January - April 2018
Airway Management for Head and Neck Free Flap Patients
David J. Hernandez, M.D.
April 3 - 7, 2018
Specific Question: When is it safe to avoid a tracheostomy in patients undergoing free tissue transfer for reconstruction of the upper aerodigestive tract?
Traditionally, all patients undergoing microvascular free flap reconstruction of the upper aerodigestive tract were managed with a tracheostomy, and at many institutions, this remains dogma. Above all else, a tracheostomy ensures that the patient has a safe airway in the immediate post-operative period. There are other benefits of a tracheostomy including the ability to easily wean the patient off the ventilator at the completion of the case (thus avoiding mechanical ventilator use in the immediate post-operative phase), the ability to perform excellent pulmonary toilet and the ease of placing the patient on a ventilator if needed at any point in the post-op period. However, there are some drawbacks to tracheostomy such as the added risk of tracheostomy-specific complications, the deleterious effect on swallowing in an already compromised patient, and the often increased length of hospital stay (either for capping trails and decannulation or for disposition planning for home tracheostomy supplies). Thus, it seems prudent to determine which patients might benefit from a tracheostomy and which might benefit most from, and tolerate, avoiding a tracheostomy.
Moore et al published an article which laid out specific criteria the senior author used when deciding whether a patient should undergo an elective tracheostomy at the time of surgery or undergo nasotracheal intubation (NTI) until POD 1. All patients in this study were undergoing oral cavity resection and free flap reconstruction. Important consideration for this study included a strong history of alcohol abuse (and thus high-risk for delirium tremens), defects that approached the junction with the oropharynx, and cases requiring resection of >50 percent of the oral tongue. If a patient had more than 1 of the above features, a tracheostomy was performed. When only one of the above characteristics were present, body habitus of the patient and expected post-operative edema were considered. Any patient with a strong risk of delirium tremens was managed with a tracheostomy due to the often fine line between maintaining adequate sedation and respiratory drive in these patients. Using this algorithm, the authors were able to demonstrate a 4 day reduction in hospital stay in patients that did not have a tracheostomy. Further, none of the NTI patients required reintubation or tracheostomy during their hospitalization. G tube utilization was also reduced in the NTI patients.
Brickman et al specifically looked at the use of tracheostomy in patients undergoing maxillectomy and found that approximately half of the patients were successfully managed without a tracheostomy, resulting in a similar rate of airway or pulmonary complications and a reduced length of hospital stay. They found that a significantly greater number of patients with cardiopulmonary risk factors were managed with a tracheostomy in this retrospective review. Lapis et al describes a small case series (n=15) of patients undergoing mandibulectomy with free flap reconstruction without a tracheostomy. Outcomes for these patients were favorable as there were no airway complications. The real value of this article is the literature review, which highlights specific favorable and unfavorable patient characteristics for avoiding a tracheostomy in head and neck free flap patients. Lastly, Cramer et al produced a large nationwide database analysis of airway complications and death for patients undergoing free tissue transfer of the upper aerodigestive tract with and without a tracheostomy. There were equivalent (not statistically different) rates of death and airway complications between the two groups of patients.
Thus, there are many factors that should be considered when determining the need for tracheostomy in free flap reconstruction of the upper aerodigestive tract. A number of studies have shown the safety of avoiding tracheostomy in select patients, which allows for a quicker return to the natural physiology of breathing and swallowing and may reduce hospital length of stays.
Moore MG, Bhrany AD, Francis DO, Yueh B, Futran ND. Use of nasotracheal intubation in patients receiving oral cavity free flap reconstruction. Head & Neck 2010;32:1056-1061. PMID: 19953615
Brickman DS, Reh DD, Schneider DS, Bush B, Rosenthal EL, Wax MK. Airway management after maxillectomy with free flap reconstruction. Head & Neck 2013;35:1061-1065. PMID: 22907774
Lapis PN, DeLacure MD, Givi B. Factors in successful elimination of elective tracheotomy in mandibular reconstruction with microvascular tissue. JAMA Otolaryngology-Head & Neck Surgery 2016;142(1):46-51. PMID: 26660711
Cramer JD, Samant S, Greenbaum E, Patel UA. Association of airway complications with free tissue transfer to the upper aerodigestive tract with or without tracheotomy. JAMA Otolaryngology-Head & Neck Surgery 2016;142(12):1177-1183. PMID: 27438584
Merkel Cell Carcinoma
Vlad C. Sandulache, M.D., Ph.D.
March 6 - 9, 2018
Specific Question: How should we approach Merkel cell carcinoma of the head and neck?
