Retromolar trigone tumors: evaluation by magnetic resonance imaging and correlation with pathological data. While some early studies suggested that T1 or T2 lesions can be treated with radiation with equal rates of locoregional control,4 current research does not support primary radiotherapy as first line therapy in patients who can tolerate surgical resection. Outcomes are most favorable when surgery is combined with adjuvant radiotherapy (pre- or postoperative). For patients who are unsuitable or unable to tolerate primary surgical treatment, combined chemoradiotherapy is now the standard in that patient population, and it has improved outcome compared to radiotherapy alone. Even the early stage cancer can have a rapid microscopic extension to surrounding soft tissue and bones with high recurrence rate. Surgical resection is based upon the extent of tumor, and may involve bony structures. Early evaluation with imaging to determine bony involvement is important for surgical planning. A selective neck dissection should be included in surgical resection for curative intent. Free flap reconstruction for advanced disease is mainstay for treatment, and improves functional and cosmetic outcomes. Marginal mandibulectomy vs segmental mandibulectomy: indications and controversies. A mandibulectomia marginal no tratamento dos tumores de loja amigdalina e região retromolar. Local control of squamous cell carcinoma following marginal and segmental mandibulectomy. A comparison of segmental and marginal bony resection for oral squamous cell carcinoma involving the mandible. The retromolar trigone: anatomy, cancer treatment modalities, reconstruction, and a classification system. Cancer of the retromolar area; a study of twenty-eight cases with the presentation of a new surgical technique for their treatment. Aggressive multimodality management of locally advanced retromolar trigone tumors. Treatment of squamous cell carcinoma of the anterior faucial pillar-retromolar trigone. Correlating the depth of invasion at specific anatomic locations with the risk for regional metastatic disease to lymph nodes in the neck for oral squamous cell carcinoma. Sentinel lymph node biopsy for oral cancer: supporting evidence and recent novel developments. Primary radiotherapy for carcinoma of the retromolar trigone: a useful alternative to surgery. Li Summary the goal of reconstruction of the retromolar trigone after cancer resection is to provide bone coverage, reducing contracture that risks trismus, and maintaining occlusion when applicable. The surgical reconstructive options are wide-ranging and can be tailored to individual patient considerations, include comorbid status, health of tissue at donor site, and prospect of future dental rehabilitation. Thoughtful reconstruction should be paired with expert rehabilitative services of speech and swallow specialists. Keywords: reconstruction, oral cancer, free tissue transfer, trismus mandibular ramus bounded by the temporal crest, anterior border of the ramus, and posterior socket of the lower third molar. Because malignant lesions of this area typically require a 1 cm gross mucosal margin during ablation-which inevitably contracts to a smaller margin-the surgical defect can become quite large and functionally significant. If a marginal mandibulectomy is performed, a soft tissue-only reconstruction is indicated. Various options along the reconstructive ladder, including advantages and disadvantages of each method, are described below. Comprehensive technical details of specific flaps are beyond the scope of this chapter. If a functional reconstruction can be achieved via a simple approach, it should be attempted first. For every patient, the goals of care, nature of the defect, and patient-specific risks must be evaluated. Flexible nasopharyngolaryngoscopy or mirror examination should be performed to evaluate for oropharyngeal tumor extension. Three-dimensional virtual surgical planning may also be utilized for bony reconstruction. Without a vascular bed, skin grafts serve only as a short-term biological dressing. In certain patients who have submucosal fibrosis-for example, due to betel nut chewing-poor vascularity will reduce skin graft viability. Flaps greater than 3 cm in width may have a higher risk of symptomatic cheek contracture, and thus should be avoided. The donor site can be closed primarily with acceptable contracture with the above dimension limits. With the majority of oral cancer patients presenting in the sixth decade of life and upward, medical comorbidities, functional status, and vessel quality become major considerations. Pedicled flaps are reliable options requiring minimal specialized equipment, training, and postoperative vascular monitoring. Palatal Island Flap the palatal island flap was first described by Gullane and Arena in 1977 for local oral cavity reconstruction after oncologic resection. Nearly the entire hard palate mucosa can be transferred for reconstruction, with healing of the donor site by secondary intention. An alternative local flap should be considered for patients with a prior radiation volume including the hard palate, or prior hard palate surgery. Because this flap requires the borrowing of maxillary mucosa to reconstruct a mandibular defect, alternative flaps may have a lower risk of promoting trismus. Retrograde dissection of the pedicle is performed to its origin between the genioglossus and hyoglossus muscles. The flap can span the entire length of the tongue and is approximately 6 mm thick with a maximal height of 4 cm. After harvest the donor site can be closed primarily or allowed to close secondarily. The flap is pedicled upon the buccal artery and vein, which enter the buccinator muscle at the posterior-inferior muscle edge on its lateral side, medial to the buccopharyngeal fascia. This flap can be harvested to a maximal height and length of approximately 4 × 7 cm. The donor site defect may be closed through primary closure or left to heal by secondary intention. Superficial Temporal Artery Island Flap the superficial temporal artery island flap can be raised as a fasciocutaneous or temporoparietal fascial flap based on either the anterior or posterior terminal branches of the superficial temporal artery. The pedicle is dissected proximally into the parotid gland, a safe dissection that passes posterior to uppermost facial nerve divisions. After blunt dissection between the masseteric and zygomatic muscles below the zygomatic arch, this pliable flap can be tunneled medially into the oral cavity. If fasciocutaneous in design, the bridging skin segment will require deepithelialization. Flaps as large as 8 × 16 cm can be harvested, and the incisional scar can be camouflaged well within hair-bearing skin. This flap has a reliable vascular supply, but its use