Publications by authors named "Ilpo Kinnunen"

39 Publications

Long-term Quality of Life After Treatment of Oropharyngeal Squamous Cell Carcinoma.

Laryngoscope 2020 Aug 25. Epub 2020 Aug 25.

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University and Turku University Hospital, Turku, Finland.

Objectives: To analyze the long-term quality of life (QOL) among oropharyngeal squamous cell carcinoma (OPSCC) survivors.

Study Design: Retrospective chart analysis and patient response to European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Core Module (EORTC QLQ-C30), Head and Neck Module (EORTC QLQ-H&N35), and M.D. Anderson Dysphagia Inventory (MDADI) survey questionnaires.

Methods: All survivors of OPSCC diagnosed and treated between 2000 and 2009 in Finland were included. There were 263 survivors (44.2% of all curatively treated patients), of which a total of 164 participated in this study (62.4%). Median follow-up was 11.79 years (range = 8.59-18.53 years, interquartile range [IQR] = 4.64 years). The mean age of the participants was 67.9 years (standard deviation = 8.0 years) at QOL follow-up.

Results: Most survivors reported a good QOL. The EORTC QLQ-C30 global health status median was 75.00 (IQR = 31.25). The single modality treatment group had significantly better QOL outcomes than the combined treatment group. Nonsmokers and previous smokers had significantly better QOL outcomes than patients who smoked at the time of diagnosis. A history of heavy alcohol use resulted in significantly worse QOL outcomes. The p16-positive cancer patients had significantly better QOL outcomes than p16-negative patients. Percutaneous endoscopic gastrostomy (PEG) tube-dependent patients reported a significantly worse QOL than patients without a PEG tube.

Conclusions: Long-term QOL in OPSCC survivors is generally good. In line with previous literature, single modality treatment was superior to combined treatment in long-term QOL outcomes, and it should be pursued whenever possible.

Level Of Evidence: 4 Laryngoscope, 2020.
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http://dx.doi.org/10.1002/lary.29042DOI Listing
August 2020

Development of a Patient-Centered Functional Outcomes Questionnaire in Head and Neck Cancer.

JAMA Otolaryngol Head Neck Surg 2020 05;146(5):437-443

Department of Oral and Maxillofacial Surgery, University of Turku, Turku, Finland.

Importance: Incorporation of patient perspectives, or patient-reported outcomes, in functional outcome measures has been gaining prominence in the literature on reconstructive surgery.

Objective: To create and validate an instrument for measuring the main functional areas of concern for patients with head and neck cancer.

Design, Setting, And Participants: This 4-phase mixed-methods qualitative study was conducted from July 1, 2013, to June 30, 2016, in a quaternary head and neck oncology center in Edmonton, Alberta, Canada. Patients were recruited from 3 Head and Neck Research Network sites: University of Alberta (Edmonton, Canada), Mount Sinai Health Network (New York, New York), and University of Turku Hospital (Turku, Finland). The inclusion criteria included 18 years of age or older, diagnosis of squamous cell carcinoma involving the subsites of the head and neck (ie, oral cavity, oropharynx, hypopharynx, and larynx), and at least 1 year since treatment completion. Those patients who were undergoing additional active treatment or with evidence of disease recurrence were excluded. Data were analyzed from July 1, 2013, to June 30, 2016.

Main Outcomes And Measures: The primary outcome measures were the clinical correlation of the Edmonton-33 instrument scores with swallowing, speech, dry mouth, and chewing assessment outcomes.

Results: In total, 10 patients with head and neck cancer (mean age, 59.6 years; 6 men [60%]) were included in phase 1 of the study, 5 patients (mean age, 55.2 years) were included in phase 2, 10 patients were included in phase 3, and 25 patients with head and neck cancer (mean age, 62.6 years; 14 men [56%]) participated in the phase 4 validation. The Edmonton-33 instrument scores correlated strongly with the swallowing scores of the MD Anderson Dysphagia Inventory (r = 0.77; 95% CI, 0.49-1.0), the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35 (EORTC QLQ-H&N35) (r = -0.73; 95% CI, -1.0 to -0.44), and the modified barium swallow test (r = -0.60; 95% CI, -0.94 to -0.25). The instrument scores were also strongly correlated with the Speech Handicap Index scores (r = -0.64; 95% CI, -0.97 to -0.31), word intelligibility scores (r = 0.61; 95% CI, 0.27-0.95), and sentence intelligibility scores (r = 0.55; 95% CI, 0.19-0.91). A moderate to strong correlation was observed between the Edmonton-33 instrument and the EORTC QLQ-H&N35 scores in the dry mouth (r = -0.54; 95% CI, -0.91 to -0.18) and chewing (r = -0.45; 95% CI, -0.84 to -0.06) domains. The factor loading values for the domains of swallowing, speech, dry mouth, and chewing were all greater than 0.3. The mean factor loading values for the items related to swallowing were 0.71 (95% CI, 0.62-0.80) and for the items related to speech were 0.76 (95% CI, 0.72-0.80). The mean factor loading values for the items related to dry mouth were 0.71 (95% CI, 0.59-0.83) and for those related to chewing were 0.77 (95% CI, 0.69-0.85).

Conclusions And Relevance: The Edmonton-33 appears to be a validated instrument that will allow patients with head and neck cancer to assess and report their own functional outcomes. It could serve as a single comprehensive measure for functional outcomes.
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http://dx.doi.org/10.1001/jamaoto.2019.4788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146527PMC
May 2020

Deep neck space infections: an upward trend and changing characteristics.

Eur Arch Otorhinolaryngol 2020 Mar 3;277(3):863-872. Epub 2019 Dec 3.

Department of Otorhinolaryngology and Head and Neck Surgery, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.

Purpose: This study reviews our experience with deep neck space infections (DNIs) requiring surgical intervention, including cervical necrotizing fasciitis. The aim of the study was to identify predisposing and aggravating factors of the disease and recognize the possible factors that can lead to life-threatening complications and slow down the healing process.

