Pharyngocutaneous fistula (PCF) remains the most common and challenging complication following total laryngectomy (TL), occurring in 17%–34% of patients despite advances in surgical technique and perioperative care. PCF significantly increases morbidity, prolongs hospitalization by an average of 2–3 weeks, delays adjuvant therapy, and substantially increases healthcare costs. The pathogenesis of PCF is multifactorial, involving patient-related factors (comorbidities including hypothyroidism, nutritional status, and smoking), disease-related factors (tumor extent, previous radiotherapy, disease-free interval, and extralaryngeal spread), and surgical factors (closure technique and use of vascularized tissue). Recent systematic reviews and meta-analyses have identified several modifiable risk factors, including preoperative anemia (hemoglobin < 12.5 g/dL), hypoalbuminemia, hypothyroidism, and active smoking. Prevention strategies encompass three critical phases: preoperative optimization of nutritional status, correction of anemia and thyroid dysfunction, and pulmonary prehabilitation through incentive spirometry; intraoperative meticulous surgical technique with appropriate pharyngeal closure methods and selective use of vascularized tissue reconstruction; and postoperative monitoring with early fistula detection protocols, anti-reflux measures, structured respiratory physiotherapy, and antiemetic and laxative regimens. Salvage TL following chemoradiotherapy carries particularly high PCF rates (20%–35%), necessitating prophylactic reconstruction with pedicled or free flaps. Evidence demonstrates that pectoralis major myofascial flaps reduce PCF rates by approximately 22% in salvage cases, while horizontal pharyngeal closure decreases fistula incidence compared to T-shaped closure. Evidence for routine salivary bypass tube use is insufficient, and selective placement based on individualized risk assessment is recommended. This narrative review synthesizes current evidence on PCF prevention with Oxford Centre for Evidence-Based Medicine level of evidence grading, examining risk stratification systems, preoperative patient optimization protocols, surgical techniques, reconstructive strategies, and postoperative management approaches to reduce PCF incidence and improve outcomes for patients undergoing TL.
Rehabilitation of the atrophic maxilla presents a significant clinical challenge due to severe alveolar bone resorption, poor bone quality, and anatomical limitations such as sinus pneumatization. While traditional bone grafting procedures are effective, they are often invasive and unsuitable for medically compromised patients. This narrative review evaluates current implant-based treatment modalities, with a focus on graftless techniques including short, tilted, pterygoid, zygomatic, and patient-specific subperiosteal implants. A comprehensive literature search was conducted across multiple databases (PubMed, Google Scholar, EBSCO, Web of Science, and Cochrane Library) for studies published between January 1998 and December 2024. A total of 40 relevant articles were selected, highlighting that graftless solutions demonstrate high survival rates and reduced morbidity. Reported survival rates include up to 96% for short implants, 98.6% for tilted implants, approximately 97% for zygomatic implants, and 91% for pterygoid implants. Implants in sinus-augmented areas show variable success, with rough-surfaced implants outperforming machined ones. Key biomechanical considerations, such as implant diameter, splinting, and angulation, significantly influence load distribution and implant longevity. Overall, advancements in digital planning, implant technology, and biomaterials have established graftless implant approaches as effective and predictable alternatives for restoring function and esthetics in patients with atrophic maxillae, while minimizing surgical invasiveness.
Collision tumors of the thyroid are rare entities characterized by the coexistence of two histologically distinct malignancies within the same gland. The combination of medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma presents unique diagnostic and therapeutic challenges. A 65-year-old female presented with a left-sided thyroid swelling and cervical lymphadenopathy. Ultrasonography revealed a TIRADS V lesion in the left lobe with metastatic lymph nodes. Fine-needle aspiration cytology suggested follicular neoplasm. The patient underwent total thyroidectomy with central compartment clearance. Histopathological examination demonstrated a collision tumor comprising MTC in the left lobe and papillary microcarcinoma (columnar cell variant) in the isthmus. Postoperative biochemical markers showed elevated calcitonin and carcinoembryonic antigen. Metastatic workup was negative. Radioiodine ablation was administered for the papillary component. However, persistent elevation of calcitonin during follow-up suggested possible residual medullary disease. This case highlights the limitations of preoperative cytology, the importance of biochemical markers, and the therapeutic dilemma posed by dual thyroid malignancies. Management should be guided by the more aggressive component, typically MTC, with emphasis on long-term biochemical surveillance.