may have been limited due to probable contracture and resulting trismus. The pedicle runs reliably within 1­2 cm of the posterior clavicular border, and can be followed with Doppler probe. The accompanying venous outflow runs in the same plane as the external jugular vein. The proximal pedicle can be precisely skeletonized for mobilization, or broadly protected. Complications include wound dehiscence with wider skin paddles, although defects as wide as 8 cm can be closed primarily. Surgical drains should be placed given the large potential space formed after harvest. Patients with multiple comorbidities and poor vascular status may have a more expeditious reconstruction via this approach. Even a dedicated microvascular surgeon often faces long operative times, and intensive postoperative monitoring. Despite a thin profile, some patients with obesity can have remarkably bulky skin paddles that are more difficult to contour. As with other bulky flaps, airway obstruction due to soft tissue edema should be considered, and the patient properly counseled preoperatively. Fasciocutaneous perforators arise from the pedicle and are most abundant in the distal third of the forearm. A sensate flap is possible with inclusion of the lateral antebrachial cutaneous nerve, which can be anastomosed to a transected inferior alveolar nerve. Restoration of mandibular continuity is described in more detail in Chapter 28 (Reconstruction of Mandibular Defects), and is an important consideration for ramus and angle defects to maintain proper dental occlusion in dentate patients. With careful harvest technique, few other complications are commonly encountered-preservation of the superficial radial nerve branches and suprafascial elevation of the skin paddle minimize risk of hand numbness and restriction of wrist motion, respectively. Patients are routinely counseled that in the long term, forearm and hand function will return to normal; however certain patients-often those with manual labor occupations-may still prefer alternative donor sites. This flap has a robust and predictable vascular pedicle (pectoral branch of thoracoacromial trunk) that is directly visualized throughout harvest. In many edentulous or frail patients, bony reconstruction for posterior mandibular defects adds no functional or cosmetic value over soft tissue coverage. The soft tissue reconstruction maintained his facial contours, and he enjoyed excellent oral excursion. As with all pedicled flaps, skeletonization of the pedicle is only for optimal mobilization of the flap, as loss of this soft tissue envelope may increase the risk of pedicle kinking. Primary closure of skin defect (if one is present) is uniformly achieved by extensive suprafascial undermining of neighboring skin. Cauterized divided buccinator fibers (white arrow) and the buccal fat pad (black arrow) are visualized. However, with dissection of the skin perforator(s), the subcutaneous fat can be thinned to as little as 3 mm thickness, while preserving a 2 cm radius of deeper adipose around the perforator(s). Typically, one to three septocutaneous or musculocutaneous perforators supply the anterior thigh skin. The donor site is nearly always closed primarily with acceptable cosmesis and preservation of muscle function. Alternative free tissue transfers for both skin and bone replacement include the scapular, parascapular, and iliac crest-internal oblique flaps-the former two typically require repositioning of the supine patient, making it difficult to perform simultaneous cancer resection and free tissue harvest. In the case of the fibula skin paddle, perforator dissection is possible to modestly increase pliability, although still constrained by close apposition to the fibula. An excessively large flap may require tracheostomy for airway management, albeit temporarily. Soft tissue flaps will progressively contract, and perioperative edema will resolve. While a smaller skin/mucosal paddle may obviate the need for a tracheostomy, the surgeon must anticipate the degree and direction of contracture and avoid an undersized soft tissue reconstruction as a priority. For free tissue transfer and regional flaps, when possible, a tunnel to the neck is best placed medial to the mandible to avoid extrinsic compression and the low but true risk of facial nerve injury. If the lingual nerve was preserved during tumor resection, this can be gently medialized while tunneling along the lingual mandibular cortex into the floor of mouth. There are countless methods for actual tissue inset-ideally resulting in excellent wound eversion-e. The suturing points that most difficult to reach-often along the posterior floor of mouth-are usually completed first. Incremental delivery of a skin paddle through the tunnel may provide better visibility of the mucosal defect edges. Either securing the endotracheal tube to the opposite oral commissure or nasotracheal intubation facilitates optimal working space. Usually ischemia time of a free tissue transfer is well within limits to complete insetting prior to microvascular anastomosis. This permits removal of oral retractors and relaxation of the mandible into its resting state, which facilitates vessel exposure in the neck and anticipation of the postoperative resting position. Once the vessel anastomoses are completed, assessment of skin paddle perfusion is confirmed with both Doppler probing for pedicle or perforator signal, and pin prick or scratch of the dermis for bright red bleeding. Implantable Doppler devices placed distally to the arterial and/or venous anastomosis may 189 Reconstruction of the Retromolar Trigone also simplify monitoring of flow-but in general "end-organ" assessment with pin prick is most definitive. For 5­14 days after surgery, patients should take no food or fluids by mouth to avoid disruption of the reconstruction and prevention of orocutaneous fistula formation. These patients should have a 10­12 French nasogastric tube placed during surgery, which can be removed once an oral diet is adequate for nutritional and hydration needs. Patients undergoing regional flap reconstruction may be best observed for a few days to ensure donor site healing, manage pain, and monitor flap perfusion. Obstruction of venous outflow due to tension during flap rotation, or twisting of a free tissue pedicle, can result in devastating loss of first-choice tissue. Poor hemostasis or a tight soft tissue tunnel to the neck can restrict venous outflow rapidly. As a preventative measure, circumferential neck pressure, straps, or ties are best avoided for regional and free flaps with pedicles within the neck. Suspected vascular compromise is an indication for immediate operative exploration. Patients with regional flap reconstruction can typically be discharged when medically stable, after 3­4 days.