Methods: We compare the results to previous data from 1985 to 2005 to find possible alterations and changing trends. The characteristics of four lethal cases are described. This retrospective analysis includes patient data from 2004 to 2015 in tertiary referral hospital and in total, 277 patients were found.

Results: Surgical drainage through a neck opening ± intraoral incision was made in 215 (77.6%) patients, an intraoral incision was only made in 62 patients (22.4%). ICU care was needed in 66 (23.8%) cases. Odontogenic etiology (44.8%) was the most common origin. The most common comorbidity was a psychiatric disorder and/or dementia and occurred in 55 (19.9%) patients. Patients with underlying illnesses were more likely to be admitted to the ICU (p = 0.020), required a longer ICU stay (p = 0.004) and repeated surgery (p = 0.009). Gas formation seemed to be predictive of a more severe course of infection. Early extraction of the odontogenic foci was related to a lower length of stay (LOS) (p = 0.039).

Conclusion: The annual numbers have risen from 14 to 24 cases per year when compared to previous data. DNIs remain a cause of lethal complications; the mortality was 1.4% and overall complications occurred in 61 (22.0%) patients.
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http://dx.doi.org/10.1007/s00405-019-05742-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031181PMC
March 2020

Desmoid tumors of the head and neck: Two decades in a single tertiary care unit and review of the literature.

Ear Nose Throat J 2018 Oct-Nov;97(10-11):362-367

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital, FIN-20521, Turku, Finland.

Desmoid tumors (DTs) of the head and neck have typically been classified as extra-abdominal, although the anatomic challenges of the head and neck warrant consideration of these DTs as a special entity. We present a review of DTs and describe our series of five patients with DTs of the head and neck treated within 2 decades. Altogether, 53 patients with DTs treated surgically at a tertiary care center over a 20-year period were retrospectively reviewed. Outcomes of the treatment of DTs of the head and neck (n = 5) were analyzed as a case series. DTs are rare, histologically benign, but locally aggressive tumors. In our series of 5 patients with head and neck DTs, no patient experienced a recurrence during a median follow-up of 47.5 months (range 13 to 150), although all had positive histologic margins. The functional integrity of vital structures over meticulous radicality of the tumor resection must be considered, especially in the head and neck.
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March 2019

Total or subtotal glossectomy with laryngeal preservation: a national study of 29 patients.

Eur Arch Otorhinolaryngol 2018 Jan 8;275(1):191-197. Epub 2017 Nov 8.

Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, P.O.Box 263, 00029 HUS, Helsinki, Finland.

Total glossectomy remains a controversial procedure as it often leads to notorious sequalae in swallowing and speaking functions. Disease entities indicating total glossectomy tend to have poor prognosis. We evaluated whether this type of surgery can be concidered justified based on our national series. We reviewed all total and subtotal glossectomies with laryngeal preservation performed in Finland between 2005 and 2014 in terms of overall survival (OS), disease-specific survival (DSS), locoregional control (LRC), and functional outcome as assessed by gastric tube or tracheostomy dependence and ability to produce intelligible speech. Of the 29 eligible patients, 15 had undergone total and 14 subtotal glossectomy with curative intent. In eight patients, total/subtotal glossectomy was performed as salvage procedure after the previous treatment. One-year estimates for OS, DSS, and LRC were 48, 59, and 66%, and corresponding 3-year estimates were 31, 46, and 46%, respectively. The gastrostomy and tracheostomy dependence rates at 1 year after operation were 77 and 15%, respectively. Fifty-nine percent of the patients were assessed to be able to communicate verbally. As in most other published studies, we found unsatisfactory survival figures after subtotal or total glossectomy and most patients remained dependent on gastrostomy tube. This surgery is, however, presumably the best and often only chance for cure in a selective patient population, and according to our opinion, it is indicated as a primary or salvage treatment provided that the reconstruction is planned optimally to guarantee a reasonable quality of life after surgery.
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http://dx.doi.org/10.1007/s00405-017-4789-zDOI Listing
January 2018

Functional and quality of life outcomes after partial glossectomy: a multi-institutional longitudinal study of the head and neck research network.

J Otolaryngol Head Neck Surg 2017 Sep 4;46(1):56. Epub 2017 Sep 4.

Department of Oral and Maxillofacial Diseases, Turku University Hospital, Turku, Finland.

Background: While aggressive treatment for oral cancer may optimize survival, decrements in speech and swallowing function and quality of life often result. This exploratory study investigated how patients recover their communicative function, swallowing ability, and quality of life after primary surgery [with or without adjuvant (chemo)radiation therapy] for tongue cancer over the course of the first year post-operation.

Methods: Patients treated for oral cancer at three institutions (University of Alberta Hospital, Mount Sinai Beth Israel Medical Center, and Turku University Hospital) were administered patient-reported outcomes assessing speech [Speech Handicap Index (SHI)], swallowing [(M.D. Anderson Dysphagia Inventory (MDADI)] and quality of life [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC-H&N35)]. Outcome measures were completed pre-operatively and at 1-, 6-, and 12-months post-operatively.

Results: One hundred and seventeen patients undergoing partial glossectomy with reconstruction participated in this study. Results indicated no significant differences in swallowing function (MDADI and EORTC-H&N35 subscales) between baseline and 6 months post-surgery and no significant differences in speech function (SHI subscales) between baseline and 1 year post-surgery. Most quality of life domains (EORTC-H&N35 subscales) returned to baseline levels by 1 year post-operation, while difficulties with dry mouth and sticky saliva persisted. A clear time trend of adjuvant (chemo)radiation therapy negatively affecting dry mouth scores over time was identified in this study, while negative independent effects of chemoradiation on MDADI swallowing, and EORTC-H&N35 swallowing, eating, and opening mouth subscales were found.

Conclusions: Assessment time influenced patient-reported speech, swallowing, and quality of life outcomes, while treatment (by time) effects were found for only swallowing and quality of life outcomes. Results of the present study will help guide clinical care and will be useful for patient counseling on expected short and long-term functional and quality of life outcomes of surgical and adjuvant treatment for oral cavity cancer.
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http://dx.doi.org/10.1186/s40463-017-0234-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5583999PMC
September 2017

Excessive intravenous fluid therapy in head and neck cancer surgery.

