The role of hyperbaric oxygen therapy in the prevention and management of radiation-induced complications of the head and neck - a systematic review of literature

Free flap jaw reconstruction with dental implantation: A single-institution experience

BACKGROUND

We sought to review our institution's experience with dental implant placement in free flap jaw reconstruction to determine factors impacting restoration of dental occlusion.

METHODS

Exactly 48 patients underwent free flap jaw reconstruction with or without dental restoration from 2017 to 2022. Primary outcome was achievement of restored dental occlusion after jaw free flap reconstruction.

RESULTS

A total of 48 patients with a mean age of 59.8 ± 16.4 years underwent jaw reconstruction from 2017 to 2022. Ten patients (20.8%) received osteointegrated dental implants. Two patients received a temporary dental prosthesis, 12 ± 4 months after initial reconstruction. Three patients received a final prosthesis, with a mean time to final prosthesis of 17.7 ± 12.4 months. Five patients did not receive any prosthesis despite placement of implants.

CONCLUSION

A minority of patients received dental implant placement with free flap jaw reconstruction and only a small subset of these received a definitive dental prosthesis.

Hyperbaric oxygen therapy for late radiation tissue injury

BACKGROUND

This is the third update of the original Cochrane Review published in July 2005 and updated previously in 2012 and 2016. Cancer is a significant global health issue. Radiotherapy is a treatment modality for many malignancies, and about 50% of people having radiotherapy will be long-term survivors. Some will experience late radiation tissue injury (LRTI), developing months or years following radiotherapy. Hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for LRTI based on the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of complications following surgery and radiotherapy.

OBJECTIVES

To evaluate the benefits and harms of hyperbaric oxygen therapy (HBOT) for treating or preventing late radiation tissue injury (LRTI) compared to regimens that excluded HBOT.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 24 January 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. survival from time of randomisation to death from any cause; 2. complete or substantial resolution of clinical problem; 3. site-specific outcomes; and 4.

ADVERSE EVENTS

Our secondary outcomes were 5. resolution of pain; 6. improvement in quality of life, function, or both; and 7. site-specific outcomes. We used GRADE to assess certainty of evidence.

MAIN RESULTS

Eighteen studies contributed to this review (1071 participants) with publications ranging from 1985 to 2022. We added four new studies to this updated review and evidence for the treatment of radiation proctitis, radiation cystitis, and the prevention and treatment of osteoradionecrosis (ORN). HBOT may not prevent death at one year (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.47 to 1.83; I2 = 0%; 3 RCTs, 166 participants; low-certainty evidence). There is some evidence that HBOT may result in complete resolution or provide significant improvement of LRTI (RR 1.39, 95% CI 1.02 to 1.89; I2 = 64%; 5 RCTs, 468 participants; low-certainty evidence) and HBOT may result in a large reduction in wound dehiscence following head and neck soft tissue surgery (RR 0.24, 95% CI 0.06 to 0.94; I2 = 70%; 2 RCTs, 264 participants; low-certainty evidence). In addition, pain scores in ORN improve slightly after HBOT at 12 months (mean difference (MD) -10.72, 95% CI -18.97 to -2.47; I2 = 40%; 2 RCTs, 157 participants; moderate-certainty evidence). Regarding adverse events, HBOT results in a higher risk of a reduction in visual acuity (RR 4.03, 95% CI 1.65 to 9.84; 5 RCTs, 438 participants; high-certainty evidence). There was a risk of ear barotrauma in people receiving HBOT when no sham pressurisation was used for the control group (RR 9.08, 95% CI 2.21 to 37.26; I2 = 0%; 4 RCTs, 357 participants; high-certainty evidence), but no such increase when a sham pressurisation was employed (RR 1.07, 95% CI 0.52 to 2.21; I2 = 74%; 2 RCTs, 158 participants; high-certainty evidence).

AUTHORS' CONCLUSIONS

These small studies suggest that for people with LRTI affecting tissues of the head, neck, bladder and rectum, HBOT may be associated with improved outcomes (low- to moderate-certainty evidence). HBOT may also result in a reduced risk of wound dehiscence and a modest reduction in pain following head and neck irradiation. However, HBOT is unlikely to influence the risk of death in the short term. HBOT also carries a risk of adverse events, including an increased risk of a reduction in visual acuity (usually temporary) and of ear barotrauma on compression. Hence, the application of HBOT to selected participants may be justified. The small number of studies and participants, and the methodological and reporting inadequacies of some of the primary studies included in this review demand a cautious interpretation. More information is required on the subset of disease severity and tissue type affected that is most likely to benefit from this therapy, the time for which we can expect any benefits to persist and the most appropriate oxygen dose. Further research is required to establish the optimum participant selection and timing of any therapy. An economic evaluation should also be undertaken.