Merkel cell carcinoma (MCC) is a rare skin malignancy of neuroendocrine origin. It is one of several head and neck malignancies associated with viral exposure (EBV-nasopharyngeal carcinoma; HPV- oropharyngeal squamous cell carcinoma); in this case MCC has been linked to the Merkel cell polyomavirus (MCPyV) which is a nearly ubiquitous component of skin flora by adulthood. Because it is rare, diagnosis of MCC requires a high index of clinical suspicion and appropriate histopathologic analysis. Treatment selection is driven largely by retrospective clinical studies and is heavily informed by the much more robust melanoma literature as is the nodal staging currently employed for MCC.
Critical components of MCC treatment include: 1) appropriate surgical resection of the primary tumor, 2) staging of the nodal basins with imaging and/or surgery (i.e. sentinel node biopsy) and 3) consideration of adjuvant radiation. Perhaps the most important aspect of MCC treatment highlighted by Miles et al. (2016) is utilization of a multi-disciplinary approach similar to that employed for head and neck melanoma or squamous cell carcinoma of the upper aerodigestive tract. This will insure appropriate pre-operative staging and consideration of radiation as an adjuvant treatment or as a definitive treatment modality for extensive nodal disease in patients with MCC. As reported by Bishop et al. (2016) there is indirect evidence that MCC may in fact demonstrate significant radiosensitivity. This should be considered in the context of treatment related morbidity particularly since MCC is most often encountered in the elderly population.
Miles BA, Goldenberg D; Education Committee of the American Head and Neck Society (AHNS). Merkel cell carcinoma: Do you know your guidelines? Head Neck. 2016 May; 38(5):647-52. PMID: 26716756
Bishop AJ, Garden AS, Gunn GB, Rosenthal DI, Beadle BM, Fuller CD, Levy LB, Gillenwater AM, Kies MS, Esmaeli B, Frank SJ, Phan J, Morrison WH. Merkel cell carcinoma of the head and neck: Favorable outcomes with radiotherapy. Head Neck. 2016 Apr;38 Suppl 1:E452-8. PMID:25645649
Lymphedema of the Head and Neck
David J. Hernandez, M.D.
Feb. 6 - 10, 2018
Specific Question: What is the prevalence of lymphedema in head and neck cancer patients and what is its impact on function and quality of life?
The changing demographics of head and neck cancer patients, namely the rising incidence of HPV-driven oropharyngeal cancer, together with the improved prognosis and survival for this subset of patients after definitive concurrent chemoradiation are leading to a rise in the number of patients that are long-term survivors of head and neck cancer. With the improved oncologic outcomes for this large subset of head and neck cancer patients, it is important to define factors that affect quality of life and functional outcomes in these patients. Lymphedema is often seen as a consequence of radiation therapy to the head and neck; however, very few patients receive treatment for it until it is severe. Lymphedema may be identified externally (face and neck) on physical exam or internally (mucosal) when flexible laryngoscopy is performed, and there exists a number of validated metrics for grading external and internal lymphedema that have been used in various studies.
The paper published by Ridner et al1 describes a longitudinal, prospective study of the lymphedema-fibrosis continuum in head and neck cancer patients. Remarkably, they found that 63% of patients had evidence of external lymphedema prior to starting radiation treatment for their head and neck cancer. This study included some patients that had already undergone surgery (33 percent) at baseline assessment – prior to radiation. These post-operative patients did not have an increased incidence of external or internal lymphedema before starting radiation. They did, however, have a higher rate of fibrosis at baseline assessment. This study found that some form of lymphedema in the post-treatment period is essentially ubiquitous for head and neck cancer patients after radiation treatment. External lymphedema at baseline did not predict external lymphedema post-treatment. Similarly, baseline fibrosis did not predict post-treatment fibrosis. Yet, internal lymphedema was associated with an increased likelihood of post-treatment internal lymphedema. Another interesting finding was that prior surgery was not associated with post-treatment internal or external lymphedema (in fact, it was associated with a decreased likelihood of internal lymphedema), but it was associated with an increased likelihood of post-treatment fibrosis.
Regarding the quality of life and functional impact of lymphedema, Jackson et al2 published an article that identified strong correlates between internal lymphedema in head and neck cancer patients and patient-reported as well as objective measures of swallowing dysfunction. In this study, a head and neck symptom survey was completed by the patients and two objective measures were obtained (dysphagia outcome and severity scale, DOSS, and national outcomes measurement system, NOMS), which were based on a patient’s modified barium swallow study (MBSS). Internal lymphedema of the aryepiglottic/pharyngoepiglottic folds, epiglottis, and pyriform sinus were most strongly associated with dysphagia based on the patient-reported and NOMS rating. External lymphedema also correlated with objective dysphagia ratings but not patient-reported items.
Manual massage therapy is one method to reduce head and neck lymphedema if performed on a regular basis. Pneumatic compression devices are now available to aid patients in performing massage of the head, neck, and chest to reduce lymphedem3. These devices are relatively easy to use, do not depend on tactile feedback (which is often altered after surgery and or radiation), and generally require less work than manual self-massage. On the other end of the spectrum, recent reports have described supermicrosurgical lymphaticovenous anastomoses to improve lymphedema in severe or recalcitrant cases with promising results4.