Head Neck 2017 01 14;39(1):37-41. Epub 2016 Jun 14.

Heart Center, Turku University Hospital and University of Turku, Turku, Finland.

Background: The purpose of this retrospective study was to present our assessment of modifiable perioperative factors for major cardiac and cerebrovascular events (MACCE).

Methods: This study included an unselected cohort of patients with head and neck cancer (n = 456) treated in Turku University Hospital between 1999 and 2008.

Results: Perioperative and postoperative univariate predictors of MACCE at 30-day follow-up were: total amount of fluids (during 24 hours) over 4000 mL, any red blood cell (RBC) infusion, treatment in the intensive care unit (ICU), tracheostomy, and microvascular reconstruction surgery. Median time from operation to MACCE was 3 days. Patients receiving >4000 mL of fluids had MACCE more often compared with those receiving <4000 mL (10.8% vs 2.4%; p < .001, respectively). Moreover, every RBC unit transfused or every liter of fluid administered over 4000 mL/24h increased the risk of MACCE 18% per unit/liter, respectively.

Conclusion: Patients with head and neck cancer receiving excessive intravenous fluid administration perioperatively and postoperatively are at high risk for cardiac complications, especially heart failure. © 2016 Wiley Periodicals, Inc. Head Neck 39: 37-41, 2017.
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http://dx.doi.org/10.1002/hed.24525DOI Listing
January 2017

Laryngeal cancer in Finland: A 5-year follow-up study of 366 patients.

Head Neck 2016 Jan 27;38(1):36-43. Epub 2015 Jan 27.

Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland.

Background: The purpose of this study was to acquire nationwide data on the management and outcome of laryngeal squamous cell carcinoma (SCC) in Finnish university hospitals over a 5-year posttreatment follow-up.

Methods: All records of patients diagnosed and treated for primary laryngeal SCC during 2001 to 2005 were reviewed.

Results: Three hundred sixty-six patients with laryngeal cancer were identified, 360 of whom had laryngeal SCC. Three hundred forty-two patients with laryngeal SCC (95%) were treated with curative intent. Five-year disease-specific survival (DSS) for T1a, T1b, T2, T3, and T4 glottic SCC was 100%, 95%, 78%, 79%, and 53%, respectively. The corresponding figures for T1 to T4 supraglottic SCC were 68%, 54%, 72%, and 59%.

Conclusion: Results of this nationwide study give a general overview of the outcome of unselected patients treated with unified guidelines. Patients with T2 tumors, usually treated with radiotherapy (RT), had a worse prognosis than expected. This patient group warrants further investigation and possibly treatment intensification.
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http://dx.doi.org/10.1002/hed.23834DOI Listing
January 2016

Subcranial craniotomy approach for frontobasal fracture correction.

J Craniomaxillofac Surg 2014 Oct 3;42(7):1371-7. Epub 2014 Apr 3.

Department of Otolaryngology - Head and Neck Surgery (Head: Professor Reidar Grénman), Turku University Hospital and University of Turku, P.O. Box 52, FI - 20521 Turku, Finland.

Objective: Frontobasilar fracture types and the outcome of patients after management with the subcranial approach technique were evaluated.

Material And Methods: A retrospective analysis of 48 patients (45 males, mean age 38,5 years; range 16-82 years) who had a subcranial approach for frontal base fracture correction between April 1996 and April 2011 at a tertiary care academic hospital in Turku, Finland.

Results: Sixteen (33%) patients had fractures including all frontobasilar fracture types (Type I-IV) i.e. fractures that involved frontal sinuses, orbital roofs, ethmoidal region, cribriform plate and sphenoidal region. Twenty-seven (56%) patients were considered to have had brain damage at presentation. Forty percent of patients were suffering from synchronous trauma. Peroperatively, 31 (65%) patients had exposure or defect of the dura due to bone dehiscence but only two patients suffered from cerebrospinal fluid (CSF) fistula following surgery. CSF fistulae were covered by pericranium in most of the cases (68%). There was no postoperative meningitis. Thirty-eight percent of the patients needed further operation with a subcranial craniotomy following primary reconstruction. At the last follow-up visit 35% were suffering from permanent neurological problems following brain injury.

Conclusions: Subcranial approach seemed successful in the management of all frontobasilar fractures in this series with reasonably low complication rate. Therefore, we would recommend it as the technique of choice in multiple and even in the most complicated frontal base fractures.
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http://dx.doi.org/10.1016/j.jcms.2014.03.028DOI Listing
October 2014

Frontobasilar fractures: proposal for image reviewing algorithm.

J Craniomaxillofac Surg 2014 Jun 11;42(4):305-12. Epub 2014 Feb 11.

Department of Otolaryngology - Head and Neck Surgery (Head: Prof. Reidar Grénman), Turku University Hospital and University of Turku, P.O. Box 52, FI-20521 Turku, Finland.

Objective: The aim of this study was to develop and test the utility of a novel systematic protocol to analyze CT images of patients with trauma in the anterior cranial base and upper midface.

Material And Methods: The radiological data and primary reports of 27 consecutive patients with a frontal skull base fracture treated in two tertiary care hospitals from 2007 to 2011 were scrutinized. A novel algorithm for systematic image reviewing was used to assess the CT images and the findings were compared with the primary radiological reports.

Results: The systematic review detected a substantial number of fractures and defects in anatomical structures that had not been systematically reported in the primary, on-call reports. Anterior skull base fracture was not initially reported in 32% of the patients; however, the algorithm detected this in 93% of them. The corresponding rates for fracture through cribriform plate were 28% and 72% and for fracture through the sella or hypophyseal area 22% and 78%. There were two fractures of the clivus and these were initially missed.

Conclusions: Despite the failure to identify these fractures radiologically in the primary setting, all patients were still considered to have received appropriate treatment, but, the use of an image-reviewing algorithm will enhance the specificity of CT in the diagnosis of frontobasilar fractures.
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http://dx.doi.org/10.1016/j.jcms.2013.05.018DOI Listing
June 2014

Prognostic markers in stage I oral cavity squamous cell carcinoma.