Additional information:

• Hydroxyurea
• Losartan
• Paroxetine

All other preparations for vaginal delivery should be in place before forceps are applied. Correct placement of forceps occurs only when the long axis of the blades corresponds to the occipitomental diameter, with the major portion of the blade lying over the face, the concave margins of the blades directed toward the sagittal suture (with the fetus in the occiput anterior position). The introduction is accomplished by starting with the handle perpendicular to the floor and the cephalic curve of the blade resting against the fetal head. The internal hand guides the blade inward, upward, and with a rotation that brings the forceps handle through a wide outward arc ending parallel to the floor. This arc is necessary to accommodate both the cephalic and pelvic curves of the device. A preliminary assessment of placement adequacy should be made before the right blade is placed. Before the two forceps blades are articulated, the position on the fetal head should be verified. A correct position will be evident by the symmetry of the blades compared with the sagittal sutures and posterior fontanel. If necessary, one or both blades may be gently maneuvered (using fingers within the vagina) to accomplish optimal positioning. Traction is generally applied by the placement of the fingers on the upper surface of the handles or shanks and the thumbs below. Traction on the articulated forceps begins in a horizontal or slightly downward (axis of the maternal pelvic canal) manner. Traction should be intermittent and, when possible, coordinated with maternal expulsive efforts. To mimic the normal birth process, traction in the horizontal plane continues until the descending fetal head distends the vulva; an episiotomy, if required, may be performed at this point. As the fetal head further distends the vulva, the axis of traction is gradually rotated upward, mimicking the normal extension process of the head as it rotates under the symphysis. Once the brow is palpable through the perineum the blades may be removed and the fetal head delivered by pressure on the perineum (modified Ritgen maneuver). More often the blades may be left in place until the fetal chin has cleared the perineum. Immediate maternal and neonatal effects of low-forceps delivery according to the new criteria of the American College of Obstetricians and Gynecologists compared with spontaneous vaginal delivery in term pregnancies. Predictors of failed operative vaginal delivery in a contemporary obstetric cohort. Both randomized trials and meta-analysis studies have failed to demonstrate conclusive differences. Both forceps delivery and vacuum extraction have been associated with the development of maternal hematomas and possibly linked to pelvic floor injury. Similarly, studies have failed to identify neonatal or fetal injuries or developmental abnormalities that can be directly linked to forceps delivery. The morbidity that previously had been considered to be because of operative vaginal delivery actually may have resulted from the process of abnormal labor that led to the need for an intervention. Rigid hysteroscopes generally include an outer sheath that surrounds the channels for the telescope, distending media inflow and outflow, and operative instruments. Contact hysteroscopes that do not require an external light source (using ambient light instead) are available, but their limited field of view and the inability to convert to an operative procedure have resulted in their infrequent use. Preoperative dilation is generally preferred and may Diagnostic hysteroscopy describes a number of techniques that allow the direct inspection of the endometrial cavity, endocervix, and fallopian tube ostia. Because of its more invasive nature, cost, and small, but not insignificant, risk for perforation or infection, this procedure is best suited for diagnosis and not screening. Office hysteroscopy is a poor choice for patients who have cervical stenosis, high levels of anxiety, comorbidities, limited mobility, in whom there is difficulty visualizing the cervix, or the presence of uterine pathology that may require operative procedures. Video, photographic, or digital capture equipment may be attached to the hysteroscope as desired (optional). Bleeding can easily obscure inspection, and the procedure may have to be rescheduled. Most diagnostic hysteroscopy can be accomplished in the office or ambulatory setting with local anesthesia. Hysteroscopes are available with viewing angles that vary from 0 to 70 degree, with the optimal angle chosen based on the needs of the planned procedure and anticipated pathology; 0-degree scopes provide panoramic views and good delineation of the endocervix, angled scopes are helpful when the cavity is misshapen or pathology near the inner cervical os is anticipated. Following informed consent, the patient is placed in the dorsal lithotomy position and sterile drapes placed as for colposcopy or cystoscopy. If desired, a paracervical block using lidocaine should be placed at this point and the anesthetic allowed a few minutes to take full effect. Some practitioners choose to sound the uterus with a blunt probe, but doing so may disrupt pathology and incite bleeding, which may lead to a suboptimal examination. Distending media, most commonly normal saline, is used to distend the uterine cavity either just prior to or during the insertion of the viewing scope. The hysteroscope may be inserted into the uterine cavity under direct visualization (0-degree scope) or with the obturator in place until the tip of the sheath is within the uterine cavity. A careful and systematic inspection of the uterine cavity and tubal ostia is then carried out. Prior to the completion of the procedure, the pressure of the distending media should be gradually reduced under direct visualization to ensure that small lesions or excrescences have not been compressed and missed. The procedure concludes with the withdrawal of all instruments and verification of hemostasis. Cervical ripening before operative hysteroscopy in premenopausal women: a randomized, doubleblind, placebo-controlled comparison of vaginal and oral misoprostol. Role of oral tramadol 50 mg in reducing pain associated with outpatient hysteroscopy: a randomised double-blind placebo-controlled trial. Comparison of Effectiveness of Laminaria versus Vaginal Misoprostol for Cervical Preparation Before Operative Hysteroscopy in Women of Reproductive Age: A Prospective Randomized Trial. A systematic review of the effect of the distension medium on pain during outpatient hysteroscopy. A randomized controlled study comparing carbon dioxide versus normal saline as distension media in diagnostic office hysteroscopy: is the distension with carbon dioxide a problem Flexible versus rigid endoscopes for outpatient hysteroscopy: a prospective randomized clinical trial. Contact hysteroscopy: another method of endoscopic examination of the uterine cavity. The choice among these options will be driven by the procedure to be performed and the experience and preference of the operator. Before the procedure begins, the fit and completeness of the hysteroscope and its associated sheath, obturator, light cord, and fluid management tubing should be verified. Hysteroscopes are available with viewing angles that vary from 0 to 70 degrees, with the optimal angle chosen based upon the needs of the planned procedure and anticipated pathology; 0-degree scopes provide panoramic views and good delineation of the endocervix, angled scopes are helpful when the cavity is misshapen or pathology near the inner