BACKGROUND:Perineural spread (PNS) of head and neck cutaneous squamous cell carcinoma (HNcSCC) is a unique diagnostic challenge, presenting with insidious trigeminal (CN V) or facial nerve (CN VII) neuropathies without clinically discernible primary masses. These patients are often sub-optimally investigated and misdiagnosed as Bell's palsy or trigeminal neuralgia. This case series highlights the red flags in history and pitfalls that lead to delays to diagnosis and treatment.METHODS:A retrospective case series of 19 consecutive patients with complete clinical histories with HNcSCC PNS without an obvious cutaneous primary lesion at time of presentation to a quaternary head and neck centre in Australia were identified and included for analysis.RESULTS:Fifteen had CN VII PNS, 17 had CN V PNS, and 13 had both. The overall median symptom-to-diagnosis time was 12-months (IQR-15 months). Eight patients had CN VII PNS and described progressive segmental facial nerve palsy with a median symptom-to-diagnosis time of 9-months (IQR-11.75 months). Eleven patients had primary CN V PNS and described well localized parathesia, formication or neuralgia with a median symptom-to-diagnosis time of 19-months (IQR 27.5 months).CONCLUSION:PNS is often mistaken for benign cranial nerve dysfunction with delays in diagnosis worsening prognosis. Red flags such as progressive CN VII palsy or persistent CN V paraesthesia, numbness, formication or pain, particularly in the presence of immuno-compromise and/or a history of facial actinopathy should raise suspicion for PNS. Gadolinium-enhanced MR Neurography should be obtained expediently in patients with persistent/progressive CN V/CN VII palsies in patients with red flags, with low threshold for referral to a Head and Neck Surgeon.

To present an institution's experience and survival outcomes for patients with head and neck cutaneous squamous cell carcinoma (HNcSCC) and perineural spread (PNS).

Background: Head and neck cancer (HNC) treatment has been significantly affected worldwide by the SARS-Cov-2 pandemic due to high viral loads in the upper aerodigestive tract. We present a single -institution experience of successful continued management of HNC patients during the pandemic.Methods: A retrospective audit was conducted comparing operative time, anaesthetic time, case volume and type (aerosol generating vs. non aerosol generating) between equivalent time periods from 2019 and 2020 during the peak of the pandemic in Australia, from a single high-volume, tertiary, academic head and neck centre. Furthermore, we document the multi-level changes instituted for each department involved in the patient cancer journey.Results: The average operative time for aerosol generating procedures (AGPs) was 85 minutes (IQR 455) in March 2019 compared with 180 minutes in March 2020 (IQR 366). Case volume and case type was similar between the two years. With appropriate patient screening, perioperative planning and judicious use of personal protective equipment (PPE), higher-risk AGPs were able to continue essentially as normal.Conclusions: HNC requires timely investigation and treatment, even in the midst of a pandemic, which can be achieved at a dedicated, COVID-free oncology centre utilising clear, rapid communication and a multidisciplinary approach.

BACKGROUND:Clinical voice assessment prior to thyroid and parathyroid surgery is essential, but the paradigm of indirect laryngoscopy (IDL), when indicated, has been challenged by the risk of aerosolised SARS-Cov-2 during endoscopy of the aerodigestive tract. Translaryngeal ultrasound (TLUS) to assess the vocal cords has been proposed as a safe, non-invasive and sensitive alternative. The aim of this review was to verify TLUS as a viable tool for perioperative laryngeal assessment.METHOD:A literature review was performed using Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials and Scopus with the following search strategy: (vocal cord OR vocal fold OR glottic OR glottis OR vocal ligaments OR rima glottidis) AND (ultras* OR sonograph* OR echography OR echotomography).RESULTS:Fifteen studies were included in this review. All studies compared TLUS to IDL in visualizing the vocal cords in adults. Ten studies compared pre-operative TLUS to IDL where 50.6-100% of vocal cords were successfully visualized. Nine studies compared post-operative TLUS to IDL and reported visualization between 39.6% and 100%. Pre- and post-operative negative predictive values ranged from 60% to 100%.CONCLUSION:Whilst promising, successful visualization of the cords is limited by inter-user variability, older age and male gender. Thus, we see the role of TLUS as an alternative to IDL in the post-operative setting in the young patient following uncomplicated surgery with a normal voice on clinical examination, to confirm recurrent laryngeal nerve integrity while minimizing the risk of aerosolization.