The dental management of patients irradiated for head and neck cancer

Patients undergoing radiotherapy for head and neck cancers are prone to a range of dental complications, including mucositis, trismus, xerostomia, radiation caries and osteoradionecrosis. Specific considerations include the preventive, restorative and rehabilitative management of such patients, and the prevention and treatment of complications. This article aims to highlight the current understanding and management of dental needs for patients who have had or will undergo radiotherapy.

Noninvasive Systemic Modalities for Prevention of Head and Neck Radiation-Associated Soft Tissue Injury: A Narrative Review

BACKGROUND

 Radiation-associated soft tissue injury is a potentially devastating complication for head and neck cancer patients. The damage can range from minor sequelae such as xerostomia, which requires frequent daily maintenance, to destructive degenerative processes such as osteoradionecrosis, which can contribute to flap failure and delay or reverse oral rehabilitation. Despite the need for effective radioprotectants, the literature remains sparse, primarily focused on interventions beyond the surgeon's control, such as maintenance of good oral hygiene or modulation of radiation dose.

METHODS

 This narrative review aggregates and explores noninvasive, systemic treatment modalities for prevention or amelioration of radiation-associated soft tissue injury.

RESULTS

 We highlighted nine modalities with the most clinical potential, which include amifostine, melatonin, palifermin, hyperbaric oxygen therapy, photobiomodulation, pentoxifylline-tocopherol-clodronate, pravastatin, transforming growth factor-β modulators, and deferoxamine, and reviewed the benefits and limitations of each modality. Unfortunately, none of these modalities are supported by strong evidence for prophylaxis against radiation-associated soft tissue injury.

CONCLUSION

 While we cannot endorse any of these nine modalities for immediate clinical use, they may prove fruitful areas for further investigation.

Diagnosis, Prevention, and Treatment of Radiotherapy-Induced Xerostomia: A Review

In patients with head and neck cancer, irradiation (IR)-sensitive salivary gland (SG) tissue is highly prone to damage during radiotherapy (RT). This leads to SG hypofunction and xerostomia. Xerostomia is defined as the subjective complaint of dry mouth, which can cause other symptoms and adversely affect the quality of life. In recent years, diagnostic techniques have constantly improved with the emergence of more reliable and valid questionnaires as well as more accurate equipment for saliva flow rate measurement and imaging methods. Preventive measures such as the antioxidant MitoTEMPO, botulinum toxin (BoNT), and growth factors have been successfully applied in animal experiments, resulting in positive outcomes. Interventions, such as the new delivery methods of pilocarpine, edible saliva substitutes, acupuncture and electrical stimulation, gene transfer, and stem cell transplantation, have shown potential to alleviate or restore xerostomia in patients. The review summarizes the existing and new diagnostic methods for xerostomia, along with current and potential strategies for reducing IR-induced damage to SG function. We also aim to provide guidance on the advantages and disadvantages of the diagnostic methods. Additionally, most prevention and treatment methods remain in the stage of animal experiments, suggesting a need for further clinical research, among which we believe that antioxidants, gene transfer, and stem cell transplantation have broad prospects.

State of Rehabilitation Research in the Head and Neck Cancer Population: Functional Impact vs. Impairment-Focused Outcomes

PURPOSE OF REVIEW

Management of head and neck cancer (HNC) typically involves a morbid combination of surgery, radiation, and systemic therapy. As the number of HNC survivors grows, there is growing interest in rehabilitation strategies to manage HNC-related comorbidity. In this review, we summarize the current state of HNC rehabilitation research.

RECENT FINDINGS

We have organized our review using the World Health Organization's International Classification of Function (ICF) model of impairment, activity, and participation. Specifically, we describe the current research on rehabilitation strategies to prevent and treat impairments including dysphagia, xerostomia, dysgeusia, dysosmia, odynophagia, trismus, first bite syndrome, dysarthria, dysphonia, lymphedema, shoulder syndrome, cervicalgia, cervical dystonia and dropped head syndrome, deconditioning, and fatigue. We also discuss the broader impact of HNC-related impairment by exploring the state of rehabilitation literature on activity, participation, psychosocial distress, and suicidality in HNC survivors. We demonstrate that research in HNC rehabilitation continues to focus primarily on impairment-driven interventions. There remains a dearth of HNC rehabilitation studies directly examining the impact of rehabilitation interventions on outcomes related to activity and participation. More high-quality interventional studies and reviews are needed to guide prevention and treatment of functional loss in HNC survivors.

