retropharyngeal Internal Carotid Artery Management in TORS Using Microvascular Reconstruction

OBJECTIVES

Guidelines for transoral robotic surgery (TORS) have generally regarded patients with retropharyngeal carotid arteries as contraindicated for surgery due to a theoretical risk of intraoperative vascular injury and/or perioperative cerebrovascular accident. We aimed to demonstrate that careful TORS-assisted resection and free flap coverage could not only avoid intraoperative injury and provide a physical barrier for vessel coverage but also achieve adequate margin control.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

Retrospective review of patients with oropharyngeal malignancies and radiologically confirmed retropharyngeal carotid arteries who underwent TORS, concurrent neck dissection, and free flap reconstruction between 2015 and 2019.

RESULTS

Twenty patients were included, 19 (95.0%) with tonsillar tumors and one (5.0%) with a tongue base tumor with significant tonsillar extension. Eighteen patients (90.0%) received a radial artery forearm flap, one (5.0%) an ulnar artery forearm flap, and one (5.0%) an anteromedial thigh flap. All 20 (100%) flaps were inset through combined transcervical and transoral approaches without mandibulotomy. There were no perioperative mortalities, carotid injuries, oropharyngeal bleeds, cervical hematomas, or cerebrovascular accidents. One patient (5.0%) had a free flap failure requiring explant. All patients underwent decannulation and resumed a full oral diet. The mean length of hospitalization was 6.8 (standard deviation 1.2) days. One (5.0%) patient had a positive margin.

CONCLUSION

In this analysis, 20 patients with oropharyngeal malignancy and retropharyngeal carotid arteries underwent TORS, neck dissection, and microvascular reconstruction without serious complication (perioperative mortality, vascular injury, or neurologic sequalae) with an acceptable negative margin rate. These results may lead to a reconsideration of a commonly held contraindication to TORS.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E821-E827, 2021.

A Review of and Algorithmic Approach to Soft Palate Reconstruction

Importance

The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity.

Objective

To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review.

Evidence Review

A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded.

Findings

The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases.

Conclusions and Relevance

Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.

Tongue reconstruction: Rebuilding mobile three-dimensional structures from immobile two-dimensional substrates, a fresh cadaver study

OBJECTIVE

To determine the two-dimensional (2D) characteristics of flaps necessary to create three-dimensional (3D) tongue anatomy.

METHODS

Dissection of 11 fresh, nonpreserved human cadavers was performed. Six defects in each were created: total tongue, total oral tongue, hemiglossectomy, oral hemiglossectomy, total base of tongue, and hemi-base of tongue. The resections were debulked to create flat, 2D mucosal flaps. The dimensions and shapes of these flaps were determined.

RESULTS

Each specimen showed consistent dimensions and geometry between cadavers. The total tongue was pear-shaped, the total oral tongue was egg-shaped, the oral hemi-tongue was bullet-shaped, the hemi-tongue resembled a dagger, the total base of tongue was rectangular, and the hemi-base of tongue was hour-glass shaped.

CONCLUSION

Typical dimensions and shapes of common tongue defects were determined. It is conceivable that customizing reconstructive flaps based on these data will increase the accuracy of neo-tongue reconstruction, and thus, improve functional outcomes.

Primary surgical management with radial forearm free flap reconstruction in T4 oropharyngeal cancer: Complications and functional outcomes

PURPOSE

Functional outcomes and complication rates after open surgery for advanced-stage oropharyngeal cancers are rarely reported. These measures are critical for choice of treatment modality and patient counseling. We describe the long term functional outcomes and associated complications of primary surgical management of T4 oropharyngeal cancers reconstructed with radial forearm free flaps.

MATERIALS AND METHODS

A retrospective review was performed of 40 patients with T4 oropharyngeal cancers treated between 2005 and 2015 at a tertiary care center.

RESULTS

Forty patients with T4 oropharyngeal cancers underwent open surgical resection and radial forearm free flap reconstruction at the time of surgery. Mandibulotomy was required in 33 (82.5%) cases. Thirty-five (87.5%) patients received adjuvant radiation or combined chemotherapy and radiation. Tracheostomy was performed in all patients, but every patient was eventually decannulated. Twenty (57.1%) patients required gastrostomy tube placement at some point during treatment; however, 91.4% were on a completely oral diet with a mean FOSS score of 1.6 by 1year after completion of treatment. The addition of adjuvant treatment was the only factor significantly associated with poorer FOSS scores. The overall rates of short and long-term complications were 60.0% and 57.1% respectively. The most common short and long-term complications were infection (30.0%) and velopharyngeal insufficiency (25.7%) respectively.

CONCLUSIONS

Traditional open surgical approaches to large tumors of the oropharynx carry higher complication rates than more recent advanced transoral approaches. However, they can still be utilized with excellent long-term functional results in certain cases of advance oropharyngeal cancers not amenable to transoral approaches. With careful reconstruction of oropharyngeal defects, over 90% of patients can achieve a completely oral diet.

