[Preservative surgery of T4 glottic cancer]

OBJECTIVE

To explore new methods of preservative surgery for T4 glottic cancer and to evaluate their long term results.

METHODS

22 cases with T4 glottic cancer were treated surgically from 1982 to 1998. The lesions and involved cartilage and extrinsic laryngeal tissues were removed entirely, the sternohyoid myofascial flap, platysma myocutaneous flap, platysma myofascial flap, thyroid perichondral flap and hypopharyngeal mucosa flap were utilized to restore the defects of larynx, while the epiglottis or lamina of cricoid cartilage were reserved for laryngeal function restruction.

RESULTS

The 3- and 5-year survival rates were 86.4% and 75.0% in all cases. 68.2% had laryngeal functions(voice, respiration and deglutition) restored and 31.8% partially restored(voice and deglutition).

CONCLUSION

Despite the fact that the T4 glottic cancer usually involved with cartilage and extrinsic laryngeal tissues, preservative surgery can be carried out for the carefully selected cases with the lesions entirely removed.

Outcome after radial forearm, gastro-omental, and jejunal free flaps in oral and oropharyngeal reconstruction

We undertook a retrospective study of the outcome of radial forearm, gastro-omental, and jejunal free tissue transfer for oral and oropharyngeal reconstruction in 30 patients (10 in each group). No significant differences were found between the type of free flap and the clinical outcome. More long-term difficulties were experienced with swallowing than with speech. The selection of free flap did not correlate with speech function (P=0.44), swallowing (P=0.68), or management of saliva (P=0.59). No significant difference was found between the patients' outcome and the site of resection of the tumour. There were more complications after gastro-omental flaps and this may influence the choice of reconstruction.

[Combined treatment of patients with oral tumors with extracorporeal neutron-photon therapy]

Combined therapy with preoperative course of remote neutron therapy was given to 29 patients with oral cavity cancer. All the patients had stage III of morphologically verified squamous cell carcinoma. Partial tumor regression after radiotherapy was observed in 39.5 +/- 8.9% patients. Complete regression was not achieved. There was no clear negative effect of preoperative course of remote therapy on the postoperative period in all patients. Local complications as wound edge disjunctions were registered in 13.4% of cases. On day 14-16 after surgery speech therapy rehabilitation was performed.

[Reconstruction of the anterior floor of the mouth with nasolabial flaps. Report of 10 years' experience]

The aim of this study was to analyse, with particular consideration to functional aspects, the results of treatment following the reconstruction of intraoral soft tissue using a pedicled nasolabial flap. Over a period of 10 years (1.1.1990-31.12.1999) the intraoral repair of the defect was carried out in 20 patients in the region of the anterior floor of the mouth, using a unilateral nasolabial flap in 13 cases and a bilateral nasolabial flap in 7 cases. The reasons for the defects were resection of squamous cell carcinomas (T1-T2) of the intraoral mucosa in 19 cases and osteoradionecrosis with soft tissue defect in one case. Local wound healing disturbance was observed in two cases. In 18 patients the prosthetic rehabilitation was successful and allowed a return to masticatory function. In another three cases a secondary operation for flap remodelling was needed. In one case three ITI-Implants were inserted between the foramina 12 months following the placement of the flap. A magnetically retained full denture has been functioning normally for more than four years. The nasolabial flap for the replacement of soft tissue in the mouth appears to represent a functionally and aesthetically satisfactory alternative to reconstruction by microsurgery, in cases of small to medium-sized defects, especially in older, medically compromised patients with an enhanced surgical risk

Pain, function, and psychologic outcome before, during, and after intraoral tumor resection

PURPOSE

The aim of the present study was to determine the quality of life of patients with respect to pain before, during, and after ablative intraoral tumor surgery.

PATIENTS AND METHODS

The Bochum Questionnaire on Rehabilitation was used to determine 147 items including the morphologic, functional, and psychosocial aspects of rehabilitation. One thousand six hundred fifty-two of 3,500 patients (47.2%) (413 women and 1,239 men) completed the questionnaire. The statistical investigation was carried out using 2-sample (independent) and paired (dependent) t tests.

RESULTS

Pain and the functional impairment of chewing and swallowing are the most important parameters before treatment. Immediately after surgical treatment, other variables, such as speech intelligibility and mobility disorders in the head, neck, and shoulder regions, became more apparent. Pain was reported in the shoulder region in 38.5% and in the neck in 34.9% of patients after surgery. The temporomandibular joint was painful in 20.1%, the oral cavity in 18.7%, and the face in 8.2%. Pain was described by 7.4% of patients in other regions of the head. Seventy-five percent of 1527 patients were not taking pain medications during the investigation. The rate of physiotherapy consequently applied after surgery was less than 10%.