Laryngoscope 2013 Oct 5;123(10):2435-41. Epub 2013 Aug 5.

Medicity Research Laboratory, University of Turku, Turku, Finland; Turku Doctoral Programme of Biomedical Sciences, University of Turku, Turku, Finland.

Objectives/hypothesis: Early-stage oral squamous cell carcinoma (OSCC) treatment is based on anatomic location, clinical TNM staging, and histological grade. It is a heterogeneous disease group. Classification of patients with OSCC by immunohistochemical analysis of established oncoproteins and evaluate disease course was our primary objective. Characterization of stage I OSCC patients in Southwest Finland was our secondary objective.

Study Design: Immunohistochemical analysis of tumor specimens and retrospective analysis of patient data of the patient treated in Turku University Hospital for T1N0M0 OSCC during the years 2000-2004.

Methods: Paraffin-embedded tumor specimens from 35 OSCC patients were collected and analyzed for HIF-1α, CD44, p16, Ki67, and podoplanin by immunohistochemistry and correlated with clinical findings.

Results: Tumoral CD44 and HIF1-α expression levels, in combination, predicted 5-year disease-free survival. Reduced expression of CD44 and elevated expression of HIF1-α is associated with the lowest probability of disease-free survival compared to the population as a whole (P < .001 in Kaplan-Meier analysis). Patients with grade I tumors demonstrated improved disease-specific survival compared to those with grade II tumors (P = .027). No association was seen between p16 expression, Ki67 labeling index, or podoplanin expression and prognosis in our 35 specimens.

Conclusions: HIF-1α and CD44 immunohistochemical detection could potentially serve as a prognostic tool in therapy selection for early-stage OSCC.

Level Of Evidence: 2b.
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http://dx.doi.org/10.1002/lary.23888DOI Listing
October 2013

The quality of the face-to-face counselling in paediatric ambulatory tonsillectomy: parental point of view.

Int J Nurs Pract 2012 Dec;18(6):559-64

Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital of Turku, Turku, Finland.

The objective of this study was to examine parental opinion on the quality of preoperative face-to-face counselling about the child's preoperative fasting. Families, whose child was admitted for ambulatory tonsillectomy were randomly assigned to the study groups (n = 116; 58/58). The intervention group received the information with face-to-face counselling, and the control group in written form. The parents assessed (visual analogue scale) the level of clarity, intelligibility and adequacy of the information, how well they had understood the meaning and the implementation of the child's preoperative fast, as well as their own skills and success to implement the child's fast. The parents in the intervention group felt that the information was significantly clearer, more intelligible and adequate and that they succeeded well. Face-to-face counselling is an effective way to educate the parents.
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http://dx.doi.org/10.1111/ijn.12002DOI Listing
December 2012

Accuracy of the current TNM classification in predicting survival in patients with sinonasal mucosal melanoma.

Laryngoscope 2012 Aug 1;122(8):1734-8. Epub 2012 May 1.

Department of Otorhinolaryngology-Head and Neck Surgery Oulu University Hospital, Oulu, Finland.

Objectives/hypothesis: The first International Union Against Cancer (UICC) TNM classification for aerodigestive malignant mucosal melanoma was not published until 2009, and since then, only a few studies have evaluated the accuracy of this staging system. Our aim was to evaluate the accuracy of this UICC staging system for sinonasal malignant mucosal melanoma (SMMM) in a nationwide survey.

Study Design: Retrospective, population-based, multicenter study.

Methods: The hospital surgical and discharge registries were used to identify the patients. A database including demographic and clinicopathologic variable was created.

Results: Altogether, 50 SMMM patients diagnosed in Finland from 1990 to 2004 were evaluated. Three- and 5-year overall survival rates were 44% and 27%, respectively. Significant differences in overall survival according to T classification (P = .028, log rank) and stage (P = .02, log rank) were found. Tumor extension to the sphenoid sinus had a significant negative impact on survival (n = 11, P = .03, log rank).

Conclusions: The current UICC staging system for mucosal melanoma provides a useful format for staging SMMMs in clinical settings.
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http://dx.doi.org/10.1002/lary.23343DOI Listing
August 2012

Post-traumatic morbidity is frequent in children with frontobasilar fractures.

Int J Pediatr Otorhinolaryngol 2012 May 25;76(5):670-4. Epub 2012 Feb 25.

Department of Otolaryngology - Head and Neck Surgery, Turku University Hospital and University of Turku, Finland.

Objective: Frontobasilar fractures are potentially life-threatening injuries also in pediatric populations, often due to associated intracranial trauma. This retrospective study was performed at a tertiary care university hospital to evaluate the management and outcome of pediatric frontobasilar fractures. The secondary aim was to re-evaluate the computerized tomography images to reveal all the skull base fracture sites predicting morbidity.

Methods: A retrospective analysis of all the 20 consecutive pediatric patients diagnosed with and treated for a frontobasilar fracture at the Turku University Hospital, Turku, Finland during 1995-2010 was performed. The referral area of this tertiary care university hospital covers 750,000 inhabitants of whom approximately 20% are 18 years or younger.

Results: The mean annual incidence of frontobasilar fractures was 1.1 per 100,000 children aged 18 years and under. A road traffic accident was the most common etiological factor. Other factors included being hit by a heavy object, falling from a height, and falling to the ground. The mean Glasgow Coma Scale score was 10 and loss of consciousness was initially detected in 15 (75%) patients in the emergency unit. Twelve (60%) patients had an intracranial injury, 17 (85%) had facial bone fractures, and 15 (75%) had a fracture of the anterior cranial base. The middle cranial fossa and sella were affected in five (25%) of the patients. There seem to be no long-term neuroendocrine sequelae following brain injury, not even when the sella or the hypophyseal area was affected. Twelve (60%) patients were treated operatively. One patient died after one week of intensive care treatment. Only four (20%) patients had no post-traumatic implications, eight (40%) suffered from various long-term sequelae, and five (25%) had permanent neurological or neuropsychological sequelae.