Primary intraosseous cavernous hemangiomas are usually found in the vertebrae. Rare in the cranial vault and account for 0.2% of cranial bone tumors. Usually, they are solitary. Multifocal cavernous hemangioma in the bones is extremely rare and common in females. The majority of these lesions are small and incidentally diagnosed. Few patients may present with painless progressively enlarging mass in the cranial bones. Computed tomography and magnetic resonance imaging scans can be helpful for evaluating intraosseous hemangioma. Histopathology examination is required for the definitive diagnosis. They tend to recur after incomplete resection. The treatment of choice is complete resection by craniotomy with adequate normal bone margin and subsequent cranioplasty.
Immune checkpoint inhibitors have significantly improved the outcomes of head-and-neck squamous cell carcinoma (SCC). However, predictive biomarkers for response remain limited, especially in tumors with low programmed death-ligand 1 (PD-L1) expression. We report the case of a 47-year-old man with SCC of the tongue who exhibited a low PD-L1 combined positive score (CPS < 1). The patient developed local recurrence 5 months after surgery and adjuvant radiotherapy. The patient achieved complete response following chemotherapy with pembrolizumab and remained disease-free after 2 years of maintenance therapy. This case emphasizes the potential durable response to pembrolizumab in patients with oral SCC with a low CPS and raises major considerations regarding immunotherapy duration.
Background: Head and neck cancers (HNCs) represent a heterogeneous group of malignancies with substantial variation in epidemiology, clinicopathological characteristics, treatment approaches, and outcomes across tumor subsites. Real-world institutional data remain essential to understanding patterns of presentation and survival outside clinical trial settings. Methods: This retrospective study included head and neck squamous cell carcinoma treated at Menoufia University Hospitals between January 2020 and December 2023. Results: A total of 121 patients were analyzed. The most common primary subsite was the larynx (66 patients; 54.5%), followed by the oral cavity (27 patients; 22.3%) and nasopharynx (19 patients; 15.7%). Advanced stage IV tumors were most frequent in the oral cavity (59.2%). With a median follow-up of 45 months (range: 6–65), disease progression occurred in 43 patients (35.5%), and 39 patients (32.2%) died. The overall progression-free survival (PFS) and overall survival (OS) rates were 58.4% and 55.4%, respectively. Median PFS and OS were not reached for laryngeal and nasopharyngeal cancers, whereas oral cavity cancer showed inferior outcomes (median PFS 35.97 months; median OS 37.5 months). On multivariate analysis, performance status (PS) (hazard ratio [HR] 5.997, P < 0.001) and TNM stage (HR 47.395 for stage IV, P = 0.002) were independent predictors of OS. Conclusions: This real-world study demonstrates clear subsite-specific differences in presentation, management, and outcomes of HNCs. Advanced stage and poor PS remain the dominant predictors of survival, highlighting the need for earlier diagnosis and optimized multidisciplinary care.
Background: Oral squamous cell carcinoma (OSCC) has a complex tumor microenvironment (TME) that modulates the progression, invasion, and migration of oral cancer cells. Tumor-infiltrating lymphocytes (TILs), a key component of the TME, play an important role in immune surveillance and modulation of cancer cells. Aim: The present study aimed to evaluate the prognostic role of tumor-infiltrating lymphocytes in OSCC. Materials and Methods: The study included 150 OSCC patients, comprising 50 cases each of well-differentiated squamous cell carcinoma (WDSCC), moderately differentiated squamous cell carcinoma, and poorly differentiated squamous cell carcinoma (PDSCC). Demographic data, including age, gender, site, and the survival data, were retrieved from departmental records, and the presence of TILs was evaluated by two oral pathologists. The data were statistically analyzed using SPSS software 23. Results: The mean age of the OSCC patients was observed as 54 ± 8 years. Stromal and intratumoral TILs were more common in WDSCC (14.66% and 28.66%, respectively) compared to PDSCC (16.67%; 0%). A statistically significant difference was observed between OSCC grades and stromal TIL groups (P = 0.00). OSCC cases with increased TILs showed reduced lymphovascular and perineural invasion. Patients with high TILs (>50%) showed a mean overall survival of 40.7 ± 1.54 months, whereas those with low TILs (<10%) had a mean overall survival of 13.4 ± 1.18 months. Conclusion: OSCC patients with high TILs showed improved overall survival, and a decreased incidence of lymphovascular and perineural invasion. Given the significant association between stromal TILs and the overall prognosis of OSCC patients, future studies should investigate its relationship with the immune microenvironment.