cervical os is anticipated. Following informed consent and the establishment of satisfactory anesthesia, the patient is placed in the dorsal lithotomy position, and sterile drapes are placed as for colposcopy or cystoscopy. The cervix should be visualized, cleansed, and grasped by the anterior lip using a tenaculum or sponge stick. Distending media is used to distend the uterine cavity either just prior to or during the insertion of the operating instruments. The hysteroscope may be inserted into the uterine cavity under direct vision (0-degree scope) or with the obturator in place until the tip of the sheath is within the uterine cavity. A careful and systematic inspection of the uterine cavity and tubal ostia is then conducted. Operative hysteroscopy enables the visual inspection and treatment of intracavitary and submucosal myometrial leiomyomata, which incorporates the use of mechanical or electrosurgical instruments. Operating hysteroscopes include an outer sheath which surrounds channels for the telescope, distending media inflow and outflow, and operative instruments. For operative procedures using monopolar electrosurgical instruments, a nonconductive fluid (eg, glycine) is required; bipolar electrosurgical procedures may use an isotonic fluid (eg, normal saline); mechanical procedures (eg, biopsy or morcellation) are generally done using saline. Preoperative dilation is generally preferred and may be accomplished with the aid of cervical ripening agents (eg, misoprostol, 200­400 mcg orally or intravaginally) or osmotic dilators (eg, laminaria). Electrosurgical Resection Monopolar electrosurgical resection is generally conducted using a resectoscope that includes a U-shaped electrode, which carries the electrosurgical energy; bipolar resection tips are available in several shapes. The path to be resected, including the polyp or portion of leiomyoma to be removed, is inspected and a practice pass made. The electrosurgical generator is activated and the loop drawn toward the observing lens, removing a shallow strip of tissue. With larger lesions, it may be necessary to periodically irrigate the uterine cavity to improve visualization and to remove pathology specimens. The correct alignment of the cutting head and fluid/tissue removal port must be verified. The size of the bites taken by the device may provide a practical limit to the dimensions of lesions that can be addressed using this technology. At the conclusion of the resection, the device should either be retracted so that the cutting window is within the sheath of the hysteroscope or completely removed before withdrawing the scope from the uterus. Selecting a distending medium that minimizes risk and being prepared to promptly recognize and treat fluid overload are all required to ensure the safety of the procedure. If at any point in the procedure there is evidence of systemic absorption, such as a deficit of 750-mL electrolyte-poor fluids, 1000­1500 mL of a nonelectrolyte solution, or 2500 mL of an electrolyte solution, further infusion should be discontinued and the procedure terminated. In an outpatient setting or those with limited acute care and laboratory capabilities, discontinuing the procedure at a lower threshold should be considered. Prior to the completion of the procedure, the pressure of the distending media should be gradually reduced under direct visualization to ensure that small lesions or excrescences have not been compressed and missed and that hemostasis of the surgical site(s) has been achieved. The procedure concludes with the withdrawal of all instruments and verification of cervical hemostasis. Any specimens removed should be placed in suitable transport media and sent for histopathologic examination. Comparison of effectiveness of laminaria versus vaginal misoprostol for cervical preparation before operative hysteroscopy in women of reproductive age: a prospective randomized trial. Resectoscopic versus bipolar electrode excision of endometrial polyps: a randomized study. The Intra Uterine Morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas. Uterine polypectomy in the management of abnormal uterine bleeding: a systematic review. Hysteroscopic morcellation compared with electrical resection of endometrial polyps: a randomized controlled trial. Once both tubal ostia have been visualized, the insert deployment device may be opened onto the sterile field. The delivery system has an introducer sheath that must be inserted into the working channel of the hysteroscope. The surgeon then advances the device until the black positioning marker is at the tubal ostium. A thumbwheel on the inserter is rotated backward until it can no longer rotate, retracting the delivery catheter and exposing the wound coil. The deployment button is depressed, and the thumbwheel is rotated again until it locks, unwinding and detaching the coil. The number of expanded coils that extend from the tubal ostium should be counted and recorded. There should be 3­8 expanded coils visible above the ostium, although 0­17 coils are considered acceptable by the manufacturer. If there are 18 or more expanded coils, the device must be removed and a new device used to reattempt placement. Three months after the procedure, a hysterosalpingogram should be performed to confirm tubal occlusion. Alternate contraception must be used until satisfactory device location and tubal occlusion is confirmed. If complete occlusion is not documented, follow up in an additional 3 months will often find sufficient scarring. A transvaginal ultrasonography alternative to hysterosalpingography has been approved but requires certification by the manufacturer. Safety and efficacy of hysteroscopic sterilization compared with laparoscopic sterilization: an observational cohort study. Success rate and patient satisfaction with the Essure sterilisation in an outpatient setting: a prospective study of 857 women. Hysteroscopic sterilization in a large group practice: experience and effectiveness. Incidence and risk factors for chronic pelvic pain after hysteroscopic sterilization. With sterile gloves the device is grasped, folded, and inserted into the distal end of the insertion tool. With the obturator held in place, the insertion tube is withdrawn, leaving the device in the correct position. The string of the device should be trimmed at a point approximately 1­2 cm from the external os. To insert this device, the package is opened, taking care to maintain the sterility of the contents. After 30 seconds are allowed for the arms to regain their full extension, at which point the inserter should be gently advanced until the flange meets the cervix, ensuring proper fundal placement of the device. Being careful not to entangle the threads, the device is now removed, and the threads are trimmed approximately 2­3 cm from the cervix. The patient must be counseled to use a backup method of contraception during this cycle. Traction on the tenaculum may result in some straightening of the canal, further aiding insertion. In some cases, it may be necessary to use a sterile uterine sound to identify the axis of the canal, provide modest cervical dilation, or confirm the depth of the uterine cavity. Prolonged folding will result in a device that will not unfold properly in the uterine cavity, increasing the risk for expulsion or contraceptive failure.

Mockeel Root (Water Hemlock). Priligy.

• How does Water Hemlock work?
• Dosing considerations for Water Hemlock.
• What is Water Hemlock?
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• Migraine headaches, painful menstrual periods, skin inflammation, and worm infestations.