Conclusions: Frontobasilar fractures in childhood are rare and often associated with intracranial trauma and long-term morbidity. However, according to this study, 75% of the patients showed no permanent neurological or neuropsychological sequelae.
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http://dx.doi.org/10.1016/j.ijporl.2012.01.040DOI Listing
May 2012

Mandibular reconstruction using free bone flap after preoperative chemoradiation.

Eur Arch Otorhinolaryngol 2012 May 12;269(5):1513-8. Epub 2011 Oct 12.

Department of Otorhinolaryngology, Head and Neck Surgery, Turku University Hospital, PL 52, 20521 Turku, Finland.

When treating head and neck cancer of an advanced stage, additional therapy modalities are often combined with surgery. This sets new challenges for the reconstructive surgery, especially after segmental mandibulectomy. There is continuous discussion considering the optimal timing of the surgery with relation to other treatment methods such as radiation therapy and chemotherapy. In this work, we have analyzed a series of 10 patients treated with segmental mandibulectomy and preoperative irradiation or chemoradiation in our institute between 1999 and 2006. Surgery was scheduled within 5 weeks from the radiation therapy. 9 out of 10 reconstruction flaps were vital at the last follow-up. In general the outcome of these patients was consistent with the results published earlier by other institutes using postoperative irradiation or chemoradiation. We conclude that preoperative irradiation does not have negative impact on microvascular reconstruction with free bone flap and this procedure offers an equal option for the treatment of these patients.
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http://dx.doi.org/10.1007/s00405-011-1795-4DOI Listing
May 2012

A national series of 244 sinonasal cancers in Finland in 1990-2004.

Eur Arch Otorhinolaryngol 2012 Feb 18;269(2):615-21. Epub 2011 May 18.

Department of Otorhinolaryngology-Head and Neck Surgery, Oulu University Hospital, Oulu, Finland.

Sinonasal cancer is still a somewhat controversial entity because most series are single-center studies. The aim of this study was to give more accurate and generalisable information about treatment of the neck and prognosis of sinonasal cancer. Retrospective, population-based, multicentre study. Altogether 244 patients diagnosed in 1990-2004 were evaluated. The 3- and 5-year disease-specific survival (DSS) rates after treatment with curative intent were 68 and 57%, respectively. Regional status at the time of the diagnosis (P < 0.001, log rank) and local recurrence (P = 0.02, log rank) during the follow-up had a statistically significant effect on DSS. Initially 13% of the patients were diagnosed with neck metastasis. The proportion of regional recurrences during the follow-up was 9%, but it did not have a statistically significant impact on DSS (P = 0.68, log rank). Histopathology had no statistically significant impact on survival in this material of 244 patients. In conclusion, routine elective neck treatment of all sinonasal cancer patients is not recommended, but the importance of the treatment of the primary location is emphasised.
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http://dx.doi.org/10.1007/s00405-011-1615-xDOI Listing
February 2012

Significance of site-specific prognosis of cancer stem cell marker CD44 in head and neck squamous-cell carcinoma.

Oral Oncol 2011 Jun 22;47(6):510-6. Epub 2011 Apr 22.

Department of Otorhinolaryngology, Head and Neck Surgery, Turku University Hospital, Turku, Finland.

In several recent studies, CD44 expression has been associated with aggressive behavior in cancers of different types. CD44 expression is also linked to cancer stem cells, which have been shown to play a significant role in tumor progression and poor prognosis in head and neck squamous cell carcinoma (HNSCC), as well as in other cancers. Although CD44 is a potential prognostic marker, it has not been adopted to wider clinical use as a part of treatment planning in HNSCC patients. The aim of this research was to study whether CD44 overexpression is associated with 5year overall survival in HNSCC. We also studied site-specific associations between increased CD44 expression and 5year overall survival. Associations between relative tumor CD44 expressions and smoking, heavy alcohol consumption, histological grade of cancer, TNM staging and HNSCC staging were also studied. In total, 135 paraffin-embedded blocks from HNSCC patients were stained immunohistochemically with a CD44 antibody and were classified by the anatomic location of the tumor. CD44 overexpression had statistically significant association with decreased 5year survival rates when all HNSCC samples were studied (p<0.001). Significant association between intense CD44 expression and poor 5year survival rates was found in the patients with SCC of the oro- and hypopharynx (p<0.001) and the larynx (p=0.042). In patients suffering from HNSCC in the oral cavity, CD44 overexpression did not have a significant effect on overall 5year survival rates. Heavy smoking of over 10 pack years had a significant association with tumor CD44 overexpression (p=0.009). Only pharyngeal (p=0.046) and laryngeal (p=0.047) SCC, but not oral-cavity SCC, had statistically significant associations between heavy smoking and CD44 overexpression when HNSCC was studied in regional groups. Alcohol consumption and tumor grade did not have a significant association with the tumor's CD44 expression. Our results suggest that CD44 overexpression could be used as a sign of aggressiveness, in addition to the HNSCC staging, as a prognostic factor in pharyngeal and laryngeal HNSCC and to assist in treatment selection.
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http://dx.doi.org/10.1016/j.oraloncology.2011.03.026DOI Listing
June 2011

Blood pressure and free flap oxygenation in head and neck cancer patients.

Acta Otolaryngol 2011 Jul 17;131(7):757-63. Epub 2011 Mar 17.

Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Finland.

Conclusion: This study suggests that although oxygen partial pressure in tissue (p(ti)O(2)) measurement is a feasible method for continuous postoperative monitoring of free flaps, low correlation between blood pressure (BP) and p(ti)O(2) might predict compromised overall outcome. Thus, it is of utmost importance to keep the BP optimal for adequate perfusion of re-anastomosed tissue transfers.

Objective: Optimal BP is an important factor in assuring adequate blood flow in a free flap. Tissue oxygenation in free flaps as a postoperative monitoring target is in routine clinical use in some clinics. Correlation between p(ti)O(2) and systemic BP was investigated.

Methods: Ten consecutive patients underwent resection of head and neck squamous cell carcinoma followed by microvascular reconstruction with a free microvascular flap. P(ti)O(2) of each flap was continuously monitored for 3 postoperative days with a polarographic measurement system. BP was measured invasively and continuously during the operation and during the first postoperative day at the intensive care unit. The correlation coefficient between p(ti)O(2) and BP was analysed.

