Introduction: Patients with head and neck cancer often necessitate complex reconstructions, considering both functional and esthetic concerns. Reconstructions are further complicated by previous radiation therapy and patient co-morbidities, which impair wound healing. A recently introduced synthetic hybrid-scale fiber matrix has been shown to provide durable wound coverage and promote tissue healing as an alternative to traditional biologic allogenic and xenogenic skin substitutes. Case Presentation: Thirteen patients were treated at a single academic hospital between December 1, 2021, and May 1, 2023 with the synthetic matrix in head and neck reconstructions. Reconstructions included exposed muscle, scalp wounds, intra-oral defects, and radial forearm free flap donor sites. Wound sizes ranged from 2 × 2 cm to 18 × 10 cm. Serial photographs were taken to evaluate wound healing at 1, 4, 8, 12, and 16 weeks timepoints after application. Outcomes measured at each timepoint included wound size, presence of granulation tissue, and extent of epithelialization. No hematomas or wound complications were encountered. Complete wound healing was noted between 6 and 12 weeks, dependent on wound size. The synthetic matrix significantly promoted wound healing via early granulation tissue formation and epithelialization, or mucosalization, in all head and neck applications. Scar formation and contracture were acceptable in all cases. Conclusion: The use of synthetic hybrid-scale fiber matrix promotes wound healing and avoids patient morbidity associated with traditional allogenic and biogenic treatments, such as split-thickness skin grafts. This synthetic matrix has been demonstrated to be a valuable asset in the head and neck reconstructive armamentarium.

Objective: To report a novel case of tracheal reconstruction using a serratus anterior-rib composite flap. Methods: Case report and literature review. Results: A 46-year-old male with a 4 cm anterior tracheal wall defect underwent reconstruction with a serratus anterior-rib composite flap. The patient experienced excellent results regarding phonation, swallowing, and cosmesis. Conclusion: The serratus anterior-rib composite flap appears to be a suitable candidate for tracheal reconstruction and merits further analysis in this context. The flap's intrinsic incorporation of a perfused rib segment allows for reliable reconstruction of the neotrachea and maintenance of proximal dynamic airway support.

The objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting. Relevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options. Specific regional pedicled flap options are presented including the pectoralis major flap, deltopectoral flap, supraclavicular flap, submental flap, latissimus flap, and trapezius flap. Regional pedicled flaps are useful options in a salvage setting even for large defects and should be in the armamentarium of any reconstructive head and neck surgeon. Each flap option carries specific characteristics and considerations.

Background Patients on chronic pharmacologic immunosuppressive therapy are at increased risk of wound infection and complications after surgery. There is a paucity of data examining perioperative complications after microvascular free tissue transfer (MVFTT) reconstruction of the head and neck in this patient population. Methods Retrospective cohort study performed at two tertiary referral centers between August 2016 and May 2020. Results Nine hundred and seventy-nine patients underwent MVFTT during the study period; of these 47 (5%) patients were taking chronic immunosuppressive medications. The most common indications for immunosuppression were solid organ transplant and autoimmune disease. Fourteen (30%) patients had surgical complications within 30 days of surgery: 8 (17%) wound dehiscences, 6 (12%) hematomas, and 2 (4%) surgical site infections. There was one total and one partial flap failure with a 30-day reoperation rate of 4%. Conclusions MVFTT of the head and neck appears to be safe in patients on chronic pharmacologic immunosuppression.

Background The American Joint Committee on Cancer (AJCC) released a new staging system for human papilloma virus (HPV) positive oropharyngeal cancer (OPC) in their eighth edition. The role of smoking in HPV positive oropharyngeal cancer remains controversial and is not factored into the updated staging system. Methods Single institutional, retrospective chart review of patients with HPV positive OPC from 2009 to 2017 was completed. Dichotomized smoking data were collected into 0-9 and >= 10 pack-year histories. Kaplan-Meier survival curves compared overall survival (OS) for smokers and nonsmokers. Results Five-year OS was not statistically different in stage I or stage II HPV positive OPC comparing nonsmokers versus smokers, but worse in stage III smokers (38% vs. 76%, p < 0.05). Conclusion Greater than 10 pack-year smoking status may negatively affect survival in late stage HPV positive OPC but not in early stage disease. HPV positive smokers may require additional risk stratification.

BACKGROUND Benign thyroid nodules (BTNs) are common in the general population, with the majority remaining asymptomatic. However, certain BTN cause significant patient concerns including compression symptoms and cosmetic issues. Traditional treatment of symptomatic benign nodules has been surgical excision, which comes with relative peri-operative complications and the slight risk of hypothyroidism. Radiofrequency ablation (RFA) for BTNs has recently gained traction among otolaryngologists for patients seeking a nonsurgical treatment option. Under local anesthesia and ultrasound guidance, RFA causes selective thyroid nodule tissue damage while avoiding critical structures including major vessels, recurrent laryngeal nerves, and the trachea. This selective tissue damage through RFA is used to shrink BTN, alleviating symptoms and avoiding the need for surgical intervention.

