Vascular events in patients with head and neck cancer: A systematic review and meta-analysis

OBJECTIVE

To assess the incidence of vascular events in patients with head and neck cancer.

REVIEW METHODS

Primary studies identified through April 2023. Meta-analysis was performed.

RESULTS

There were 146 studies included in the systematic review. Rates of events were collected in the overall group, those with chemoprophylaxis, and those that underwent surgery, radiation, or chemotherapy. Of 1 184 160 patients, 4.3% had a vascular event. Radiation therapy had highest risk of overall events and stroke when compared to surgery and chemotherapy. Chemotherapy had a higher risk of stroke and overall events when compared to surgery.

CONCLUSIONS

Vascular events occur in 4%-5% of patients with head and neck cancer. Our data does not support the use of routine anticoagulation. Patients undergoing radiation therapy had the highest frequency of events.

Impact of the COVID-19 Pandemic on the Management of Head and Neck Malignancies

The impact of the coronavirus disease 2019 (COVID-19) pandemic on the management of head and neck cancer must be addressed. Immediate measures to reduce transmission rates and protect patients and providers take priority and necessitate some delays in care, particularly for patients with mild symptoms or less aggressive cancers. However, strict guidelines have yet to be developed, and many unintentional delays in care are to be expected based on the magnitude of the looming public health crisis. The medical complexity of head and neck cancer management may lead to prolonged delays that worsen treatment outcomes. Therefore, those caring for patients with head and neck cancer must take action to reduce these negative impacts as the country rallies to overcome the challenges posed by this pandemic.

Preoperative Stellate Ganglion Block for Perioperative Pain in Lateralized Head and Neck Cancer: Preliminary Results

Patients with head and neck cancer represent a vulnerable population at particular risk of opioid dependence due to frequent histories of substance abuse, requirement of extensive surgery, and the synergistic toxicity of multimodal therapy. Regional anesthetic techniques have been used by other surgical disciplines to facilitate early recovery after surgery and decrease postoperative patient narcotic requirements. This pilot study investigates the efficacy of a preoperative regional analgesia using stellate ganglion block in lateralized head and neck cancer surgery. From our early results, stellate ganglion blockade may hold promise as an effective preoperative intervention for controlling early postoperative pain, lessening narcotic requirements, and improving quality of life.

Reconstruction of TORS oropharyngectomy defects with the nasoseptal flap via transpalatal tunnel

The nasoseptal flap (NSF) has been described as reconstructive option for soft palate defects following transoral robotic surgery (TORS). As described, this technique is does not provide adequate coverage of the lateral oropharyngeal wall, parapharyngeal space, exposed vessels, or exposed mandibular bone. The NSF for TORS reconstruction has been limited to soft palate reconstruction, given the limitations on length when passed via the nasopharynx. In this article, we describe (1) a novel technique for TORS reconstruction using direct transposition of the ipsilateral NSF into the oropharynx via a transpalatal tunnel at the hard-soft palate junction, and (2) its use in select patients.

Applications of Evolving Robotic Technology for Head and Neck Surgery

OBJECTIVE

Assess the use and potential benefits of a new robotic system for transoral radical tonsillectomy, transoral supraglottic laryngectomy, and retroauricular thyroidectomy in a cadaver dissection.

METHODS

Three previously described robotic procedures (transoral radical tonsillectomy, transoral supraglottic laryngectomy, and retroauricular thyroidectomy) were performed in a cadaver using the da Vinci Xi Surgical System. Surgical exposure and access, operative time, and number of collisions were examined objectively.

RESULTS

The new robotic system was used to perform transoral radical tonsillectomy with dissection and preservation of glossopharyngeal nerve branches, transoral supraglottic laryngectomy, and retroauricular thyroidectomy. There was excellent exposure without any difficulties in access. Robotic operative times (excluding set-up and docking times) for the 3 procedures in the cadaver were 12.7, 14.3, and 21.2 minutes (excluding retroauricular incision and subplatysmal elevation), respectively. No robotic arm collisions were noted during these 3 procedures. The retroauricular thyroidectomy was performed using 4 robotic ports, each with 8 mm instruments.

CONCLUSIONS

The use of updated and evolving robotic technology improves the ease of previously described robotic head and neck procedures and may allow surgeons to perform increasingly complex surgeries.

Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost-effectiveness of transoral robotic surgery (TORS) for the diagnosis and treatment of cervical unknown primary squamous cell carcinoma (CUP).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic hospital.

SUBJECTS AND METHODS

A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with nondiagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Direct costs were obtained from the hospital's billing system, and national data were used for inpatient hospital costs and physician fees. The proportion of tumors found in 3 strategies was used as effectiveness to calculate the incremental cost-effectiveness ratio.

RESULTS

In total, 206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. The primary tumor was located in 19 of 22 patients (86.4%). The incremental cost-effectiveness ratio for sequential and simultaneous examination under anesthesia with tonsillectomy (EUA) and TORS base of tongue resection was $8619 and $5774 per additional primary identified, respectively.

CONCLUSION

Sequential EUA followed by TORS is associated with an incremental cost-effectiveness ratio of $8619 compared with traditional EUA alone. Bilateral base of tongue resection should be considered in the workup of these patients, particularly if the palatine tonsils have already been removed.

Robot-assisted level II-IV neck dissection through a modified facelift incision: initial North American experience

BACKGROUND

Cosmesis is of increasing importance to the otolaryngology patient population. This is the first report of clinical outcomes of robot-assisted neck dissection by North American groups.

METHODS

This is a retrospective case-control study. Cases included three patients who underwent isolated, ipsilateral robot-assisted neck dissection. Operative time, estimated blood loss, lymph node retrieval, total drainage, hospital stay and complications from this group were compared against the outcomes of six consecutive patients who underwent conventional neck dissection.

RESULTS

Operative times were longer in robot-assisted neck dissection (mean 234 min) compared with the conventional neck dissection (mean 110 min). There were no significant differences between the two groups in other outcomes.

CONCLUSIONS

Robot-assisted selective neck dissection of levels II-IV is feasible through a modified facelift incision. Our initial data suggest that this procedure is surgically sound. It should be applied by experienced surgeons who wish to avoid a cervical incision.

Extracapsular dissection for benign parotid tumors: a meta-analysis

OBJECTIVES/HYPOTHESIS

Recent studies suggest that extracapsular dissection (ECD) is an option for the resection of certain benign parotid tumors. This study investigates complication rates and effectiveness of ECD versus superficial parotidectomy (SP) for the treatment of primary benign parotid neoplasms.

STUDY DESIGN

Systematic literature review with meta-analysis.

METHODS

Studies available for inclusion evaluated the complications and effectiveness of ECD and SP as surgical techniques for the treatment of solitary, benign parotid tumors. An Ovid/Medline search revealed nine articles that met inclusion criteria. A critical review and meta-analysis of these articles was performed.

RESULTS

The included studies evaluated a total of 1,882 patients. There was no observed difference in tumor recurrence between the ECD and SP groups (odds ratio [OR], 0.557; 95% confidence interval [CI], 0.271-1.147). There was a significantly lower rate of transient facial nerve paresis (OR, 0.256; 95% CI, 0.174-0.377) in the ECD group (59 of 741; 8.0%) compared to the SP group (81 of 397; 20.4%); however, there was no observed difference in permanent facial paralysis between the ECD and SP groups (OR, 0.878; 95% CI, 0.282-2.730). Frey's syndrome was less often observed (OR, 0.117; 95% CI, 0.071-0.191) after ECD (27 of 602; 4.5%) compared to SP (75 of 287; 26.1%).

CONCLUSIONS

This systematic review with meta-analysis suggests that ECD has a similar recurrence rate as SP with fewer postoperative complications. ECD may be considered an alternative surgical modality for select benign parotid neoplasms.

Recurrent salivary gland cancer

OPINION STATEMENT

Salivary gland cancer is the most diverse cancer in the body consisting of up to 24 different pathologic subtypes. Although these cancers arise within a common group of glands in the head and neck region, these diverse cancers differ substantially in clinical behavior. As a result, salivary cancers are often categorized as low, intermediate, or high-risk for recurrence and metastasis based on histopathologic subtype and tumor stage. Appropriate risk classification of a given salivary tumor provides a useful guide to the physicians who determine the appropriate treatment regimen. Low-risk tumors can be treated successfully with surgery alone, whereas intermediate and high-risk tumors often require multimodality therapy. Recurrent salivary cancer should be considered high-risk by definition, especially if previously treated with appropriate therapy, and therefore requires aggressive multimodality therapy in order to achieve adequate local control and disease-free survival.