Background: Total laryngectomy, a surgical procedure typically performed for advanced laryngeal cancer, results in patients breathing through a stoma instead of the nose. This alteration can impair their sense of smell and taste. Objective: The objective is to compare the smell and taste abilities of laryngectomized patients with those of healthy controls. Materials and Methods: A total of 56 subjects were included in the study, consisting of 28 laryngectomized patients and 28 healthy controls. Olfactory function was assessed using the smell detection threshold test, smell discrimination test, and smell identification test. Gustatory function was assessed through a modified taste strip test, electrogustometry, and regional (spatial) taste testing. Results: The smell detection threshold differed significantly between the two groups when analyzing the right and left nasal cavities separately (P = 0.01 and P = 0.02). However, bilateral smell testing did not show a statistically significant difference (P = 0.2). Smell discrimination scores were significantly different between the two groups. However, the results from a smell identification test, modified taste strip test, electrogustometry, and regional (spatial) taste test were not significantly different between the two groups. Conclusion: Laryngectomized patients exhibited significantly higher smell detection thresholds compared with controls when each nasal cavity was tested separately, but not when bilateral testing was performed. Smell discrimination scores were also significantly lower in the laryngectomized group. However, their ability to identify familiar odors and perceive taste did not differ significantly from that of the control group. Techniques aimed at enhancing olfactory function may help improve the quality of life in laryngectomized patients.
Updates and advancements in the medical sciences are essential to address the increasing number of health-related problems. The treatment of such health issues depends heavily on the diagnosis and available technology. Different diagnostic imaging technologies with advanced features, such as positron emission tomography (PET)/magnetic resonance (MR), are available today. The technology provides biological and anatomical details, offering better soft-tissue contrast from MR and comprehensive metabolic data from PET, opening a new path in diagnostic imaging. Cancer is one of the major global health issues, and the correct diagnosis of the disease is essential for the best treatment. PET/MR plays a vital role in the diagnosis of cancer, especially in head and neck cancer, by helping determine the stage, distinguish tumor from healthy tissues or organs, plan treatment modality, and provide the information required to treat a life-threatening disease like cancer. The article highlights PET/MR’s role in HNCs, its innovations, and the technical challenges encountered along the way. The article discusses the research and review articles from the past 14 years to provide an overview of PET/MR, its significance in head and neck oncology, and its role in the upcoming days.
Assessment of possible association between formaldehyde exposure and risk for the development of laryngeal, hypopharynx, and nasopharynx cancer. The review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines 2020 and registered in PROSPERO – Not registered in PROSPERO. Electronic databases were searched for studies evaluating the possible association between formaldehyde exposure and the development of laryngeal, hypopharynx, and nasopharynx cancer. Screening and data extraction were done by two independent reviewers. The quality assessment of studies was evaluated through the Newcastle–Ottawa scale tool. The risk ratio (RR) was used as a summary statistic measure with a random effect model and P < 0.05 as statistically significant through Review Manager (RevMan) version 5.3. Eleven studies were included in qualitative synthesis and five studies for meta-analysis, with data evaluated from 329,397 occupational workers exposed to formaldehyde with a mean exposure duration year of ± 10 years with an exposure dosage ranging from 0.02 to 0.50 ppm. Included studies showed moderate-to-low ROB. Meta-analysis revealed that occupational workers exposed to formaldehyde had shown an increased risk for laryngeal (RR: 1.42 [1.01–2.01]), hypopharynx (RR: 1.10 [0.75–1.61]), and nasopharynx cancer (RR: 1.16 [0.99–1.36]). The funnel plot did not show the presence of publication bias in the meta-analysis. Occupational formaldehyde exposure demonstrated a statistically significant association with laryngeal cancer risk. However, the associations with hypopharyngeal and nasopharyngeal cancers were not statistically significant. Further large-scale prospective studies controlling for smoking and alcohol-related confounders are recommended.