CONCLUSIONS

Quality of life after ablative intraoral surgery is not greatly affected by pain. Because functional disorders play the dominant role in the impairment of postoperative quality of life, functional reconstruction, using microvascular techniques, and early rehabilitation, including physiotherapy, should be intensified.

Prosthetic rehabilitation of a patient following maxillectomy with orbital exenteration

The maxillectomy patient despite the drastic nature of the procedure can often be restored to an acceptable aesthetic and functional condition. The treatment of maxillectomy patient presents an excellent opportunity for the surgeon and the prosthodontist to coordinate their efforts to enhance the patient's rehabilitation. This clinical report describes the prosthetic rehabilitation of a patient with squamous cell carcinoma of the right maxilla requiring maxillectomy with orbital exenteration.

Incorporation of an ERA attachment for obturator framework design: a clinical report

Swinglock framework designs have been used to retain obturators for some time. One of the problems with Swinglock designs has been loss of retention due to wear of the metal latch assembly. This clinical report describes the incorporation of an ERA attachment as the latch assembly of a Swinglock framework for an obturator. The premise behind this design was that wear would be at the expense of the nylon retention male component, which is easily interchangeable, rather than the metal component of the assembly. The life of the latch assembly, framework, and prosthesis would thereby be prolonged.

Alcohol consumption is associated with improved health-related quality of life in head and neck cancer patients

The study aim was to investigate the relationship between alcohol consumption and health-related quality of life (HRQL) in post-therapeutic head and neck cancer patients. A cross-sectional study design was used with a sample of 191 subjects. Data were collected through interview and chart review. Alcohol consumption was evaluated through the dichotomous response to the question "During the past month have you drunk alcohol on one or more occasions?" HRQL was evaluated through the EORTC QLQ-C30 and H&N35 instruments. Data were also collected concerning sociodemographic and clinical variables. Multivariate regression was used to evaluate the hypothesized association. Of 28 domains comprising the EORTC QLQ-C30 and H&N35 instruments, eight were significantly associated with alcohol consumption, while 19 of the 20 remaining domains showed a tendency towards an association. Alcohol drinking was associated with significantly better physical and role functioning, and better global HRQL, plus less fatigue, pain, problems swallowing, dry mouth and feelings of illness. This suggests that, while the study findings are limited by its design and the sample bias, despite alcohol's role as an aetiological factor, it may be reasonable to drink a little as one recovers from head and neck cancer.

Fabrication of conventional complete dentures for a left segmental mandibulectomy patient: a clinical report

Without preprosthetic reconstructive surgery, denture fabrication for mandibulectomy patients becomes extremely difficult. Implant-assisted overdentures may improve denture retention and stability, but some patients cannot afford this treatment. For the segmental mandibulectomy patient described in this report, properly fabricated conventional complete dentures provided comfort and sufficient function.

Functional reconstruction of mobile tongue and suprahyoid muscles after resection of cancer of the tongue

The mobile tongue and the suprahyoid muscles were reconstructed in a man who had had a total resection of the mobile tongue with the oral floor and bilateral radical neck dissection (extensive resection of the bilateral suprahyoid muscles) for cancer of the tongue. A rectus abdominis musculocutaneous flap with the tenth intercostal nerve anastomosed to the remaining hypoglossal nerve was used for the reconstruction. The rectus abdominis muscle was inserted between the mandible and the hyoid bone, taking account of the anatomical positions of the tongue and suprahyoid muscles; the rectus sheath was then firmly sutured to the mandible and hyoid bone. This procedure created firm tendinous insertions between the mandible and hyoid bone. After the operation, the reconstructed tongue showed no sign of atrophy, and the reconstructed supra-hyoid muscles (rectus abdominis muscle) could be moved, and the hyoid bone could be raised.

Implant-supported mandibular telescopic prostheses in oral cancer patients: an up to 9-year retrospective study

PURPOSE

The aim of this retrospective study was to present the results of implant-supported telescopic prostheses in the mandible after removal of malignant tumors.

MATERIALS AND METHODS

Between 1991 and 2000, 24 patients with squamous cell carcinoma (16 irradiated, eight nonirradiated) underwent mandibular rehabilitation with implant-supported telescopic prostheses. A total of 111 dental implants were placed. Treatment complications were observed. The cumulative survival rates of the implants and prostheses were evaluated by lifetable analysis.