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Nonetheless, in the modern era of head and neck reconstruction, surgeons have an armamentarium of tools at their disposal with various local, regional, and complex free tissue transfer options, all designed with the primary goal of dynamic or static closure of the velopharyngeal port. Injection Pharyngoplasty the posterior pharyngeal wall may be augmented for smaller palatal defects to bring the posterior pharyngeal wall in closer proximity to the residual soft palate. Multiple augmentation techniques have been described including injectable Teflon,15 hyaluronic acid, calcium hydroxyapatite or other injectable implants,16 and autologous fat. Additionally, it may be difficult to accurately estimate how much material to inject, resulting in over- or under- correction of the defect. Overcorrection is not without risk as patients may be at higher risk for sleep apnea, hyponasality, or dysphagia. Defects of the hard palate, if unrepaired, may result in oronasal or oroantral fistulae, cosmetic deformities with mid-facial retraction, asymmetry and loss of nasal tip support, loss of dentition, and difficulty with oral alimentation and articulation. Optimal reconstruction is predicated on a comprehensive understanding of the extent of the maxillary defect and relevant anatomy. Buttresses serve to resist the vertical forces of mastication, and the four processes function as a frame for the palate and midface. Palatal Prosthesis Obturators may be employed in the reconstruction of soft palatal defects in an adynamic fashion. There are numerous advantages to obturation including ease of placement at the time of surgery or immediately after, minimal additional surgical time and morbidity, and ease of surveillance of the defect postoperatively. They permit immediate restoration of speech and swallowing in the postoperative setting, obviating the need for alternative means of enteral nutrition. The ability to use an obturator is often determined by the dentate status of the patient and extent of surgical resection. Edentulous patients are difficult to rehabilitate with an obturator alone due to limited anchor points for the prosthesis. Challenges in stabilization of the prosthesis often limit the functional and rehabilitative outcomes obtained. They may also cause injury to surrounding mobile mucosa and may be inconvenient and uncomfortable to wear. Patients need to understand that obturators are often not worn during radiation therapy given the increased sensitivity and mucositis of the tissues, they may need multiple adjustments as tissues contract and scar tissue forms, they require regular cleaning and maintenance, and they are removed during sleep. They must be worn at times when patients desire optimal speech and swallowing function, they may cause irrita- tion to the surrounding mucosa, and patients may have trouble with an imperfect seal resulting in undesired regurgitation or leakage. These local options are best suited for small defects involving less than half of the soft palate. Regional Flaps Regional flaps may be utilized for larger defects when local flaps are insufficient. The submental island flap was described in 1993 and may be employed in palatal reconstruction. The skin paddle is generally determined by skin laxity in the submental region, although prior anatomic studies suggest the flap can be maximized at 18 cm by 7 cm. The reconstructive surgeon must exercise caution when harvesting to avoid injury to the marginal branch of the facial nerve. The flap is located in a hair-bearing area; therefore, appropriate counseling with the patient is necessary. It is also susceptible to marginal necrosis, which can occur more frequently if the pedicle is congested due to a narrow tunnel. The temporal muscle passes under the zygomatic arch and fans across the lateral skull and can be used to reconstruct defects of the ipsilateral maxilla and palate. A minor pedicle arises from the superficial temporal vessels, which frequently must be sacrificed. The flap is typically harvested as muscle only and can be grafted with skin secondarily. The temporoparietal fascial flap was first described in 1898 and has become a versatile flap for reconstruction of a wide variety of defects in the head and neck. The reconstructive surgeon should be aware of potential pitfalls including injury to the temporal branch of the facial nerve and scar alopecia. In contrast to the temporalis muscle, this is a thin, pliable fascial flap that has greater reach and is better suited for soft palate defects that do not require much bulk. The flap is supplied by the pectoral branch of the thoracoacromial artery and its venae comitantes. The flap is limited in rotation by the clavicle and can be harvested as a muscle only or musculocutaneous flap. While it can be used for defects cephalad to the oral floor, the flap is limited by size, excessive bulk, dependency, and risk of distal tip necrosis. First described by Strong et al22 in 1971, the technique allows for recreation of the sphincteric function of the velopharynx. The transected edge of the soft palate is sutured to a transected edge of the superior constrictor muscle in the posterior pharyngeal wall, thereby creating a muscular valve to recreate the velopharynx. In patients with unilateral soft palate paralysis after high vagal injuries, a similar technique in which the paralyzed hemi-soft palate is sutured to the posterior pharyngeal wall (palatal adhesion) has been described, and may be applied to smaller soft palate defects in a similar fashion. The uvulopalatal flap, a myomucosal flap, was first described in 1998 by Zohar et al. This technique employs principles of uvulopalatopharyngoplasty26 and is an excellent option for small defects that do not involve the contralateral palate and in which a portion of the soft palate remains. It can be used to decrease the size of a palatal defect obviating the need for an obturator in most cases. Proponents of this technique argue that free flap reconstruction offers multiple advantages over obturation including improved velopharyngeal competence and the ability to overcome sensory impairment with the use of innervated flaps. Local and regional flaps have reliably demonstrated success in closure of the velopharyngeal port on the ipsilateral side with maintenance of function on the contralateral side. Therefore, our preferred reconstructive ladder for small soft palate defects includes: Primary closure if possible. Defects 1/3 to 1/2 of the Soft Palate Moderately sized defects involving less than 1/2 of the soft palate present additional challenges to the reconstructive surgeon as primary closure or local options may not be sufficient and unilateral velopharyngeal port closure may be difficult. Indeed, multiple techniques may be used together to optimize velopharyngeal port closure. In general, more complex reconstruction with free tissue transfer should be avoided as similar functional outcomes can be achieved with less invasive techniques. Our preference for moderately sized soft palate defects include: Local and regional flaps, alone or in combination. Defects Greater than 1/2 of the Soft Palate Large defects involving > 1/2 of the soft palate present significant challenges for postoperative velopharyngeal insufficiency, hypernasality, and nasal regurgitation. Both are adynamic techniques and therefore the determination of which technique to employ is