Background: Patients with oral cancer experience psychosocial issues. Body image distress (BID) is a crucial psychosocial issue. Diagnosis, treatment, and psychosocial effects can also significantly impact the quality of life (QoL). Aim: The aim of this study was to determine the BID and QoL of oral cancer patients before and after surgery and their relationship with each other. Setting and Design: This longitudinal prospective study was conducted at a tertiary cancer center in Southern India. Materials and Methods: Patients with oral cancer (n = 44) whose primary treatment modality was surgery were assessed using the Inventory to Measure and Assess imaGe disturbancE-Head and Neck and Functional Assessment of Cancer Therapy-Head and Neck before and after surgery. Statistical Analysis: Paired t-test, Pearson correlation coefficient, and one-way analysis of variance were used to analyze the data. Results: The study found that BID increased and QoL decreased after surgery. A significant negative correlation was observed between QoL and the BID. Although there was no significant difference in QoL and BID based on sociodemographic factors, there was a significant difference in QoL and BID based on the oral cavity subsites. Conclusion: The findings concluded the presence of body image concerns and affected QoL after surgery in oral cancer patients, which required psychosocial prehabilitation and rehabilitation.
Background: To minimize complications of blood transfusion, alternative approaches like autologous transfusion have been introduced. Aim of Study: To evaluate if acute normovolemic hemodilution (ANH) reduces allogeneic blood transfusion requirements compared to standard care in patients undergoing head and neck surgeries with anticipated major blood loss. Hemodynamic parameters, inotrope requirements, adverse events associated with blood transfusion, and length of hospital stay were also compared between groups. Settings and Design: This was a prospective, randomized controlled, open-label study. Methods: A total of 48 patients were recruited and randomly assigned to either the ANH group (Group A) or the control group (Group B). In Group A, a standard blood unit was withdrawn and replaced with Ringer’s lactate. The collected blood was stored in Citrate Phosphate Dextrose Adenine Solution, USP buffer and retransfused as needed. Vital signs were continuously monitored. Volume replacement was maintained with Ringer’s lactate or other fluids. In Group B, no ANH was performed. Intraoperative blood loss was calculated, and arterial blood gas analysis, hemoglobin (Hb) measurements, and complete blood count were performed. Results: The need for allogenic blood transfusion was significantly lower in Group A compared to Group B (20.33% vs. 62.5%, P = 0.0033). There was a significant fall in Hb before and after ANH in Group A (13.83 ± 1.03 vs. 11.89 ± 1.16, P < 0.001). Need for inotrope support (8.33% vs. 16.67%, P = 0.098), and postoperative Hb values (P > 0.05) were comparable in both groups. Conclusion: The need for allogenic blood transfusion after ANH was significantly lower compared with patients receiving standard care with homologous blood transfusion.
Background: Mucoepidermoid carcinoma (MEC) is the leading malignant salivary gland tumor, with ambiguous neck management for clinically node-negative (cN0) patients. The effectiveness of ipsilateral neck node irradiation (INNI) following surgery and adjuvant radiotherapy is not clearly established due to varying risk factors. Objective: This preliminary study presents a series of parotid MEC patients treated surgically with adjuvant radiotherapy, highlighting a two-step algorithm for INNI based on clinical, radiological, and pathological evaluations. We assess outcomes, toxicity, and the rationale for INNI in accordance with established guidelines. Methods: Ten patients underwent surgical procedures and received adjuvant radiotherapy (60 Gy). INNI was implemented via a two-step approach: (1) initial clinical and radiological evaluation, followed by (2) postsurgical pathological assessment. INNI was omitted in cN0/pN0 cases, applied in cN0/pN + cases, and considered in cN0 without neck dissection when high-risk features were present. cN + patients were treated based on pathological findings and a multidisciplinary approach. One-year outcomes were evaluated. Results: All patients remained alive and disease-free after 1 year, with no recurrences observed. INNI was utilized for four patients (two cN0/pN + and two cN0 with high-risk features). No significant acute or late grade ≥3 toxicity was reported. The decision algorithm facilitated personalized neck management, minimizing unnecessary irradiation. Conclusion: The proposed risk-adapted algorithm for INNI in parotid MEC appears feasible and is associated with acceptable short-term toxicity. These findings are exploratory and hypothesis-generating only, given the very small sample size and limited follow-up. Selective INNI for high-risk patients can be easily applied with the proposed algorithm.