Objective Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC). Study design Retrospective case series and subsequent prospective cohort study Setting Tertiary care academic teaching hospital Subjects and methods Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 – December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 – December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost. Results Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively ( p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease ( p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD. Conclusion Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments. Graphical abstract

Objective To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature. Methods Retrospective review. Results Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety‐six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort ( P = .03). Postoperative gastrostomy (G)‐tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ ( P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G‐tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09). Conclusion Despite MVFTT reconstruction after STL, G‐tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes. Level of Evidence 4 Laryngoscope , 131:E875–E881, 2021

As the COVID-19 pandemic continues to unfold, guidelines related to the delivery of medical and cancer care are being disseminated in an effort to flatten the curve of transmission while continuing to provide appropriate guideline based care for cancer patients.Head and neck squamous cell carcinoma (HNSCC) is unique in its location in the upper aerodigestive tract, a known location that harbors SARS-Cov2, the causative virus in COVID-19.Otolaryngologists and associated multidisciplinary team members caring for head and neck cancer patients are at heightened risk of transmission through mucus, blood, and aerosolized particles.A high rate of transmission to otolaryngologists has been reported in China, Italy, and Iran, with reports of morbidity and death [1].The limited availability of COVID-19 testing, personal protective equipment (PPE), disposable medical supplies, hospital and ICU beds, ventilators, and ancillary staff force clinicians to triage which procedures are "essential" and which can be safely delayed.Healthcare providers who contract the virus have generally been mandated to selfquarantine, thereby reducing the availability of the hospital workforce.In the midst of the ongoing pandemic, patients diagnosed with HNSCC now have the added stress in how COVID-19 will impact their care and treatment.The current evidence supports that cancer patients have a higher risk of infection and serious complications from COVID-19 relative to other patient subgroups [2].Uncertainties such as whether treatment will continue and how these high risk patients will continue to access services, are being addressed as the situation continues to evolve.Patients, physicians, health care workers, health care systems, ethicists, and attorneys among others have become aware of the number of complex dilemmas and issues that have arisen during this pandemic that include but are not limited to

Introduction:The abscopal effect is a rarely observed outcome of radiotherapy wherein there is a reduction in metastatic disease burden outside of the targeted treatment area. Likely due to an in situ vaccine effect of radiotherapy, the abscopal effect may be augmented by immunotherapy. This report is the first case of the abscopal effect observed in metastatic head-and-neck squamous cell carcinoma (hnscc) treated with concurrent radiotherapy and single-agent nivolumab.Case Description:An otherwise healthy 57-year-old man underwent craniofacial resection and adjuvant chemoradiotherapy for advanced sinonasal squamous cell carcinoma. Distant metastatic disease developed shortly after primary treatment, and immunotherapy in the form of nivolumab was initiated. Subsequent oligometastatic progression despite immunotherapy prompted palliative radiotherapy to a single metastasis due to pending symptomatology. Post-radiotherapy, the abscopal effect was observed with all distant sites of metastatic disease shrinking. Five months following treatment, a sustained reduction in disease burden has been demonstrated.Summary:We present the first case of the abscopal effect in a patient with metastatic hnscc treated with palliative radiotherapy concurrent with single-agent nivolumab immunotherapy, and only the third case of the abscopal effect in metastatic head-and-neck cancer. Dual treatment with immunotherapy and radiotherapy may be an important treatment option in the future, mediated through the abscopal effect.

Background The laryngeal framework provides a natural barrier preventing tumour spread to extralaryngeal structures. Transoral laser microsurgery (TLM) for laryngeal squamous cell carcinoma (SCC) may violate these boundaries, altering the pathways of tumor spread for potential recurrences. Our project objective is to describe laryngeal SCC recurrence patterns and overall survival in patients requiring total laryngectomy (TL) after TLM. Methods Patients undergoing TLM for laryngeal SCC requiring salvage TL were identified from a prospective CO2 laser database containing all patients undergoing TLM for head and neck malignancies at the QEII Health Sciences Center in Halifax, Nova Scotia between March 2002 – May 2014. Surgical pathology reports were analyzed for tumor characteristics, extent of recurrence and invasion of local structures. Kaplan-Meier analyses were performed to evaluate overall survival, disease specific survival (DSS) and locoregional control. Results Fifteen patients were identified from the database as receiving salvage TL for recurrent disease after initial TLM resection for laryngeal SCC. Final pathology reports demonstrated that 67% (10/15) of patients had thyroid cartilage involvement while 53% (9/15) of patients had cricoid cartilage involvement on salvage TL pathology. 33% (5/15) of patients had perineural invasion and 27% (4/15) had lymphovascular invasion. Mean and median follow-up times were 36.7 months and 26.8 months respectively (range 3.9–112.6). The Kaplan-Meier estimate for overall survival at 36 months was 40% post TL with a standard error (SE) of 13.6%. DSS was 47% (SE 14.2%), and locoregional control was 55% (SE 14.5%) post TL. Conclusions Laryngeal recurrence sites following TLM seem to be consistent with historical data at known laryngeal sites of vulnerability. Treatment with TLM does not predispose patients to a lower rate of locoregional control and overall survival after total laryngectomy and salvage outcomes are consistent with literature values.

