Head & neck
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This retrospective study assesses the outcomes and patterns of failure in patients with squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary site treated with combined surgery and postoperative radiotherapy. ⋯ Relapse occurred infrequently in patients treated with excisional biopsies and postoperative radiotherapy. Extracapsular extension and multiple nodes were associated with worse regional control and disease-specific survival. These results appear consistent with those expected for patients with advanced neck disease and a known primary site, and the absence of a primary site should not exclude patients from studies aiming to improve outcomes in patients with extensive neck disease from a head and neck squamous cell cancer. We continue to recommend radiation to the necks and pharyngeal axis for patients suspected of having residual microscopic disease following surgery for squamous cell carcinoma metastatic to the neck from an unknown primary site.
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The purpose of this study was to evaluate the efficacy of the modern diagnostic evaluation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. ⋯ The primary lesion will be detected in over 40% of patients with physical examination of the head and neck and CT and/or MRI followed by panendoscopy and biopsies. Limited data pertaining to FDG-SPECT suggest that this provides additional useful information in a small subset of patients. Tonsillectomy is useful for those with suggestive findings on physical examination and/or radiographic evaluation.
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Retropharyngeal hematoma is a rare entity which may progress rapidly to airway obstruction. Previously documented causes have included coagulopathic states, trauma, infection, parathyroid adenoma rupture, and foreign-object ingestion. Four cases of spontaneous retropharyngeal hematomas without any known predisposing risk factors have been previously reported. Two of these cases had fatal outcomes. ⋯ The possible etiology for this case is discussed, and a review of the literature and the role of surgery in the management of this entity is outlined.
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Case Reports
Free composite myo-osseous flap with serratus anterior and rib: indications in head and neck reconstruction.
Although the microvascular transfer of the serratus/rib myo-osseous composite flap has been previously described, the indications for its use in head and neck reconstruction have not been fully explored. Slender and easily contoured, rib bone offers reconstructive advantages over other bone sources under certain circumstances. The serratus/rib myo-osseous flap can provide vascularized muscle, bone, and cartilage; in combination with the latissimus dorsi muscle, the serratus/rib flap provides additional soft-tissue bulk on a single thoracodorsal vascular pedicle unrestricted by orientation requirements of the bone. Many orientations of bone and soft tissue are possible. ⋯ The serratus/rib composite myo-osseous flap reliably provides vascularized bone of relatively delicate composition which offers advantages in certain reconstructive circumstances. In addition, when combined with latissimus dorsi muscle on a single vascular pedicle, it supplies additional soft-tissue bulk which can be positioned without being constrained by the bone placement. Finally, this is a useful "backup" supply of vascularized bone when other sources cannot be used due to, for example, inability to use fibula in the face of severe peripheral vascular disease and inability to use iliac crest if this has been previously used as a donor site for nonvascularized free grafts (as in secondary reconstructions).
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Metastatic neck nodes in patients with squamous cell carcinoma of the head and neck are most commonly managed by surgery, radiotherapy, or combined-modality therapy. For combined-modality cases, the sequencing of surgery and radiotherapy is generally guided by which modality is considered preferable for treatment of the primary tumor. A postradiotherapy neck dissection is often considered for those patients with > N1 disease in which the primary is treated with radiotherapy alone. ⋯ In this series of postradiotherapy neck dissections, two thirds of the dissections demonstrated no evidence of residual tumor (19/28, or 68%). However, there was not a direct correlation between pretreatment nodal size (neck staging), radiation dose delivered, and the likelihood of achieving a cancer-free neck dissection. Only one of 28 postradiotherapy neck dissections identified tumor outside of nodal stations II-IV. The predictable pattern of residual disease in pathologically positive cases suggests that a selective neck dissection encompassing levels II-IV may be appropriate in a majority of patients.