RESULTS

Within a mean follow-up period of 30 months (1 to 108 months), only three implants failed. All other implants are still in function. Of 24 patients, 23 were satisfied with their implant-supported telescopic restorations. Soft tissue, implant, or prosthetic complications occurred very rarely. The cumulative implant survival rate was about 97% and the cumulative prosthesis survival rate was about 95% at 9 years.

CONCLUSION

Implants and implant-supported telescopic maxillofacial prostheses can successfully remain in function over a long period. Increased implant and prosthetic complications should not be expected. Therefore, telescopic implant attachments seem to be very useful as a treatment option for prosthetic restoration of the mandible in tumor patients.

Tissue-engineered mucosa graft for reconstruction of the intraoral lining after freeing of the tongue: a clinical and immunohistologic study

PURPOSE

This article describes the use of tissue-engineered mucosal grafts instead of split-thickness skin grafts after freeing of the tongue in patients who had previous resection of an oral squamous cell carcinoma and initial primary wound closure.

PATIENTS AND METHODS

Tissue-engineered mucosal grafts, up to 75 cm2 in size, were cultured from biopsy specimens of the hard palate in 6 patients, starting 3 to 4 weeks before the operation. After freeing of the tongue, the engineered mucosa was implanted on the wound surface by using vaseline gauze as carrier and fixed with an intraoral gauze wound dressing.

RESULTS

A good glossoalveolar sulcus was formed in 5 patients, resulting in good mobility of the tongue and a satisfactory denture-bearing surface. In 1 patient, there was a disturbance of wound healing, leading to severe shrinkage of the glossoalveolar sulcus and very limited improvement in tongue mobility. Preoperative bromodeoxyuridine (BrdU) labeling of the graft and postoperative immunohistochemical staining of biopsy specimens from the grafted areas with anti-BrdU showed that the cultured cells are integrated into the newly formed mucosal epithelium. Postoperative histologic investigations showed a differentiation process in the grafted mucosal epithelium, with a change in the expression of cytokeratins. At 6 months postoperatively, the typical pattern of normal nongrafted mucosa was regained.

CONCLUSIONS

This investigation provides evidence that tissue-engineered mucosal cells can serve as a graft for large intraoral wounds. Complete intraoral lining is quickly reestablished, and normal epithelial differentiation is seen in the graft area within a 6-month postoperative period.

Vascularized free fibular flap for mandibular reconstruction: a report of 26 cases

PURPOSE

Mandibular reconstruction represents a challenge to the oral and maxillofacial surgeon and has been revolutionized by the modern microvascular techniques. Rehabilitation using techniques such as reconstruction plates frequently produce a functional and cosmetic defect. The primary objective of the current study was to evaluate the usefulness of the osteomuscular free fibular flap for this purpose.

PATIENTS AND METHODS

The results of 26 vascularized free fibula flaps with or without a skin paddle that were used for mandibular reconstruction is presented. The "double barrel" technique was used in 6 cases. The donor site was closed directly in 2 cases and with an abdominal full-thickness skin graft in 24 cases.

RESULTS

All flaps except 1 were viable. There was partial necrosis of the skin island in 1 patient. The average length of the fibula graft was 10.96 cm, and the number of osteotomies ranged from 0 to 3. In the donor site, the most significant problem was unsatisfactory scarring related to the use of a skin graft. There were no long-term functional complications in the lower leg. Two patients have been secondarily rehabilitated with osseointegrated implants.

CONCLUSION

The fibula flap provides a successful bone graft for mandibular restoration with an acceptably low complication rate. This method meets most of the requirements for oral and mandibular replacement.

[Hormonal replacement therapy in patients with cervical and ovarian cancers]

Hormonal replacement therapy in women following primary treatment for squamous cell carcinoma of the cervix uteri is harmless. In case of adenocarcinoma of the cervix, guidelines for hormonal replacement therapy according to those valid for endometrial cancer are recommended. In women treated for ovarian cancer, a combined cyclic or continuous estrogen/gestagen substitution - the latter also in hysterectomized women - is to be favored. Signs of androgen deficiency are to be respected. Short-term clinical, sonographical, and biochemical control investigations are recommended.