[An original "double-arched" radial forearm flap for soft palate reconstruction. Case report]

INTRODUCTION

Reconstruction of the soft palate after oncologic resection remains a surgical challenge. Speech and swallowing problems are the consequences of velopharyngeal incompetence following soft palate resection. Free tissue transfer like radial forearm flaps can be used in larger defects for complex reconstruction. The conformation of the flap in order to be closer to the shape of the soft palate improves the functional outcome. In the same way, we describe an original "double-arched" flap design.

METHODS

A double arch of the exact length of the soft palate tumor resection is designed. After suturing, the flap spontaneously formed a double arch of the exact dimensions of the resected piece.

RESULTS

The patient achieved good functional recovery without any surgical complications.

CONCLUSION

The original "double-arched" forearm flap design allows a tailored reconstruction with exactly the same shape and dimensions, preserving the functional requirements of speech and deglutition.

Structured review of papers reporting specific functions in patients with cancer of the head and neck: 2006 - 2013

Health-related quality of life (HRQoL) focuses on 4 core domains: physical and psychological function, social interaction, disease, and treatment-related symptoms, and is a key outcome in patients with cancer of the head and neck. We reviewed papers published between 2006 and 2013 that used validated questionnaires to report functional outcome in this group. A total of 572 papers were identified and 118 of them concerned function. Specific outcomes included anxiety, chewing, maxillectomy, mucositis, pain, shoulder function, and trismus. The specific functions most often identified were xerostomia, speech or voice, and swallowing or dysphagia. A considerable body of evidence has now accumulated on HRQoL and functional outomes although the precise role of HRQoL during the planning of treatment remains controversial. Over time, the emphasis of the studies included has tended to move away from the reporting of outcomes in general to more hypothesis-driven and group-specific work.

Predictive factors of dysphagia after lateral and superior oropharyngeal reconstruction with free flap transfer

BACKGROUND AND OBJECTIVES

Lateral and superior oropharyngeal reconstruction is technically challenging and can be complicated by postoperative dysphagia. The aim of this retrospective study was to identify the predictive factors of dysphagia after lateral and superior oropharyngeal reconstruction with free flap transfer and to establish better management for cases with these predictive factors.

METHODS

We performed a retrospective chart review of 109 patients who had undergone lateral and superior oropharyngeal reconstruction with free flap transfer for oropharyngeal cancer. Preoperative, operative, and postoperative variables were examined, and possible predicative factors for dysphagia were subjected to univariate analysis and multivariate logistic regression analysis.

RESULTS

Dysphagia occurred in 16 patients (14.7%). Multivariate logistic regression analysis identified extensive tongue base resection, postoperative radiotherapy, and history of radiotherapy to the head and neck region as independent factors contributing to dysphagia after lateral and superior oropharyngeal reconstruction. Of these factors, extensive tongue base resection was the most important.

CONCLUSIONS

Early intervention to minimize the risk of dysphagia should be performed for patients identified with these predictive factors.

[Soft palate reconstruction]

Soft palate reconstruction is complex. It has to restore swallowing and speech replacing the defect by dynamic and sensitive tissues. The means are multiple from direct suture to free flaps. Local flaps have the advantage to bring a mucosa animated by thin muscles, like in sphincteroplasty. Free flaps allow reconstruction of large defects, but they need some local adaptation (association with a local flap, adherence, suspension with tendon…) to improve the functional result. Indications depend on defect's size and local condition especially radiotherapy history.

Head and neck oncology--2010, part II

Part II this article reviewed the current state of the art in head and neck oncology. These include very important and stimulating new areas of interest including the marked acceptance of chemoradiation in favor of surgery in patients with cancer of the head and neck. The concept of HPV as a cause of cancer of the oropharynx is relatively new and very important in the epidemiology of these tumors. New modalities such as PET CT scanning and robotic surgery are discussed and appear to be very important in management of cancer of the head and neck. Endoscopic endonasal skull base surgery is another new high technology contribution to the field of head and neck surgery as is the use of endoscopic assisted thyroid surgery. These and other new concepts are discussed in this manuscript.

Recent advances in surgery for head and neck cancer

PURPOSE OF REVIEW

This paper reviews the advances in surgery in head and neck cancer patients.

RECENT FINDINGS

Sentinel node biopsy is a promising diagnostic technique to detect occult lymph node metastases, especially in oral carcinomas. Fludeoxyglucose-PET seems to be useful in detecting recurrent (laryngeal) carcinoma after radiotherapy. The role of fludeoxyglucose-PET to detect residual disease in the neck after radiotherapy with or without chemotherapy is not yet clear. The armamentarium of reconstructive surgery is still expanding. Endonasal endoscopic, robotic surgery and image-guided surgery are used as minimal invasive surgery in selected patients. Other advances include photodynamic therapy, ultrasonic surgery and mechanical sutures.

SUMMARY

New diagnostic techniques are used to avoid futile extensive surgery. Technical improvements have been made to treat head and neck cancer patients with minimal invasive surgery. Large prospective trials are needed to determine the indications for each technique.