Radiation-Induced Fibrosis in Patients with Head and Neck Cancer: A Review of Pathogenesis and Clinical Outcomes

Radiotherapy-related fibrosis remains one of the most challenging treatment related side effects encountered by patients with head and neck cancer. Several established and ongoing novel therapies have been studied with paucity of data in how to best treat these patients. This review aims to provide researchers and health care providers with a comprehensive review on the presentation, etiology, and therapeutic options for this serious condition.

Functional requirements for polymeric implant materials in head and neck surgery

BACKGROUND

The pharyngeal reconstruction is a challenging aspect after pharyngeal tumor resection. The pharyngeal passage has to be restored to enable oral alimentation and speech rehabilitation. Several techniques like local transposition of skin, mucosa and/or muscle, regional flaps and free vascularized flaps have been developed to reconstruct pharyngeal defects following surgery, in order to restore function and aesthetics. The reconstruction of the pharynx by degradable, multifunctional polymeric materials would be a novel therapeutical option in head and neck surgery.

MATERIALS AND METHODS

Samples of an ethylene-oxide sterilized polymer (diameter 10 mm, 200μm thick) were implanted for the reconstruction of a standardized defect of the gastric wall in rats in a prospective study. The stomach is a model for a "worst case" application site to test the stability of the implant material under extreme chemical, enzymatical, bacterial, and mechanical load.

RESULTS

Fundamental parameters investigated in this animal model were a local tight closure between the polymer and surrounding tissues, histological findings of tissue regeneration and systemic responses to inflammation. A tight anastomosis between the polymer and the adjacent stomach wall was found in all animals after polymer implantation (n = 42). Histologically, a regeneration with glandular epithelium was found in the polymer group. No differences in the systemic responses to inflammation were found between the polymer group (n = 42) and the control group (n = 21) with primary wound closure of the defect of the gastric wall.

CONCLUSIONS

A sufficient stability of the polymeric material is a requirement for the pharyngeal reconstruction with implant materials.

Colgajo de pectoral mayor para reconstrucción de defectos faríngeos. Descripción de un caso

Introducción: La fístula faringocutánea post-laringectomía total (LT) continúa siendo una complicación frecuente luego de esta intervención especialmente tras tratamiento radioterápico. Cuando fracasan las medidas conservadoras, es necesario recurrir a cirugía reconstructiva. En nuestro centro se utiliza el colgajo miocutáneo de pectoral mayor (CMPM), que asegura un flujo sanguíneo adecuado para el tratamiento fístulas post-irradiación. Descripción: Presentamos un paciente con una fístula faringocutánea tras LT que requirió una amplia reconstrucción mediante CMPM asimismo discutiremos el importante papel que juega el tratamiento con oxígeno hiperbárico en el manejo de las consecuencias post-radioterapia. Conclusión: En la era de la reconstrucción microvascular, el PMMC puede ser utilizado para la reconstrucción de grandes defectos de cabeza y cuello, consiguiendo una adecuada cobertura tras protocolos de preservación de órgano o pacientes con historia de enfermedad vascular.

The Multidisciplinary Team (MDT) Approach and Quality of Care

The core function of a multidisciplinary team (MDT) is to bring together a group of healthcare professionals from different fields in order to determine patients' treatment plan. Most of head and neck cancer (HNC) units are currently led by MDTs that at least include ENT and maxillofacial surgeons, radiation and medical oncologists. HNC often compromise relevant structures of the upper aerodigestive tract involving functions such as speech, swallowing and breathing, among others. The impairment of these functions can significantly impact patients' quality of life and psychosocial status, and highlights the crucial role of specialized nurses, dietitians, psycho-oncologists, social workers, and onco-geriatricians, among others. Hence, these professionals should be integrated in HNC MDTs. In addition, involving translational research teams should also be considered, as it will help reducing the existing gap between basic research and the daily clinical practice. The aim of this comprehensive review is to assess the role of the different supportive disciplines integrated in an MDT and how they help providing a better care to HNC patients during diagnosis, treatment and follow up.