dependent upon patient and disease context. Less than 1/3 In patients with smaller defects, the ability to restore "like with like" using a simple and safe technique is an attainable goal. This section highlights techniques in hard palate reconstruction, spanning prosthetic devices to microvascular free flap reconstructive techniques. A combination of these flaps may also be used for optimal reconstruction of significant defects of the oral cavity and midface. As with soft palate defects, hard palate obturators provide an adynamic but functional restoration of speech and swallowing with an obturator bulb that can seal against the surrounding mucosa. Stability of the obturator, however, is directly correlated with size of the defect and status of the residual dentition; there is a greater risk of air and fluid leakage around the bulb and into the nasal cavity with larger defects. Some of these flaps have been highlighted previously in the reconstruction of soft palate defects. Additional local and regional flaps have been described including forehead flaps,37 deltopectoral flaps,37,38 tubed flaps,39 and nasoseptal flaps. It is based on the palatine neurovascular bundle and can be raised with mucoperiosteum to separate the oral and nasal cavities. The defect from the donor site is allowed to granulate and typically heals in 3­4 weeks and patients may quickly transition to an oral diet. Advantages of local and regional techniques include immediate coverage of the defect in appropriately selected patients; however, many of these options are limited by inadequate bulk and pedicle length, difficulty in permitting eventual dental rehabilitation, and need for secondary procedures for pedicle division. Notably, calvarial bone grafts may also be used in conjunction with local soft tissue flaps. Additional criteria must be considered including anticipated use of osseointegrated implants, donor-site morbidity, and functional rehabilitation goals. Free Flap Reconstruction Microvascular free flap surgery has modernized the reconstructive approach to large hard palate defects. Free tissue transfer provides multiple advantages including immediate reconstruction without the need for staged procedures, substantial bulk and soft tissue density, ability to permit osseointegrated dental rehabilitation, and improved speech intelligibility and overall quality of life for larger sized defects. Okay Class I Our preference for small defects is either obturation alone, if sufficient residual dentition is present, or local flaps. Additionally, defects with bone around all edges are optimal to obturate as they can be stably seated with excellent speech and swallow results. The oral cavity should be clear of any lines and tubes to permit optimal access during reconstruction. This can be achieved with transnasal intubation with or without subsequent tracheostomy depending on the extent of reconstruction, anticipated swelling, and patient habitus. Nasal trumpets may be utilized in the immediate postoperative setting to help maintain a patent nasal airway. Patients in whom the nasopharyngeal port is completely closed must receive close pulse oximetry monitoring, and education to the patient and care providers about their nasopharyngeal anatomy is paramount. Patients may resume oral diet immediately postoperatively if they undergo obturation or limited local reconstruction. In patients who undergo regional or free tissue transfer, oral diversion may be required to permit adequate wound healing. Several factors should be considered including the size and bulk of the reconstruction, preoperative evaluation of swallowing function, and risk of wound breakdown including history of malnutrition and radiation. Overall, palatal reconstruction may be susceptible to crusting and debris formation that may require meticulous debridement and hygiene in the postoperative setting. The role of the speech-language pathologist in the preand postoperative care of these patients cannot be understated. Reconstructive goals should be reviewed with a multidisciplinary team and the patient prior to surgery. Multidisciplinary care is necessary immediately postoperatively to help patients adapt to their new palatal lining and re-learn strategies for eating and speaking. As with any reconstruction, tissue is prone to scarring and Soft and hard palate reconstructions are perhaps the most challenging endeavor in head and neck reconstructive surgery given the inherent challenges in not only restoring a mucosal defect, but rehabilitating the patient functionally. The decision to reconstruct or not, followed by the type of reconstruction, is perhaps the most nuanced and challenging aspect of patient care, and requires careful review of the patient, and surgical and disease factors. Multidisciplinary care is imperative for patients undergoing soft or hard palate reconstruction given the immediate functional and long-term implications. We propose the defect size as a guiding principle for reconstructive management and highlight the strengths and weaknesses of various reconstructive options. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients. Injection pharyngoplasty with calcium hydroxylapatite for velopharyngeal insufficiency: patient selection and technique. Autologous fat injection combined with palatoplasty and pharyngoplasty for velopharyngeal insufficiency and cleft palate: preliminary experience. Palatal adhesion: the treatment of unilateral palatal paralysis after high vagus nerve injury. Applied anatomy of the submental island flap and its clinical application in the repair of defects following hypopharyngeal carcinoma resection. The use of the temporalis muscle flap in facial and craniofacial reconstructive surgery: a review of 182 cases. The use of the temporoparietal fascia flap in various clinical scenarios: a review of 71 cases. A comparison of surgical and prosthetic treatment for speech disorders attributable to surgically acquired soft palate defects. Primary reconstruction after total or extended total maxillectomy for maxillary cancer. A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Reconstruction of palatal defects resulting from treatment of carcinoma of palate, antrum, or gingiva. Reconstruction of the maxilla with a double musculoperiosteal flap in connection with a composite calvarial bone graft. Microvascular free flap reconstruction versus palatal obturation for maxillectomy defects. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. Osteomyocutaneous deep circumflex iliac artery perforator flap in the reconstruction of midface defect with facial skin loss: a case report. Retrospective case series of primary and secondary microvascular free tissue transfer reconstruction of midfacial defects. Primary tumors could be odotogenic (tooth forming elements), nonodontogenic (from bone and cartilage), or miscellaneous (melanoma, lymphoma). Secondary tumors are the most common and are due to direct involvement from an oral cavity malignancy. Metastatic involvement is rare and is usually from primaries arising in the infraclavicular region. Thorough understanding of the anatomic considerations, blood supply, ossification centers, route of spread, in addition to biological factors specific to the type of tumor, is imperative for appropriate management of these tumors. Surgery with adequate margins is the mainstay of treatment along with adjuvant therapy in presence of high risk features.

Usage: ut dict.