Clinical analysis of implant losses in oral tumor and defect patients

In the period between 1990 and 1996, 279 endosteal dental Bone-Lock implants were placed in 79 patients. Of them 63 have been treated with ablative tumor and reconstructive surgery in the oral cavity, the rest presented with maxillo-mandibular defects of different origin. The circumstances of implant loss were noted down for descriptive analysis concerning age, sex, topography, implant dimensions, loading, time in place and type of superstructure. Failure analysis was done concerning the implants and the patients. Five causes for implant loss could be detected: lacking primary osseointegration, acute inflammation, bone loss, biomechanical overloading and tumor recurrence. No predictive factors for implant loss and no age influence on implant loss could be detected, no specific local implant site and no specific superstructure had an identifiable higher risk. Survival rate of all placed implants in oral tumor and defect patients was 83.5% after 6 years observation. Male tumor patients were found to have a higher risk to lose implants than females. Free iliac bone grafts impaired osseointegration of implants. The mandible offered a better prognosis for the implants than the maxilla. Shorter and thinner implants had a higher risk of being lost. A quarter of all patients (26.3%) had to face implant loss. Clustering of implant loss in several patients was caused by free iliac bone grafting and by prosthetic faults. Chemotherapy had no negative influence on implant survival. Most implants were lost early (76%) before fabrication of the prosthesis. After restoration there was a nearly 100% probability of function. It is concluded that implant treatment can be equally effective for tumor and defect patients as it is known for healthy subjects.

Neutral zone approach for denture fabrication for a partial glossectomy patient: a clinical report

According to the neutral zone concept, an appropriate denture form can be molded into a physiologic tooth arrangement by using a narrow rim bar occlusion, tissue conditioner, and a direct relining technique for both intaglio and cameo surfaces by using VLC reline resin. Denture stability can be obtained with this "border molding" technique, not only for edentulous patients but also for those with oral deformities.

Neuronal structure of microvascular transplants with and without neuronal anastomosis

OBJECTIVE

Latissimus dorsi transplants have little neuronal regenerative capacity without neuronal anastomosis. Histologic differences between transplants with and without neuronal anastomosis and 2 distinct types of neurosurgical reanastomosis are highlighted in this study.

PATIENTS AND METHODS

Fifty-four patients with squamous cell carcinomas of the oral cavity (T4) were treated by tumor resection and homolateral neck dissection. The defect was covered with a microvascular latissimus dorsi transplant. In 15 patients, no neuronal anastomoses were performed. In 21 patients, the thoracodorsal nerves were used for microneurosurgical reanastomosis, whereas in 18 patients, the cutaneous branches of the intercostal nerves were used for microneurosurgical reanastomosis. The transplant was examined during surgery and 9 months after surgery by means of a histologic examination of a biopsy specimen. The number of fascicles, the degree of fibrosis, and the myelination were examined. Furthermore, a neurosensory examination was performed 9 months after surgery.

RESULTS

Overall, our patients had an average of 12.1 fascicles during surgery. After surgery, patients without neuronal anastomosis showed an average of 4.9 fascicles, patients with nerve anastomosis to the cutaneous branches of the intercostal nerve showed an average of 6.2 fascicles, and patients with anastomosis to the thoracodorsal nerve showed an average of 9.6 fascicles. In cases of nerve anastomosis, a lesser degree of fibrosis was found, together with good myelinization. The clinical examination showed the best neurosensory function in the transplants with anastomosis to the thoracodorsal nerve and the worst function in those without neuronal anastomosis.

CONCLUSION

Neuronal reanastomosis led to more surviving neuronal structures in the postoperative histologic specimen. The highest density of fascicles was found in the well vascularized thoracodorsal nerve. The neurosensory function agrees with the histologic result.

The L-shaped osteotomy for vertical callus distraction in the molar region of the mandible: a technical note

The following report refers to a well described surgical procedure using a prototype vertical distractor developed in Cologne in cooperation with Martin Medizintechnik GmbH. The surgical technique has been refined by an L-shaped osteotomy stabilized posteriorly by a miniplate to limit the amount of callus regeneration in the molar region where no increase in vertical height is required. The surgical technique with its advantages and one complication is described as used in four patients undergoing six distraction treatments.

Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery

The authors present their experience of 27 cases with repairs of defects following radical maxillectomies with free flaps. A total of 28 flaps were used (five latissimus dorsi, six scapula, 16 combination flaps of scapula and latissimus dorsi and one combination of scapula, latissimus dorsi and serratus anterior flap). Only one scapula flap was completely lost and in three cases where a combination of scapula and latissimus dorsi flap was used, partial necrosis of one component occurred. The authors first choice for reconstruction is a scapula bone flap raised on the angular artery combined with the latissimus dorsi flap. The combination of flaps with a long pedicle and of the bony and muscular components provides the surgeon with the option of customizing the flap to meet individual patient needs. For intraoral closure the authors prefer the latissimus dorsi muscle which rarely requires secondary procedures for prosthesis placement following epithelialization and atrophy. The main disadvantage of the flap is the difficulty of two teams working simultaneously, thus increasing the average operating time. All postoperative corrections and prosthetic rehabilitation should be postponed for at least 2 months following surgery because of postoperative swelling.