Parathyroid gland injury during thyroid surgery is common and can lead to postoperative hypocalcemia. This study aims to determine the utility of near-infrared autofluorescence (NIRAF) technology for parathyroid gland identification in thyroid surgery. A prospective case series of patients who underwent thyroid surgery between March and June 2021 were examined. Following intra-operative visualisation, parathyroid glands and surrounding tissues were exposed to near-infrared light with a wavelength of approximately 800 nm using the Storz® Near-Infrared Range/Indocyanine Green (NIR/ICG) endoscopic system. Parathyroid glands were expected to show autofluorescence following exposure. Twenty patients who underwent thyroid surgery were included. Eighteen patients (90

BACKGROUND:Head and neck surgeons are moving away from routine tracheostomy in free-flap reconstruction. We reviewed prophylactic tracheostomy use in patients undergoing oral cavity or oropharynx free-flap reconstruction to identify patient groups who avoided tracheostomy. Secondary aims were to describe complications associated with and without tracheostomy.METHODS:A retrospective cohort study was undertaken, using a prospectively maintained database. Inclusion criteria was free-flap reconstruction for an oral cavity or oropharyngeal defect, excluding partial or total laryngectomy. Variables collected included demographics, comorbidity, American Society of Anesthesiologists grade, Charlson Comorbidity Index, tumour site and subsite, extent of resection, surgery duration, tracheostomy, complications, return to theatre and re-intubation.RESULTS:A total of 344 head and neck free-flap reconstructions were performed between January 2017 and July 2019. A total of 164 (87.7%) oral cavity and 23 (12.3%) oropharyngeal reconstructions were included totalling 187 free flaps. A total of 107 (57.2%) were males and 80 (42.8%) females, mean age 62.4 years (range 21-89). Of 187 patients, 100 (53.5%) underwent prophylactic tracheostomy at time of reconstruction. Longer operative time (P < 0.001), resection site (P < 0.001), number of subsites resected (P = 0.007), segmental mandibulectomy (P = 0.04), lip-split (P = 0.05), floor of mouth resection (P < 0.001), lingual release (P = 0.007), glossectomy (P < 0.001), extent of tongue resection (P < 0.001), extent of hard palate resection (P = 0.04), soft palate resection (P < 0.001) and double free-flap reconstruction (P = 0.04) were associated with tracheostomy use.CONCLUSION:A personalized approach to postoperative airway management allowed almost half of our cohort to avoid tracheostomy. In high-volume institutions with the necessary expertise and support, appropriately selected patients may be safely managed without routine tracheostomy.

Intra-operative identification and preservation of parathyroid glands is an important but challenging aspect of thyroid surgery. Failure to do so may lead to transient or permanent hypocalcaemia, where the latter represents a serious complication causing life-long morbidity. It would be beneficial, therefore, if a simple and reliable modality can be developed to assist in the identification of parathyroid glands intra-operatively. The aim of this literature review is to provide an overview of intra-operative modalities used to identify parathyroid glands with a particular focus on near-infrared autofluorescence (NIRAF). Twenty-seven studies were considered relevant in this literature review. Several modalities have been used to aid parathyroid gland identification, including Raman spectroscopy, indocyanine green angiography, and NIRAF. NIRAF technology allows parathyroid glands to spontaneously give off light (autofluorescence) when exposed to near-infrared light at a wavelength of 785 nm, creating a contrast between tissues to allow intra-operative differentiation. Studies utilising NIRAF technology were able to identify 76.3%-100% of parathyroid glands intra-operatively. Furthermore, two randomised controlled trials comparing NIRAF and white light showed that the use of NIRAF was able to significantly increase the mean number of parathyroid glands detected and reduce the incidence of post-operative hypocalcaemia. NIRAF is an emerging tool that has been shown to increase the number of intra-operative parathyroid gland identification and reduce the rate of post-operative hypocalcaemia in a safe and reproducible manner. Future trials are needed to evaluate the real-life impact of NIRAF technology in outcomes of patients following thyroid surgery.

BACKGROUND:Renal cell carcinoma (RCC) is the most common malignancy that metastasises to the thyroid. This study aims to better understand the clinical characteristics of patients with thyroid metastasis from RCC.METHODS:A retrospective case series of patients with thyroid metastasis from RCC between 2008 and 2020 from two tertiary centres were examined. MEDLINE and PubMed database searches were performed to retrieve the relevant literature.RESULTS:Fifteen patients (eight males) were identified, with a median age of 57.0 (interquartile range (IQR) 51.0-63.0) at time of RCC diagnosis. Median time to thyroid metastasis was 92.0 months (IQR 40.0-156.0), with 12 (80.0%) patients undergoing thyroidectomy within 2 months of diagnosis. No patients developed post-operative complications or local thyroid recurrence. The two most common non-thyroid metastatic sites in this case series are lungs and bone (five patients, respectively; 33.3%) and pancreas (four patients; 26.7%). Ten (66.6%) patients underwent systemic chemotherapy, and five (33.4%) patients underwent radiotherapy for other sites of metastasis. Median survival following thyroid metastasis was 54.0 months (IQR 15.0-100.0). The literature review was conducted through MEDLINE and PubMed database searches, and 30 papers were considered relevant to this review. Results from our study are comparable to those reported in the literature.CONCLUSION:Thyroid metastases can occur long after nephrectomy and portends a better prognosis. To prevent development of central neck disease, thyroidectomy should be considered.