Background: Cytology categories Bethesda III and Bethesda IV thyroid nodules present a diagnostic challenge for both clinicians and patients owing to their heterogeneity and variable risk of malignancy (ROM). According to the Bethesda System, the estimated malignancy risk for these categories is 13%–30% and 23%–34%, respectively. However, institutional variations may exist. This study aimed to determine the ROM specific to our institution and to identify clinical factors associated with malignant outcomes. Methodology: This retrospective study included patients with Bethesda III and IV cytology who underwent thyroidectomy at a tertiary cancer center in Kerala between 2018 and 2022. Demographic, clinical, radiological, and histopathological data were analyzed. Statistical analyses were performed using Chi-square, Mann–Whitney U, and logistic regression tests, with P < 0.05 considered statistically significant. Results: A total of 140 patients were included, the majority being females below 55 years of age. In the Bethesda III category, firm nodule consistency was significantly associated with malignancy (P = 0.009). In the Bethesda IV group, nodule size, consistency, and TIRADS category showed significant correlations with malignancy. The overall malignancy rates were 72% for Bethesda III (18/25 cases) and 57% for Bethesda IV (66/115 cases), both higher than the standard Bethesda estimates. Conclusion: The malignancy rates for Bethesda III and IV nodules in our cohort were notably higher than those reported in the Bethesda system, emphasizing the need for institution-specific risk assessment. Firm to hard nodule consistency was strongly associated with malignancy, underscoring its value in clinical evaluation.
Background: Prolonged overall treatment time in laryngopharyngeal squamous cell carcinoma contributes to accelerated tumor repopulation and poorer outcomes. In resource-limited settings, socioeconomic factors further increase treatment interruptions. Accelerated radiotherapy may reduce treatment duration, but concerns regarding acute toxicity remain. Objectives: The objective of this study was to assess the feasibility and acute toxicity of a seven-fractions-per-week accelerated radiotherapy regimen, with or without concurrent chemotherapy, in laryngopharyngeal squamous cell carcinoma. Methods: This prospective pilot study included 92 patients with stage I–IV laryngopharyngeal squamous cell carcinoma treated between June 2020 and March 2021 at a tertiary cancer center in Northeast India. Patients received 70 Gy in 35 fractions delivered 7 days/week, with weekly cisplatin (40 mg/m2) when indicated. Treatment was delivered using two-dimensional telecobalt radiotherapy with aluminum tissue compensation. Acute toxicity was assessed weekly using Radiation Therapy Oncology Group criteria. Results: Grade 3 mucositis occurred in 23.9% of patients and Grade 3–4 skin toxicity in 17.4%. Eighteen patients (19.6%) completed planned chemoradiation within 35 days. At 3 months, 50% achieved complete clinical response at both primary and nodal sites. Median overall survival was 841 days, with 1- and 2-year survival rates of 71.4% and 53.8%, respectively. Conclusion: Seven-day-per-week accelerated radiotherapy appears conditionally feasible with acceptable acute toxicity in resource-constrained settings. Further randomized studies are warranted to evaluate long-term outcomes.