Lymphedema is not only extremely common in head and neck cancer patients (even in those who have yet to undergo radiation), it is a persistent finding that peaks about a year after radiation treatment, and it has a significant impact on swallowing dysfunction (in addition to negatively affecting cosmesis, airway patency, voice, neck mobility, etc). Consequently, it behooves us to identify lymphedema at its early stages and provide early interventions as well as continue to investigate novel treatment options.
Ridner SH, Dietrich MS, Niermann K, Cmelak A, Mannion K, Murphy B. A Prospective Study of Lymphedema and Fibrosis Continuum in Patients with Head and Neck Cancer. Lymphat Res Biol 2016 Dec; 14(4): 198-205. PMID: 27305456
Jackson LK, Ridner SH, Deng J, Bartow C, Mannion K, Niermann K, Gilbert J, Dietrich MS, Cmelak AJ, Murphy BA. Internal Lymphedema Correlates with Subjective and Objective Measures of Dysphagia in Head and Neck Cancer Patients. J of Palliative Medicine 2016 Nov; 19(9): 949-956. PMID: 27227341
Mayrovitz HN, Ryan S, Hartman JM. Usability of advanced pneumatic compression to treat cancer-related head and neck lymphedema: A feasibility study. Head Neck 2018 Jan; 40(1): 137-143. PMID: 29131439
Mihara M, Uchida G, Hara H, Hayashi Y, Moriguchi H, Narushima M, Iida Y, Yamamoto T, Koshima I. Lymphaticovenous anastomosis for facial lymphoedema after multiple courses of therapy for head-and-neck cancer. J Plast Reconstr Aesthet Surg 2011 Sep; 64(9): 1221-5. PMID: 21377943
Management Head and Neck Cancer in the Elderly
Vlad C. Sandulache, M.D., Ph.D.
Jan. 16 - 20, 2018
Specific question: Can free flap reconstructions be performed safely in elderly patients with head and neck cancer?
As a result of its association with traditional carcinogens such as tobacco and alcohol, head and neck squamous cell carcinoma (HNSCC) is primarily a disease of the elderly. Although the HPV epidemic is slowly changing the demographics of patients with HNSCC localized to the oropharynx, the frequency of HNSCC development in patients over the age of 70 is likely to increase over the next few decades. Popularized in the 1990s and early 2000s, free flap reconstruction is now the mainstay option for addressing large surgical defects associated with HNSCC treatment. Because advanced age is generally associated with a higher comorbidity burden, clinicians are frequently faced with questions regarding the safety of free flap reconstruction in the elderly.
Several retrospective studies published within the last year address this topic. Reiter et al. (2017) recently reviewed clinical outcomes for patients over the age of 75 and correlated higher American Society of Anesthesiologists-status and Adult Comorbidity Evaluation-27 scores with a higher rate of complications. However, the study failed to identify advanced age alone as a driver of complications following free flap reconstruction. Of note, pneumonia was the most common non-surgical complication encountered, bringing to light the importance of pre-operative pulmonary function and post-operative pulmonary toilet.
Mitchell et al. (2017) evaluated similar outcomes in patients >80 years of age with a higher comorbidity burden compared to the control patient cohort. Length of stay and complication rates were not higher in the elderly group, although discharge to nursing facility was more common compared to the control group. These findings were confirmed by Fagin et al. (2017) in a smaller population of patients over the age of 90. Finally, Patel et al. (2017) reviewed outcomes for patients undergoing free flap reconstruction for recurrent HNSCC. Patient >70 years of age demonstrated similar reconstructive and overall complication rates.
Surgical resection and free flap reconstruction represent critical components of HNSCC management in patients of all ages. Although pre-operative testing and counseling should be tailored to each patient’s age and comorbidity status, the most recent studies to date indicate that free flap reconstruction can be performed safely, with an acceptable complication rate in the elderly population.
Fagin AP, Gelesko S, Wax MK, Petrisor D. Morbidity and Functional Outcomes With Head and Neck Free Flap Reconstruction in Patients Aged 90 Years or Older. J Oral Maxillofac Surg. 2017 Jul;75(7):1549-1554. PMID: 28063274
Mitchell CA, Goldman RA, Curry JM, Cognetti DM, Krein H, Heffelfinger R, Luginbuhl A. Morbidity and Survival in Elderly Patients Undergoing Free Flap Reconstruction: A Retrospective Cohort Study. Otolaryngol Head Neck Surg. 2017 Jul;157(1):42-47. PMID: 28319459
Patel VM, Stern C, Miglani A, Weichman KE, Lin J, Ow TJ, Garfein ES. Evaluation of the Relationship between Age and Outcome after Microvascular Reconstruction among Patients with Recurrent Head and Neck Squamous Cell Carcinoma. J Reconstr Microsurg. 2017 Jun;33(5):336-342. PMID: 28235217