Preoperatively, baseline risks such as trismus or impaired cervical mobility due to cervical arthritis can increase the difficulty of intubation. An airway that is difficult to access can be exacerbated by procedures such as maxillary mandibular fixation and free tissue reconstruction. These are some of the influences that factor into the use of awake fiberoptic-guided intubation, transnasal intubation, and awake tracheostomy. When lacrimal duct violation is necessary, dacyrocystorhinostomy stent placements are helpful. With many complications involving wound healing, diet and nutrition are critical perioperatively. An estimated 75 to 80% of head and neck cancer patients lose weight during treatment 40. Diets are often slowly advanced particularly after free flaps in coordination with swallow evaluation. Speech and swallow rehabilitation can help foster return of function of the oral cavity and improve overall conditioning. Speech language pathologists are critical components of the multidisciplinary head and neck treatment team. Therapy provided can promote the use of the following muscles: the muscles of mastication to reduce trismus, the tongue musculature to reduce dysarthria, and tongue and the swallowing muscles to reduce dysphagia. For overall conditioning, even following free flap reconstruction, early mobilization is encouraged. Clean-contaminated head and neck surgeries have reported infection rates ranging from 24 to 87% without antibiotics. Multiple randomized control trials have shown that prolonged courses of antibiotics do not offer definite additional benefits in comparison to shorter courses. Exposed or Infected Hardware To prevent hardware infection and exposure, adequate tissue coverage during the initial surgery promotes thorough vascularization and healing of the surgical site. This is especially important if adjuvant radiation is planned given expected atrophy and microvascular injury. Once hardware is exposed or infected, strong consideration should be given for removal. If supportive plating is removed before adequate osteogenesis, external fixation or intermaxillary fixation are the options. The exposed site should also be covered with vascularized tissue in the form of a local or free tissue flap. Also, in select cases coverage of an exposed bone segment with a soft tissue free flap can restore blood flow to the area, preserve the bone, and avoid the need for an osseous free flap. Orocutaneous Fistula Orocutaneous fistulas can occur after oral cavity resections and reconstruction. Adequate prophylaxis often includes ampicillin/sulbactam or amoxicillin/clavulanic acid. After the wound is cleaned, gauze packing and removal 2 to 3 times a day will help develop granulation tissue for wound tract closure. There are cases in which the fistula tract crosses or abuts the carotid artery or other large-caliber vasculature. If the fistula is not properly drained in this situation, there is a risk for the amylase and oral flora-related inflammation and infection to spread to the blood vessels possibly leading to rupture. These approaches and strategies for optimizing outcomes and reconstruction have been presented in prior chapters with a summary of key points for each procedure (Table 40. Complications that are common across multiple surgical approaches are critical to recognize and have specific treatments 333 Complications of Oral Cancer Surgery Table 40. The most common complications include systemic infections and surgical site infections and/or dehiscence. Medical factors that can be modified include perioperative nutrition, prophylactic antibiotics, and rehabilitative therapy. Key considerations of surgical approaches include: Avoid unnecessary nerve injury. Mandibulectomy osteotomies should be made in the middle of an extracted tooth socket with account for bony resorption at the osteotomy site. Repair any iatrogenic injury to salivary ducts by stent placement, marsupialization, or salivary gland excision. Treatment-related determinants of survival in early-stage (T1­2N0M0) oral cavity cancer: a population-based study. Increasing use of nonsurgical therapy in advanced-stage oral cavity cancer: a population-based study. Risk factors for postoperative complications in oral cancer and their prognostic implications. Incidence and types of complications after ablative oral cancer surgery with primary microvascular free flap reconstruction. Complications and mortality following surgery for oral cavity cancer: analysis of 408 cases. Accuracy of administrative and clinical registry data in reporting postoperative complications after surgery for oral cavity squamous cell carcinoma. Free versus pedicled flaps for reconstruction of head and neck cancer fefects: a systematic review. Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy. Critical weight loss in head and neck cancer-prevalence and risk factors at diagnosis: an explorative study. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. The risk for bloodstream infections is associated with increased parenteral caloric intake in patients receiving parenteral nutrition. Optimal perioperative care in major head and neck cancer surgery with free flap reconstruction: a consensus review and recommendations from the Enhanced Recovery After Surgery Society. Prophylactic antibiotics in oral, pharyngeal and laryngeal surgery for cancer: (a double-blind study). Antibiotic prophylaxis in clean-contaminated head and neck surgery: a systematic review and meta-analysis. Three-dose vs extended-course clindamycin prophylaxis for free-flap reconstruction of the head and neck. Potential risk factors for jaw osteoradionecrosis after radiotherapy for head and neck cancer. Page, and Harry Quon Summary Radiation therapy is an integral part of the management in those with oral cavity cancer. However, its benefits come with the risk of numerous acute and long term toxicities. A strong understanding of the pathogenesis and management of these toxicities is necessary to avoid serious complications and guide a patient through a course of therapy. This article therefore details these possible complications and how to treat them when they arise. The future directions of reducing and managing radiation toxicities will also be addressed. Similar to surgical procedures, radiotherapy is a locally directed therapy and most (though not all) related sequelae are anatomically directed and dependent on the volumes a radiation oncologist decides to treat. Therefore, deciding what to treat and what not to treat is a crucial part of radiotherapy design. Side effects of radiotherapy can be viewed as a continuum of acute (during radiotherapy and several weeks after recovery), intermediate (within several months post radiotherapy), and late term (1 year or later) effects in their manifestation. In the oral cavity, these may include progressively worsening oral mucositis or ulceration, thickened saliva, radiation dermatitis, which may result in desquamation at its peak, dysgeusia or ageusia (dysfunction in taste), lymphedema, cosmetic alteration in skin and tissue integrity, and overgrowth of opportunistic pathogens, such as candida, or soft-tissue infections. Late manifesting complications in the neck include skin and muscle and fibrovascular tissue fibrosis, fistula