Context: Head and neck cancers (HNC) represent a significant health burden in India, particularly in the northern region, with radiotherapy (RT) serving as a cornerstone treatment modality. Aims: This study aimed to investigate the determinants of noncompliance to curative-intent RT among HNC patients at a tertiary care center in Northwestern India. Settings and Design: This retrospective analysis evaluated 297 HNC patients who underwent curative-intent RT between January 2020 and December 2024 at our center. Subjects and Methods: Patient-initiated premature discontinuation without clinical authorization was classified as noncompliance. Socioeconomic, disease, and treatment parameters were assessed through medical records, with telephone interviews conducted to ascertain reasons for discontinuation. Statistical Analysis Used: Data were compiled and analyzed using Microsoft Excel. Proportions were compared using appropriate statistical tests, with P ≤ 0.05 considered statistically significant. Results: The overall noncompliance rate was 40.07% (119/297 patients). Statistically significant predictors included age (highest in 41–60 years, 46.41%, P = 0.049), occupation (highest in retired, 60.0%, and unemployed, 53.42%, P = 0.037), distance from hospital (52.0% for >100 km vs. 32.92% for < 50 km, P = 0.019), and concurrent chemotherapy (43.42% vs. 28.99%, P = 0.032). RT-related toxicities (31.93%) and lack of belief in RT efficacy (19.33%) were the primary reported reasons for discontinuation. Conclusion: Noncompliance with RT remains a significant challenge in managing HNCs. Early identification of high-risk patients based on socioeconomic and treatment-related factors, alongside proactive toxicity management and comprehensive patient education, may improve treatment completion rates and outcomes.
Purpose:This study evaluates the patterns of failure in patients with differentiated thyroid cancer. It identifies clinicopathologic features and biomarkers, such as microvessel density (MVD) and microlymphatic vessel density (MVLD), associated with recurrence and disease-free survival.Methodology:In this single-center retrospective cohort study, patients who underwent total thyroidectomy with or without neck node dissection for differentiated thyroid carcinoma between 2011 and 2020 were included. Patterns of failure, along with clinicopathologic factors associated with recurrence, were also analyzed. MVD and MVLD were assessed in a subset of patients who had nodal and/or distant metastasis and compared to those who did not.Results:A total of 358 patients were evaluated. A multivariate analysis showed that the risk of recurrence in patients with pT4 tumors was significantly higher (hazard ratio (HR) 16.18, 95% confidence interval (CI) (1.01-55.91). Patients with N1b disease were also at a significant risk for nodal recurrence (HR 4.09, 95% CI (3.7-16.54). Positive correlation for MVD (measured number of vessels/x20 field taken as an average of five fields) was seen in patients with recurrence (71.11 vs. 63.87), tumors showing lymphovascular invasion (LVI) (74.92 vs. 65.66), and distant metastasis (72.51 vs. 64.88). However, these differences were not statistically significant.Conclusion:Factors associated with recurrence in differentiated thyroid carcinoma were pT4 disease, N1b disease and those who had received a higher dose of radio-iodine ablation. Higher MVD and MVLD in the primary tumor did not predispose to the risk of local or distant recurrence.
Objectives:The aim of this study is to determine the elasticity of the disc by measuring the amount of elongation during mouth opening and its correlation with the degree of temporomandibular joint (TMJ) disorders.Materials and Methods:Forty patients were included in this study. All patients underwent a complete clinical assessment. Magnetic resonance imaging (MRI) was performed with PD-FSE, T1, and T2-weighted sequences in both open and closed mouth positions using a 3T system. Based on the Clinical and MRI findings, all participants were divided into three groups: Group 1 (Normal), Group 2 (Disc Derangement with reduction), and Group 3 (Disc Derangement without reduction). The obtained MRI was used to calculate the disc length at maximal elongation while the mouth is open and closed. The Elongation Ratio (ER) was then computed. Statistical analysis was performed using SPSS software (version 26) 3T MRI System: Siemens Magnetom Skyra, Siemens Healthineers, Erlangen, Germany. P <0.05 is to be considered statistically significant. Descriptive statistics were performed. Kruskal-Wallis test was used to compare the differences in the ER Values based on Pathology.Results:Of the 80 TMJs examined, 17 were normal, 46 had disc displacement with reduction, and 17 had disc displacement without reduction. The highest ER value was found in the normal joints (2.76 +/- 1.48), followed by joints with disc displacement with reduction (1.45 +/- 1.32), and the least ER value was found in joints with disc displacement without reduction (0.17 +/- 1.23). This difference was found to be statistically significant (P = 0.001).Conclusion:we conclude that ER can be a strong indicator of disc elasticity has the potential to add information to earlier grading systems.
