BACKGROUND Orocutaneous fistula (OCF) is one of the frequently encountered postoperative complications following surgery for oral cancer, leading to prolonged hospital stay and delay in the initiation of adjuvant therapy. METHODS We included all patients with oral cancer operated between January 2016 to December 2017 and at risk to develop an OCF. We assessed the incidence of OCF, its management, and factors predisposing to its development. RESULTS Of 587 eligible patients, 9% developed OCF. On univariate and multivariate analysis, patients undergoing bilateral neck dissection or with surgical site infection (SSI) (P < .001) were at maximum risk. On univariate analysis, the incidence was higher following resections for tongue-floor of mouth sub site (P = .002), irrespective of the type of flap used for reconstruction. Majority (57%) required surgical intervention for management. CONCLUSION The presence of SSI and performing bilateral neck dissection posed the maximum risk for developing OCF in patients undergoing surgery for oral cancer.

Factors predisposing to the development of orocutaneous fistula following surgery for oral cancer: Experience from a tertiary cancer center.

Pharyngocutaneous fistulae (PCF) are one of the most common complications after laryngectomy. Predisposing risk factors have been studied, yet knowledge to determine which patients are prone to developing a fistula remains scarce. This study aims to establish prognostic parameters to identify individual patients at risk for PCF development. As PCF and inflammation seem to be interwoven, this work focuses on markers able to detect an inflammatory response. We retrospectively analyzed all patients who had undergone a laryngectomy at our clinic in the years 2007 to 2017 (n = 182). Immunohistochemical expression of bradykinin type 1 and 2 receptor and vascular endothelial growth factor receptor 2 was studied in all available tumor samples. Additionally, the clinical inflammation parameters ‘body temperature’, ‘pain’, ‘c-reactive protein (CRP)’, and ‘leucocytes’ were postoperatively tracked in all patients. The times between fistula diagnosis, therapeutic approach, and hospital discharge were recorded. We found a strong correlation between inflammation and the formation of a fistula. High bradykinin 1 receptor expression in the tumor samples correlated with postoperative PCF development. Persistently elevated CRP and leukocyte levels beyond the 6th postoperative day were also risk factors. A decreased time lapse between PCF diagnosis and surgical revision clearly correlated with a shorter hospital stay. In this study, we identified a bradykinin 1 receptor positive patient group at high risk for development of PCF. We recommend close monitoring for fistula formation in these patients to ensure timely intervention.

/pdf/bradykinin-receptor-b1-and-c-reactive-protein-as-prognostic-4jsvdh2mfi.pdf

Bradykinin Receptor B1 and C-Reactive Protein as Prognostic Factors for Pharyngocutaneous Fistula Development After Laryngectomy

Objective The aim of this study is to identify the risk factors associated with orocutaneous fistula (OCF) formation after free flap reconstruction for oral squamous cell carcinoma (SCC). Methods Patients undergoing free flap reconstruction for oral SCC were retrospectively enrolled. The relationship between clinicopathologic variables and OCF formation was analyzed by univariate and multivariate analyses. Results A total of 87 OCFs occurred in 856 patients. Univariate analysis revealed cachexia, tumor at the tongue/floor of the mouth (TFOM), T4 stage, preoperative hemoglobin level, pull-through procedure, preoperative albumin level, and surgical site infection were associated with the formation of OCF. Multivariate analysis confirmed the independence of cachexia, TFOM, T4 stage, and surgical site infection in predicting OCF development. Conventional wound care could achieve successful fistula closure in 82.4% of the patients with a median time of 28 days. Conclusions OCF formation was common after free flap reconstruction. The presence of cachexia, TFOM tumor site, T4 stage, and surgical site infection significantly increased the risk of OCF formation. Although it required a long period, conventional wound care can obtain satisfactory outcomes in OCF management.

/pdf/orocutaneous-fistula-formation-in-free-flap-reconstruction-1r24e5oi.pdf

Orocutaneous Fistula Formation in Free Flap Reconstruction for Oral Squamous Cell Carcinoma

