Head and Neck Ablative and Reconstructive Surgery Reflection

Here are some key takeaways from a head and neck ablative and reconstructive surgery information session. Writing these reflections helps me engrain the material and hopefully the summaries spark some intrigue in you too.


Sleep apnea

One treatment option for sleep apnea involves an apparatus that modulates the hypoglossal nerve. When you don’t breathe, your chest doesn’t rise. A component of this apparatus is a lead that can detect a lack of chest expansion. Reduced chest expansion causes the signal-generator to activate the hypoglossal nerve. It’s a short surgery, minimally invasive and few surgeons are doing it today.


Maxillo-mandibular advancement is another way to treat sleep apnea. It’s an invasive procedure, necessitating diligent considerations for healing time and capacity, especially in older patients.


Transoral robotic surgery is an option for tongue surgery and sleep apnea, but it is going out of favour.


Cancers


Trends suggest that the younger patient-population is going to have complications with osteoradionecrosis, as more younger people are being diagnosed with oropharyngeal cancer. This trend is associated with increased levels of HPV in youth, but not all are HPV related. HPV associated cancers in the back of throat have a better prognosis than HPV associated cancers in the anterior.


Treatment for osteosarcoma usually involves chemotherapy, then surgery and then chemotherapy. The chemotherapy is primarily employed to control micro-metastases.


Induction chemotherapy is done before surgery to reduce tumour size. Surgery is followed-up by adjunctive chemotherapy. Once you take out a tumour, you need to establish that there is no residual disease left.


Osteosarcomas are of mesenchymal stem cell. It is the development of tumor-bone; three forms of the disease exist.


Symptoms of tumors include a widened PDL, mobile tooth, sunray appearance on a radiograph and numb lips. 70% of the cases are in Caucasians. The differential diagnosis of these symptoms is osteomyelitis.


Squamous cell carcinoma is the most common malignancy seen by a dental professional. Osteosarcoma is 2nd most common malignancy seen by dental professionals.


Dermatofibrosarcoma Protuberance is uncommon low-grade sarcoma of fibroblast origin. It spreads quickly superficially. Metastasis is infrequent and no neck dissection is required.


Solitary Fibrous Tumor can be benign or malignant. They are of pericyte origin (blood vessel) so bleeding complication is possible during surgery. It is encapsulated and can reoccur. Metastasis is infrequent and no neck dissection necessary. Surgery is recommended.


The temporalis muscle can atrophy after a surgery that involves its fibres, so the surgeon may need to create volume in that area at a later date.


Mucosal melanoma and pancreatic cancer are insidious and may spread to the lymph nodes. Even small manifestations of mucosal melanomas require a large mass of tissue removal, and they may reoccur in as little as one year. They are rare and account for 1% of melanomas. The 5-year survival is 10-15%. A patient is automatically placed in the t3 stage when diagnosed with mucosal cancer.


A mucosal melanoma is analyzed by a sulfur colloid injection, followed by a lymphoscintigraphy scan. This test determines into which lymph node(s) the melanoma is draining. It is followed up by a test that analyzes for the presence of metastasis. If this test comes back positive for metastasis, a neck dissection is indicated.


Ameloblast carcinoma can re-occur after many years.


The fibula may be used to reconstruct the jaw. It is no longer placed at the inferior border so that there is a better outlook for implant placement.


Clinical dilemma: once a tumor has passed the dura, should you do surgery? Prognosis is very poor. People with bran metastasis don’t do well.


Reflections


This was an information-dense presentation. I appreciate small group presentations which provide a conspectus on a specific subject. It is critical to be able to know the early signs and symptoms of oral cancers as we may be the first point of detection.


People come to their general dentist regularly and this information session re-emphasized the importance of a head and neck exam. Anything suspicious should be reported and/or biopsied. The earlier you catch cancer, the better the prognosis. For example, mistaking a mucosal melanoma for an amalgam tattoo and not seeing inflammation of soft tissue or ignoring a sunray pattern on a radiograph would have devastating consequences for the patient. Be prepared and always err on the side of caution.









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