formation, chronic orofacial/neck pain, and decreased range of mobility in the neck. Evaluation of the oral cavity can reveal dry mucous membranes, loss of enamel, or tooth decay suggesting xerostomia. Externally, lymphedema can be characterized by painless swelling of soft-tissue structures, while radiation fibrosis presents with reduced tissue elasticity and flexibility and reduced range of motion, usually of the neck. Visualization of structures further along the aeordigestive tract, including those of the larynx and pharynx, can be done using a rhinolaryngoscope allowing for assessment of anatomic integrity. Emerging strategies to quantify swallow function include the use of high-resolution manometry and impedance that has been traditionally limited to the esophagus. As such, progressive clinically evident mucosal injury can be observed as fractionated radiotherapy progresses. If insufficient healing of mucosal injury during treatment should occur, persistent mucositis leading to chronic mucosal ulceration has been described as seen in randomized studies evaluating the benefit of continuous daily irradiation including weekend days. For more accelerated radiotherapy schedules involving multiple fractions per day, depending on the size of the radiotherapy fraction, the peak of the injury can occur after completion of the course of the radiotherapy. In the upper aerodigestive tract, mucositis typically is associated with functional effects on swallow, speech, and taste. The risk of developing oral mucositis increases as the radiation dose to the oral cavity increases. Narayan et al25 found that oral mucositis could be limited to mild (grade 1 or less) and short term (one week or less) when point doses to the oral cavity were kept less than 32 Gy. Narayan et al found more moderate (grade 2) and longer lasting (3 weeks or longer) mucositis was associated with oral cavity point doses of 39. In addition to the impact of radiotherapy dose, the volume of mucosa irradiated is also an important factor in the development of mucositis. Higher ratios of involved to normal mucosa, indicating a large primary tumor, places an individual at higher risk for severe (grade 3) mucositis. However, when combined they act synergistically to increase the risk of severe mucositis in a multiplicative rather than additive fashion. In the oral cavity, radiotherapy target volumes that approximate the lips present unique challenges to reduce the impact of mucositis. Similarly, the introduction of a mouth piece with a spacer displacing the palate from the tongue can be beneficial to reduce the risk of mucositis on the palate. This is a particularly beneficial strategy for oral cavity/tongue malignancies where the tongue may be more immobilized due to the effects of surgery limiting its movement and ensuring its position is reproducible with each radiotherapy fraction. However, in patients with a mobile tongue and where it is part of the target volume, judgment is recommended as to whether the benefits with the introduction of a mouth piece displacing it from the palate may be offset by the risk of day-to-day variability in the tongue position due to the presence of the mouth piece. During radiotherapy, ongoing close surveillance of the oral cavity mucosa to identify areas of mucositis is beneficial for several reasons. It not only ensures additional quality assurance of the delivery of the radiotherapy plan, but also allows for several interventions that can reduce its impact on oral cavity function. Mucosal injury arising from bite-line trauma offers opportunities for dental solutions to minimize the damage. Often, it is the secondary mucosal edema that may be exacerbated by the prior oncologic surgery that contributes to the risk of developing dental trauma and requires ongoing evaluation. In addition, dental amalgam can create scatter beta-radiation contributing to premature mucositis beyond what is expected based on the planned dosimetry. In the oral cavity, the buccal and oral tongue mucosa are particularly sensitive to this given the proximity to the teeth and their movement in the oral swallow phase preparing the food bolus. Identifying these areas offers opportunities to either replace the amalgam or to introduce a spacer with either a dental roll or wax, provided this does not alter the reproducibility of the target volumes. Lastly, ongoing surveillance of areas of mucosal ulceration is important to determine if sufficient normal tissue repair response is occurring based on the severity of the acute mucositis. This is important as it has been demonstrated that severe acute mucosal ulceration in the setting of insufficient normal mucosal repair during the radiotherapy can lead to an increased risk of consequential late mucosal side effects24,35 due to injury to the 338 41. Maintaining oral hygiene is imperative to reduce microbial overgrowth that can lead to an aggravation of mucositis. Pain control is essential for patients to maintain nutrition, engage the muscles to reduce the risk of late swallowing complications,39,40 and avoid treatment breaks. Topical anesthetics, such as lidocaine, can be used alone or in combination with diphenhydramine solution and simethicone-based antacid products for initial pain management. Its role in the management of mucositis pain remains an active area of investigation and one with significant promise as it has been associated with decreased narcotic use and treatment breaks. Long-acting narcotics can be used as well, but with extreme caution if short-acting narcotics are still to be titrated up given the risk of respiratory depression and sedation these agents can cause. Several other drugs, including amifostine42,43 and granulocyte macrophage stimulating factor44,45 have demonstrated mixed results. Beyond a perceived feeling of discomfort, xerostomia can also result in pain, dental caries, changes in voice quality, and swallowing dysfunction. A mean dose of 10 to 15 Gy to the parotid typically results in minimal impairment of gland function. However, evidence in both animal models and more recently in humans supports the conclusion that parotid gland function is not uniform and offers unique opportunities to develop new strategies to further reduce this complication. The importance of the dosimetry to these parotid sub-volumes offers the potential to develop future radiotherapy strategies to further reduce this risk. While it is clear that the parotid dosimetry to these sub-volumes (especially the cranial portions) dictates a great deal of the risk of severe xerostomia, patient factors along with the dosimetry to the oral cavity minor salivary glands54,55 and submandibular glands56 appear to be secondarily modifying this risk. Lozenges with acidic, bitter, or sweet flavors can be used as 339 Radiotherapy Related Side Effects in the Treatment of Oral Cavity Malignancies 41. Affected tissues can become hypovascular, hypocellular, and hypoxic reducing the chances of future healing. Conservative management includes local irrigation (with saline, bicarbonate, or chlorhexidine), avoidance of irritants such as smoking and alcohol, and continued maintenance of oral hygiene. Surgical management is the most invasive intervention, but has benefited from technological advancements.