Results: The correlation coefficient between p(ti)O(2) and BP was relatively high in all patients with uneventful flap survival (r (mean) = 0.63, n = 5). In flaps with haemodynamic problems or compromised flap vitality the correlation appeared low (r(mean) = -0.02, n = 5).
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http://dx.doi.org/10.3109/00016489.2011.554438DOI Listing
July 2011

Fast growth associated with aberrant vasculature and hypoxia in fibroblast growth factor 8b (FGF8b) over-expressing PC-3 prostate tumour xenografts.

BMC Cancer 2010 Oct 30;10:596. Epub 2010 Oct 30.

Institute of Biomedicine, Department of Cell Biology and Anatomy, University of Turku, Turku, Finland.

Background: Prostate tumours are commonly poorly oxygenated which is associated with tumour progression and development of resistance to chemotherapeutic drugs and radiotherapy. Fibroblast growth factor 8b (FGF8b) is a mitogenic and angiogenic factor, which is expressed at an increased level in human prostate tumours and is associated with a poor prognosis. We studied the effect of FGF8b on tumour oxygenation and growth parameters in xenografts in comparison with vascular endothelial growth factor (VEGF)-expressing xenografts, representing another fast growing and angiogenic tumour model.

Methods: Subcutaneous tumours of PC-3 cells transfected with FGF8b, VEGF or empty (mock) vectors were produced and studied for vascularity, cell proliferation, glucose metabolism and oxygenation. Tumours were evaluated by immunohistochemistry (IHC), flow cytometry, use of radiolabelled markers of energy metabolism ([18F]FDG) and hypoxia ([18F]EF5), and intratumoral polarographic measurements of pO2.

Results: Both FGF8b and VEGF tumours grew rapidly in nude mice and showed highly vascularised morphology. Perfusion studies, pO2 measurements, [18F]EF5 and [18F]FDG uptake as well as IHC staining for glucose transport protein (GLUT1) and hypoxia inducible factor (HIF) 1 showed that VEGF xenografts were well-perfused and oxygenised, as expected, whereas FGF8b tumours were as hypoxic as mock tumours. These results suggest that FGF8b-induced tumour capillaries are defective. Nevertheless, the growth rate of hypoxic FGF8b tumours was highly increased, as that of well-oxygenised VEGF tumours, when compared with hypoxic mock tumour controls.

Conclusion: FGF8b is able to induce fast growth in strongly hypoxic tumour microenvironment whereas VEGF-stimulated growth advantage is associated with improved perfusion and oxygenation of prostate tumour xenografts.
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http://dx.doi.org/10.1186/1471-2407-10-596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2984431PMC
October 2010

Perfusion in free breast reconstruction flap zones assessed with positron emission tomography.

Microsurgery 2010 Sep;30(6):430-6

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital, Turku, Finland.

The aim of this pilot study was to determine the postoperative blood perfusion (BF(PET)) and perfusion heterogeneity (BF(PET) HG) in free microvascular breast reconstruction flap zones with positron emission tomography (PET). Regional BF(PET) and BF(PET) HG of the adipose tissue in medial, central, and lateral parts of 13 free flaps were assessed on the first postoperative morning with PET using oxygen-15-labeled water ([(15)O]H(2)O) in 12 patients undergoing breast reconstruction with a deep inferior epigastric perforator (DIEP) or a transverse rectus abdominis muscle (TRAM) flap. The mean BF(PET) values did not differ between DIEP and TRAM flaps (P = 0.791). The mean BF(PET) values were higher in zone III compared with zone I (P = 0.024). During follow-up, fat necrosis was identified in three patients in the medial part (zone II) of the flap. However, the adipose tissue BF(PET) assessed on the first postoperative day from all zones of the flap using PET with radiowater was normal. The BF(PET) HG was higher in the control side (i.e., in the healthy breast tissue) compared with the flap (P = 0.042). The BF(PET) HG was lower in zone III than in zone I (P = 0.03) and in zone II (P < 0.001). In this pilot study, PET was used for the first time for studying the adipose tissue perfusion in different zones in free flaps in a clinical setup, finding that the mean BF(PET) values did not differ between DIEP and TRAM flaps, and that zone II was sometimes not as well perfused as zone III supporting revisited zone division.
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http://dx.doi.org/10.1002/micr.20770DOI Listing
September 2010

Survey of current functional outcomes assessment practices in patients with head and neck cancer: initial project of the head and neck research network.

J Otolaryngol Head Neck Surg 2010 Oct;39(5):523-31

Department of Speech Pathology and Audiology, Faculty of Rehabilitation Medicine, University of Alberta, and Institute for Reconstructive Sciences in Medicine, Misericordia Community Hospital, Edmonton, AB.

Background: Functional outcomes assessment has become increasingly important in informing treatment decisions in the area of head and neck cancer. However, consistency of assessment methods across studies has been lacking. For the literature to inform clinical decision making, consensus regarding outcomes measurements is necessary.

Objective: The Head and Neck Research Network (HNRN) was founded in January 2008 to become a conduit for high-quality research in the area of functional outcomes in patients with head and neck defects. The present study surveyed experts in functional outcomes assessment to determine what are considered the most important tools for assessing speech and swallowing and what background patient characteristics are important to capture.

Design, Participants, And Measures: Respondents to the online survey included 54 participants with a background in speech-language pathology, with the majority of respondents from the United States, Canada, and the United Kingdom.

Results And Conclusions: The results from the survey indicated that clinicians consider both subjective and objective measures as important to use when assessing function. More advanced technical tools were often rated as less important; however, it also was noted that clinicians were most often not able to access these tools or were unfamiliar with them.
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October 2010

Management and outcome of pediatric skull base fractures.

Int J Pediatr Otorhinolaryngol 2010 Nov 25;74(11):1245-50. Epub 2010 Aug 25.

Department of Otolaryngology - Head and Neck Surgery, Turku University Hospital and University of Turku, Finland.

