Immediate postoperative care on high dependency unit or ward following microvascular free tissue transfer: lessons learnt from a change in practice imposed during the COVID-19 pandemic

The COVID-19 pandemic resulted in sudden changes to the established practice of using the high dependency unit (HDU) for the first night of postoperative care following microvascular free tissue transfer. Patients were managed instead on the head and neck ward. This retrospective case-note review aimed to report outcomes in consecutive patients treated before and during the pandemic, and to reflect on the implications of ward-based rather than HDU care. A total of 235 patients had free tissue transfer between 3 January 2019 and 25 February 2021: 125 before (lockdown 23 March 2020), and 110 during the pandemic (52 ward-managed and 58 HDU-managed). There were subtle case-mix differences during the pandemic, with 92% of ward-treated patients having oral cancers compared with 64% of HDU patients, and 73% of ward patients having a tracheostomy compared with 40% of HDU patients. Ward patients were less likely to receive electrolyte replacement (45% HDU vs 0% ward) and inotropes (12% HDU vs 2% ward). There were fewer returns to theatre for evacuation of a haematoma or re-anastomosis during the pandemic than there were before it. Other than fewer haematoma complications during the pandemic, the nature of complications was similar. In conclusion, the dramatic changes imposed by the pandemic have shown that the ward is a safe place for patients to be cared for immediately postoperatively, and it alleviates the bed pressures experienced in HDU. Careful case selection and clear criteria are required to identify patients who need the HDU.

Clinical characteristics, treatment intent, and outcome in a consecutive 10-year cohort of oral cancer patients aged 75 years and older

The prevalence of oral squamous cell carcinoma (OSCC) in the elderly is expected to increase by nearly a third in the next decade. Its management in older patients is potentially more challenging due to their pre-existing medical comorbidities, frailty, reduced life expectancy, and social issues. The aim of this retrospective review was to report on treatment given to patients aged 75 years and over, case mix, and survival. All patients aged 75 years and over who were diagnosed with OSCC in Merseyside between 1 January 2007 and 31 December 2016, and treated with either curative or palliative intent, were included. Their hospital notes were reviewed. Fisher's exact test and Kaplan-Meier analysis were used for data analysis. There were 236 patients (median (IQR) age 81 (78-86) years); 67% were treated curatively and 33% palliatively. Factors associated with palliation included older age, advanced tumour stage, cognitive impairment, and residence in a nursing or residential home. Of the 165 patients who were offered curative treatment, six (4%) declined due to personal or family reasons. Overall survival for palliative patients was 12% at one year and 7% at two years, whereas for patients treated curatively it was 74% at one year, 56% at two years, and 34% at five years. Patients over 85 years of age were less likely to have composite free flaps and postoperative radiotherapy. Perioperative mortality was 2.6%. Improvements in surgical techniques and perioperative management have enabled clinicians to offer treatment with curative intent to older frail patients, and with careful case selection outcomes can be very good.

Outcomes of microvascular composite reconstruction for mandibular osteoradionecrosis

The aim of this retrospective study was to compare outcomes and reconstruction-related complications in patients receiving a composite free flap reconstruction of the mandible for ORN with those reconstructed for other indications. The records of all patients who underwent composite reconstruction of a mandibular defect at Aintree University Hospital, Liverpool, were reviewed and analysed. Based on radiotherapy exposure and ORN history, the study cohort was divided into three separate case-matched groups. Local wound healing issues were markedly more common in the ORN setting, as was infection and subsequent osteosynthesis plate(s) removal. Free flap survival was similar among all three case-matched groups. Advanced mandibular ORN may be safely and predictably reconstructed with composite free flaps, and that while the rate of local complications is greater than non-irradiated, and non-ORN case-matched controls, the free flap survival rate compares favourably.