•Branchial cleft abnormalities are commonly encountered by otolaryngologists in the pediatric and young adult population.•Second branchial cleft cysts are the most common and have an optional deep tract extending from the anterior neck to the tonsillar fossa.•Parapharyngeal space has important anatomical contents and is anatomically separated into pre-styloid and post-styloid divisions.•Only 25 isolated parapharyngeal space second branchial cleft cysts have been reported and this is the oldest presentation in the literature.

Background: To assess the functional donor site morbidity of the forearm free flap in patients surviving at least 2 years after ablative head and neck cancer surgery in a tertiary care centre.Methods: This study involved nine long-term survivors (2 year post-operative) who had forearm free flaps to reconstruct head and neck defects. All flaps were raised from the non-dominant arm. The non-donor side acted as a control for all patients. Objective measurements were as follows: grip, tip pinch and key pinch strength measured with dynamometers; flexion, extension, radial and ulnar deviation and pronation and supination range of motion at the wrist measured with goniometry; A timed manual dexterity task was performed with a grooved pegboard test, and sensation of the radial nerve was tested with Semmes Weinstein monofilaments. Subjective measurements included a validated patient questionnaire of hand function and opinions of scar appearance as well as a validated scar assessment from two different observers.Results: Pronation at the wrist, manual dexterity and sensation were found to be significantly reduced in the donor side compared to the non-donor side. Inter-rater agreement between the two observers was found to be poor, except for an acceptable correlation between overall scar opinions. No correlations were found between any subjective or objective items or between the patient's and the observers' subjective evaluations.Conclusions: Donor site morbidity can be demonstrated with objective testing however this is accepted and well tolerated by head and neck cancer patients.

Objective: Patulous eustachian tube (PET) can have a significant negative impact on a patient's quality of life. Previous work has demonstrated that temporarily mass loading and stiffening the tympanic membrane significantly reduces these symptoms. This study examined KTP laser myringoplasty (LM) and cartilage tympanoplasty (CT) as a means to manipulate the tympanic membrane to alleviate PET symptoms.Study Design: Retrospective case review.Setting: Academic tertiary care referral hospital.Patients: Patients (n = 20) were identified from the senior authors' (M.B.) specialty eustachian tube disorders clinic. Patients met previously established diagnostic criteria for PET. All patients had a clinically apparent flaccid segment of the eardrum and had symptom improvement after simple mass loading of their eardrum in the clinic.Interventions: Patients in this study received either KTP LM (10 patients, 15 ears) or CT (10 patients, 11 ears) to treat their flaccid eardrum segment in an attempt to alleviate PET symptoms.Main Outcome Measures: Preoperative and postoperative questionnaire scores and tympanometry measurements were compared.Results: Patients undergoing CT for PET had a significant reduction in their symptoms of autophony (p <= 0.001), conducted breath sounds (p = 0.001), and aural fullness (p = 0.009). KTP LM did not significantly reduce symptoms.Conclusion: Cartilage tympanoplasty provides a safe and accessible surgical option for the treatment of PET and significantly reduces the symptoms of autophony, conducted breath sounds, and aural fullness. Further studies are needed to investigate whether addressing PET symptoms simultaneously from both the tympanic membrane and the eustachian tube orifice can improve patient symptoms even further.

BACKGROUND AND AIM:We sought to evaluate the long-term impact of post-cardiac surgery atrial fibrillation on the risk of stroke and survival.METHODS:Patients undergoing isolated CABG surgery from April 1, 1995 to March 31, 2007 were identified (n = 8058). Long-term stroke data were compiled using Cox modeling adjusted for clinical characteristics comparing patients with new-onset atrial fibrillation (NwAfib) and those without.RESULTS:NwAfib developed in 2214 patients (27.5%). Overall in-hospital mortality was 2.4% and was not different between groups. Unadjusted in-hospital outcomes suggest patients with NwAfib were more likely to suffer a permanent stroke (1% vs 2.5%; p < 0.001) require prolonged mechanical ventilation (p < 0.001) and prolonged stay in hospital (p < 0.001). After discharge patients were followed for a mean of 5.7 years. Stroke was reported in 268 (12.1%) patients in the NwAfib group compared to others (8.4%). After adjustment NwAfib was independently associated with a higher risk for stroke with a hazard ratio of 1.26 (1.08-1.47; p = 0.0034) and a higher risk of death with a hazard ratio of 1.2 (1.08-1.32; p = 0.0007).CONCLUSIONS:Patients with NwAfib perioperatively have increased risk of stroke and early death after discharge independent of other clinical risk factors.