Objective: The management of skull base fractures in the pediatric age group continues to be a major challenge even for experienced multidisciplinary teams. This retrospective study was undertaken at a tertiary care academic hospital to evaluate the management and outcome of pediatric skull base fractures.

Methods: Retrospective analysis covering a period of 13.5 years (from 1996 to 2009) and 63 patients (mean age 10.7 years; range 1-18 years) was performed.

Results: A road traffic accident was the most frequent etiological factor (38%). The most common skull base fracture type was temporal bone fracture (64%). Longitudinal temporal fractures were observed in 45% and transversal in 23% of these patients; in 10 cases (25%) the fracture was comminuted or mixed type. A fracture involving the spheno-ethmoidal complex was the second most common type of basilar skull fracture (41%) followed by fracture through the orbital bone (35%). Forty-three percent of the patients had a concomitant intracranial injury. Early neurological deficits were diagnosed in 21 patients (33%) and 10 patients (16%) had permanent neurological deficits. One patient died after 1 week of intensive care treatment. Fifty-four patients (86%) were discharged home and 8 patients (13%) were discharged for further rehabilitation. Glasgow Coma Scale score of 8 or lower correlated with moderate to poor outcome.

Conclusions: We conclude that skull base fracture is a rare injury in childhood. Mortality is uncommon, but this trauma is commonly associated with intracranial injury. Early neurological deficits are caused by traumatic brain injury and were observed in one-third of the patients. However, only less than one-sixth suffered from permanent neurological or neuropsychiatric disorders.
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http://dx.doi.org/10.1016/j.ijporl.2010.07.023DOI Listing
November 2010

The effect of preoperative fasting on postoperative thirst, hunger and oral intake in paediatric ambulatory tonsillectomy.

J Clin Nurs 2010 Feb;19(3-4):341-50

Department of Nursing Science, University of Turku, Turku, Finland.

Aims And Objectives: The aim of this prospective study was to examine whether preoperative face-to-face counselling about a child's fasting and active preoperative nutrition have an effect on thirst, hunger and postoperative oral intake in paediatric ambulatory tonsillectomy. Families, whose child was admitted for ambulatory tonsillectomy, participated in the study (n = 116; 58/58).

Background: Children undergoing tonsillectomy have difficulties in postoperative recovery and nutrition. However, former studies have shown that shorter preoperative fasting seems to promote postoperative well-being and promote the child's postoperative oral intake.

Design: A prospective, randomised intervention study.

Methods: The study groups were randomly allocated. The intervention group received the instructions through face-to-face counselling about the child's active preoperative nutrition, the control group received the instructions according to the current practice. The postoperative thirst and hunger were scored during the first postoperative hour and at two, four, eight and 24 hours postoperatively. The first scoring was performed by the nurse on a 0-10 scale. The rest of the estimations were made by the children using a visual analogue scale (VAS), by the parents using a 0-10 scale.

Results: In the intervention group, the VAS scores in thirst and hunger were low during the first 24 postoperative hours, whereas in the control group, they increased towards the following morning when the children in the control group, according to the children and the parents, were thirstier (p = 0.051, 0.005, respectively) and significantly hungrier (p = 0.042, 0.005) than those in the intervention group.

Conclusions: Children's perioperative fluid fasting can be decreased with preoperative nutritional face-to-face counselling. Children's perioperative thirst and hunger can be relieved by the limited preoperative fasting.

Relevance To Clinical Practice: Clinical practice should take the child's perioperative fasting into account in a more accurate way in preoperative counselling of the parents.
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http://dx.doi.org/10.1111/j.1365-2702.2009.03051.xDOI Listing
February 2010

The use of pedicled temporal musculoperiosteal flap with or without free calvarial bone graft in maxillary reconstructions.

Eur Arch Otorhinolaryngol 2010 Aug 16;267(8):1299-304. Epub 2010 Mar 16.

Department of Otorhinolaryngology, Head and Neck Surgery, Turku University Central Hospital, 20520 Turku, Finland.

Various techniques have been used to repair maxillary defects. The aim of this study was to evaluate the suitability of pedicled temporal musculoperiosteal flap (PTMF) and free calvarial bone graft for the reconstruction of maxillary defects. In this retrospective series, 34 patients operated on from 1995 to 2006 at Turku University Central Hospital because of defects of maxilla reconstructed using PTMF with or without free calvarial bone graft were evaluated. The diagnosis, the indication for surgery, the location and staging of the tumours, and the type of radiotherapy used were reviewed. The classification of the maxillary defects was performed according to the classification of Brown (Br J Oral Maxillofac Surg 40:183-190, 2002) and the success rates of the reconstructions were evaluated. Of the patients, 32 had been operated on due to a malignant tumour, one due to a benign tumour and one due to posttraumatic palatal defect. Preoperative radiotherapy (n = 14), preoperative chemoradiotherapy (n = 2) or postoperative radiotherapy (n = 11) had been used in the tumour group. As a reconstructive method, PTMF had been used with (n = 21) or without (n = 13) free calvarial bone graft. The use of free calvarial bone graft did not have a significant effect on flap survival. At 1-month follow-up, the flap survival in the 32 patients was 71.9%, whereas 28.1% of the patients suffered from partial flap loss, but there was no total flap loss. At 6-month follow-up, the flap survival in 26 patients was 76.9%, whereas 7.7% of the patients suffered from partial flap loss, and there were four (15.4%) total flap losses. If unilateral alveolar maxillectomy had been performed (Brown classification a), at 1-month follow-up, the flap survival was 82.6%, 17.4% of the patients suffered from partial flap loss, and there was no total flap loss. At 6-month follow-up, the flap survival was 89.5%, while 10.5% of the patients suffered from partial flap loss, and there was no total flap loss. The application of PTMF with or without free calvarial bone graft for reconstruction of limited palatal and maxillary defects appears to be feasible.
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http://dx.doi.org/10.1007/s00405-010-1225-zDOI Listing
August 2010

Acute dysphagia associated with aortic dissection: a case report and review of the literature.

Acta Otolaryngol 2010 May;130(5):637-40

Department of Otolaryngology-Head and Neck Surgery, Turku University Central Hospital and University of Turku, Turku, Finland.