Health-related quality of life in patients with T1N0 oral squamous cell carcinoma: selective neck dissection compared with wait and watch surveillance

Management of the neck in patients with clinical T1N0 oral squamous cell carcinoma (SCC) is controversial. The aim of this study was to report the health-related quality of life (HRQoL) in a consecutive group of patients with stage 1 disease at a time closest to two years after primary surgery. Of 216 patients treated between 2007 and 2012 (after excluding early death and regional recurrence), 195 were eligible. HRQoL was measured using the University of Washington quality of life questionnaire version 4. The overall response rate was 65% (126/195). HRQoL outcomes were good, but compared with patients in the wait and watch group, those who had selective neck dissection (SND) had more problems regarding appearance (14% compared with 1%, p=0.008) and pain (19% compared with 6%, p=0.04). Similar trends were seen for shoulder (14% compared with 8%), mood (16% compared with 8%), and speech (5% compared with 1%), and for poorer overall QoL (30% compared with 16%). It is difficult to establish why patients did or did not have neck dissection in a retrospective sample, but it is likely that those who had SND had larger tumours. The findings highlight the impact that SND has on HRQoL in domains such as appearance, pain, speech, swallowing, and chewing. Previous studies on SND have tended to focus on injury to the accessory nerve and shoulder function, but these new data emphasise the need to include other domains in future trials that compare wait and watch, SND, and sentinel lymph node biopsy.

The Patient Concerns Inventory: A Tool to Uncover Unmet Needs in a Cancer Outpatient Clinic

The Patient Concerns Inventory (PCI) is a holistic, patient reported tool that aids in identifying concerns and issues. it is a 55-item checklist of issues that may be grouped into categories of general function, specific head and neck function, emotional-psychological and others, which include finances, treatment related matters and social care. The PCI also gives patients an opportunity to identify from a list of 15 multidisciplinary team (MDT) members whom they would like to see or be referred on to.

Tracheostomy tape: more trouble than it's worth?

In many units where microvascular free-tissue transfer in the head and neck region is practised, tracheostomy is completed with the suturing of the tube in place and the removal of the supporting struts from the tube flange. The thinking is that in removing the struts the risk of occlusion of the vascular pedicle of the free flap, as it lies in the neck, is reduced as the cervical tape cannot be applied. The evidence base for vascular obstruction resulting from a correctly positioned tape is lacking. Presented here is a case in which potential flap failure, as a result of a cervical tracheostomy tape, was avoided by early detection of ischaemia using microdialysis.

Chondroradionecrosis of larynx following radiotherapy for metastatic neck disease originating from oral carcinoma

Chondroradionecrosis of larynx is a rare but serious complication of radiotherapy. Here is described a case of chondroradionecrosis after 20 years of completion of radiotherapy for oral cancer. The patient underwent excision of necrotic anterior skin of the neck, together with devitalized thyroid cartilage and most of the cricoid cartilage, and reconstruction with pectoralis major muscle transposition. This resulted in preservation of laryngeal function, and avoided further exploration of the irradiated neck and possible further skin loss.

Use of Palacos®R-40 with gentamicin to reconstruct temporal defects after maxillofacial reconstructions with temporalis flaps

The temporalis muscle flap is a useful flap for the reconstruction of oral ablative defects. A complication of its use that was overlooked was the crater-like defect created when the muscle is stripped from its attachment on the temporal fossa. The cold-cure acrylic we use is Palacos R-40 with Gentamicin (Heraeus Kulzer GmbH). This material is radio-opaque, rapidly setting and contains gentamicin. We present a total of 41 cases over an 11-year period (1994-2005). We have a 97.6% (n = 40) success rate. Infection developed in only one case, which leads to the removal of the acrylic implant. The use of Palacos R-40 with Gentamicin is easy to use, it can be custom-moulded to fit and fill the defect any of shape and size. It has minimal complications and high success rate with acceptable results to the patients.

Surgical emphysema following dental treatment: two cases

Surgical emphysema is an uncommon complication of dental treatment despite the frequent use of air-driven handpieces and high-speed water-cooled equipment in dental practice. As a consequence it may either go unrecognized or be misdiagnosed. Although most cases resolve spontaneously, some patients require emergency intervention. This article outlines the condition and its management and describes two cases that arose during routine dental treatment.