Early detection of pharyngocutaneous fistula (PCF) after total laryngectomy (TL) could prevent severe complications such as major vessel rupture. We aimed to develop prediction models for detecting PCF in the early postoperative period. We retrospectively analyzed patients (N = 263) who received TL between 2004 and 2021. We collected clinical data for fever (>38.0 °C) and blood tests (WBC, CRP, albumin, Hb, neutrophils, lymphocytes) on postoperative days (POD) 3 and 7, and fistulography on POD 7. Clinical data were compared between fistula and no fistula groups, and significant factors were selected using machine learning. Using these clinical factors, we developed improved prediction models for PCF detection. Fistula occurred in 86 (32.7%) patients. Fever was significantly (p < 0.001) more common in the fistula group, and ratios (POD 7 to 3) of WBC, CRP, neutrophils, and neutrophils-to-lymphocytes (NLR) were significantly higher (all p ≤ 0.001) in the fistula group than in the no fistula group. Leakage on fistulography was more common in the fistula group (38.2%) than in the no fistula group (3.0%). The area under curve (AUC) of fistulography alone was 0.68, but predictive models using a combination of fistulography, WBC at POD 7, and neutrophil ratio (POD 7/POD 3) showed better diagnostic performance (AUC of 0.83). Our predictive models may detect PCF early and accurately, which could reduce fatal complications following PCF.

/pdf/improved-early-detection-models-of-pharyngocutaneous-fistula-3mjr56yv.pdf

Improved Early Detection Models of Pharyngocutaneous Fistula after Total Laryngectomy

Surgical Site Complications and Management

OBJECTIVE
This study aimed to investigate the prognostic factors and treatment outcomes in patients with the external auditory canal (EAC) squamous cell carcinoma (SCC).


METHODS
All patients diagnosed with EAC SCC and treated with curative intent at a single tertiary institution were retrospectively reviewed over a 22-year period. Treatment modalities included surgery with adjuvant treatment or definitive radiotherapy. The primary endpoints were overall survival (OS) and disease-specific survival (DSS).


RESULTS
There were 51 patients in our cohort. The 5-year OS and DSS were 64.0% ± 7.0% and 72.0% ± 7.0% respectively. Patients in the surgical arm and RT arm showed no significant difference in OS, DSS, and LRFS (p = 0.075, 0.062, 0.058 respectively). Compared to other routes of spread within the temporal bone, pattern of posterior disease invasion (involving mastoid/sigmoid sinus) showed poorer OS and DSS on multivariate analysis (hazard ratio, HR4.34 and 5.88; p = 0.006 and 0.009). On multivariate analysis, the following factors were independently prognostic of poorer OS and DSS: Previous radiotherapy (HR 3.29 and 4.81, p = 0.021 and p = 0.029); Presence of facial nerve palsy (HR 3.80 and 7.63, p = 0.013 and p = 0.003); Posterior pattern of invasion (HR4.05 and 3.59, p = 0.013 and p = 0.043). Advanced modified Pittsburgh stage was not predictive of poor OS and DSS (HR1.17 and 1.17 E+5, p = 0.786 and p = 0.961).


CONCLUSION
Presence of previous radiotherapy, facial nerve palsy and posterior pattern of disease invasion were independent prognostic factors of poorer survival in patients with EAC SCC.


LEVEL OF EVIDENCE
4 Laryngoscope, 2022.

Analysis of Prognostic Factors For External Auditory Canal Carcinoma: A 22-Year Experience.

Objective
Orocutaneous and pharyngocutaneous fistula (OPCF) is a debilitating complication of head and neck surgery for squamous cell carcinoma (SCC), resulting in delayed adjuvant treatment and prolonged hospitalization. As yet, there is no established test that can help in prompt and accurate diagnosis of OPCF. This study aims to determine the accuracy of bedside blue dye testing and its role as part of an algorithm for early diagnosis. We also analyze the risk factors predisposing to OPCF.

Study design
Retrospective cohort study from 2012 to 2014

Methods
Patients with head and neck SCC who underwent major resection and reconstruction, at risk of OPCF, were included. Results of blue-dye and video-fluoroscopic swallow-studies (VFSS) testing for OPCF were recorded. For the patients that were noted to develop OPCF, the length of time to diagnosis of fistula and subsequent mode of management were examined.

Results
Of the 93 patients in this study, 25 (26.9%) developed OPCF. Advanced T-classification (T3/T4) was the only significant predisposing risk factor (p = 0.013). The sensitivity and specificity of the bedside blue dye testing was found to be 36.4% and 100%, respectively. The test positive patients were diagnosed with OPCF at a median of postoperative day (POD) 9.5 as compared to POD 13 for the test negative patients (p = 0.001). Early diagnosis was associated with faster fistula resolution with treatment.

Conclusion
Blue dye testing is a simple bedside test that can assist in the early diagnosis of OPCF in patients, allowing treatment to be instituted earlier with improved outcomes.

Level of Evidence
3

https://onlinelibrary.wiley.com/doi/pdf/10.1002/lio2.112

Salivary fistula: Blue dye testing as part of an algorithm for early diagnosis.

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Analysis of Prognostic Factors For External Auditory Canal Carcinoma: A 22-Year Experience.

Salivary fistula: Blue dye testing as part of an algorithm for early diagnosis.