Thoracic aortic aneurysm and dissection are rare causes of neurologic symptoms as well as of dysphagia. We report on a 58-year-old otherwise healthy male patient who presented with acute-onset intermittent dysphagia, mild dyspnea, and chest symptoms. He was referred to an emergency ENT unit for a suspected peritonsillar abscess but died of a massive aortic dissection and cardiac tamponation a few hours later. This rare condition is discussed in the differential diagnosis of adult acute-onset dysphagia.
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http://dx.doi.org/10.3109/00016480903334437DOI Listing
May 2010

The effect of preoperative nutritional face-to-face counseling about child's fasting on parental knowledge, preoperative need-for-information, and anxiety, in pediatric ambulatory tonsillectomy.

Patient Educ Couns 2010 Jul 28;80(1):64-70. Epub 2009 Oct 28.

University of Turku, Department of Nursing Science, Turku, Finland.

Objective: The objective of this study was to define how preoperative nutritional face-to-face counseling on child's fasting affects parental knowledge, preoperative need-for-information, and anxiety, in pediatric ambulatory tonsillectomy.

Methods: The participants in the prospective, randomly allocated study were parents (intervention 62/control 62) with children (4-10 years) admitted for ambulatory tonsillectomy. Data were collected by the knowledge test designed for the study and with The Amsterdam preoperative anxiety and information scale (APAIS). The intervention group was invited to a preoperative visit to receive written and verbal face-to-face counseling. They were initiated into the child's active preoperative nutrition. The parents of the control group received current information without face-to-face counseling.

Results: The parents followed the instructions. Their knowledge about the child's fast increased (p=0.003), and need-for-information and anxiety decreased (p<0.0001) significantly.

Conclusion: The preoperative face-to-face counseling with written information improves parental knowledge about the child's fasting and active preoperative nutrition, and relieves their need-for-information and anxiety.

Practice Implications: The primary responsibility remains with the health care professionals when the active preoperative nutrition of the child and counseling on it are introduced into nursing practice.
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http://dx.doi.org/10.1016/j.pec.2009.10.003DOI Listing
July 2010

The effect of preoperative fasting on postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy.

Int J Pediatr Otorhinolaryngol 2009 Feb 4;73(2):263-73. Epub 2008 Dec 4.

University of Turku, Department of Nursing Science, Turku, Finland.

Objective: The aim of this prospective randomized study was to examine whether active counseling and more liberal oral fluid intake decrease postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy.

Methods: Families, whose child was admitted for ambulatory tonsillectomy or adenotonsillectomy, were randomly assigned to the study groups (n=116; 58 families in each group). The intervention group received the fasting instructions with face-to-face counseling for the child's active preoperative nutrition, and the control group the fasting instructions according to the hospital's standard procedure. The level of postoperative pain and nausea was scored in the postanesthesia care unit (PACU) during the first postoperative hour, as well as at 2, 4, 8 and 24h postoperatively. The first scoring in PACU was performed by the attending nurse with a 0-10 scale. The rest of the estimations were made independently and simultaneously by the children using a VAS scale, and by the parents using a 0-10 scale.

Results: The children in the control group were in more pain in the PACU than the children in the intervention group, and the difference between the groups was statistically significant (p=0.0002). All pain scores, according to the children and the parents, increased after the surgery. In both groups the highest score values were found at home 8h after surgery, and no significant difference was found between the study groups. On the first postoperative morning, the children in the control group were in pain (p=0.047). The children did not have significant nausea in the PACU, but the nausea increased postoperatively. Four hours after surgery the children were most nauseous according to all estimations (60%, n=116). More than half of the children vomited and most vomited clotted blood. Nausea and vomiting decreased during the evening of the surgery, but six children vomited the next morning, four of them vomited blood. The incidence and intensity of postoperative nausea and vomiting between the intervention and control groups were not statistically significant. However, preoperative nutritional counseling and more liberal per oral fluid intake appeared to have a positive effect on the children's well-being and helped them to better tolerate postoperative nausea and vomiting.

Conclusions: The preoperative counseling about active preoperative nutrition significantly reduces the child's pain during the first posttonsillectomy hours and might prepare the child to better tolerate the stress of potential postoperative nausea and vomiting.
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http://dx.doi.org/10.1016/j.ijporl.2008.10.014DOI Listing
February 2009

The limitations of tissue-oxygen measurement and positron emission tomography as additional methods for postoperative breast reconstruction free-flap monitoring.

J Plast Reconstr Aesthet Surg 2010 Feb 6;63(2):314-21. Epub 2008 Dec 6.

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Central Hospital, FIN-20521, Turku, Finland.

Twelve patients who underwent breast reconstruction with a microvascular flap were monitored postoperatively with continuous partial tissue oxygenation (p(ti)O(2)) measurement. The regional blood flow (BF) of the entire flap was evaluated with positron emission tomography (PET) using oxygen-15-labelled water on the first postoperative (POP) morning to achieve data of the perfusion of the entire flap. A re-exploration was carried out if the p(ti)O(2) value remained lower than 15 mmHg for over 30 min. The mean p(ti)O(2) value of the flaps was 52.9+/-5.5 mmHg, whereas the mean BF values were 3.3+/-1.0 ml per 100 g min(-1). One false-positive result was detected by p(ti)O(2) measurement, resulting in an unnecessary re-exploration. Another re-operation suggested by the low p(ti)O(2) results was avoided due to the normal BF results assessed with PET. Totally, three flaps were re-explored. This prospective study suggests that continuous tissue-oxygen measurement with a polarographic needle probe is reliable for monitoring free breast flaps from one part of the flap, but assessing perfusion of the entire flap requires more complex monitoring methods, for example, PET. Clinical examination by experienced personnel remains important in free-breast-flap monitoring. PET could be useful in assessing free-flap perfusion in selected high-risk patients as an alternative to a re-operation when clinical examination and evaluation by other means are unreliable or present controversial results.
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http://dx.doi.org/10.1016/j.bjps.2008.09.029DOI Listing
February 2010