Qualification: 
MS, MCh
subu@aims.amrita.edu

Dr. Subramania Iyer K. currently serves as Professor & Head at the Department of Head & Neck Surgery, School of Medicine, Kochi.

Qualification : MS (Otorhinolaryngology), MCh (Plastic Surgery), FRCS

Publications

Publication Type: Journal Article

Year of Publication Title

2019

E. Berglund, Ljungdahl, M. Andersen, Bogdanović, D., Berglund, D., Wadström, J., Kowalski, J., Brandacher, G., Kamińska, D., Kaufman, C. L., Talbot, S. G., Azari, K., Landin, L., Höhnke, C., Dwyer, K. M., Cavadas, P. C., Thione, A., Clarke, B., Kay, S., Wilks, D., Dr. Subramania Iyer K., Iglesias, M., Özkan, Ö., Özkan, Ö., Krapf, J., Weissenbacher, A., Petruzzo, P., and Schneeberger, S., “Clinical Significance of Alloantibodies in Hand Transplantation - A Multicenter Study”, Transplantation, 2019.[Abstract]


BACKGROUND: Donor-specific antibodies (DSA) have a strong negative correlation with long-term survival in solid organ transplantation. Although the clinical significance of DSA and antibody-mediated rejection (AMR) in upper extremity transplantation (UET) remains to be established, a growing number of single-center reports indicate their presence and potential clinical impact.

METHODS: We present a multicenter study assessing the occurrence and significance of alloantibodies in UET in reference to immunological parameters and functional outcome.

RESULTS: Our study revealed a high prevalence and early development of de novo DSA and non-DSA (43%, the majority detected within the first three post operative years). HLA class II mismatch correlated with antibody development, which in turn significantly correlated with the incidence of acute cellular rejection. Cellular rejections preceded antibody development in almost all cases. A strong correlation between DSA and graft survival or function cannot be statistically established at this early stage but a correlation with a lesser outcome seems to emerge.

CONCLUSIONS: While the phenotype and true clinical effect of AMR remain to be better defined, the high prevalence of DSA and the correlation with acute rejection highlight the need for optimizing immunosuppression, close monitoring and the relevance of an HLA class II match in UET recipients.

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2019

N. Subramaniam, Deepak Balasubramanian, Reddy, R., Thankappan, K., and Dr. Subramania Iyer K., “Organ Preservation Protocols in T4 Laryngeal Cancer: A Review of the Literature”, Indian J Surg Oncol, vol. 10, no. 1, pp. 149-155, 2019.[Abstract]


Population-based studies indicate that chemoradiation has become the most popular treatment for advanced laryngeal cancers; however, by extrapolating trial results to the general population, several issues have emerged, such as reduced overall survival, non-functional laryngeal preservation, and poor response to treatment. Although included in these trials, T4 laryngeal and hypopharyngeal cancers with cartilage invasion formed a small percentage of these patients and questions over whether they were appropriately staged remain unanswered. Literature on the use of chemoradiation in this set of patients, including the challenges, treatment considerations, and factors predicting response to treatment and outcomes, was reviewed. Current evidence indicates that all patients of T4 laryngeal and hypopharyngeal cancer are not suitable candidates for organ preservation; this modality should be offered only to select patients with good performance status and access to rehabilitative care and regular follow-up in order to achieve good results.

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2019

S. Vidhyadharan, Thankappan, K., Subramaniam, N., Ramu, J., Ajith, A., Deepak Balasubramanian, and Dr. Subramania Iyer K., “Robot-Assisted Surgery Avoids Mandibulotomy in a Case of Adenoid Cystic Carcinoma of Base of the Tongue.”, Craniomaxillofac Trauma Reconstr, vol. 12, no. 2, pp. 163-166, 2019.[Abstract]


Surgical management is increasingly preferred in human papilloma-related oropharyngeal squamous cell carcinoma. Robotic surgery has a different role to play in oropharyngeal salivary origin tumors, where surgery is the primary essential modality. This modality may be used for better access to the oropharynx, avoiding a lip split approach with mandibulotomy. The organ preservation approach such as in oropharyngeal squamous cell carcinoma, with nonsurgical modalities like chemoradiotherapy, is not preferred in such cancers, as in the present case. In this context, robot-assisted surgery helps in reducing the morbidity by avoiding the mandibulotomy

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2019

Girish C. M., Dr. Subramania Iyer K., Dr. Krishnakumar T., GS, G., Dr. Manzoor K., and Shantikumar V Nair, “A Novel Surface Enhanced Raman Catheter for Rapid Detection, Classification, and Grading of Oral Cancer”, Advanced Healthcare Materials, vol. 8, no. 13:e1801557, 2019.[Abstract]


Fabrication and testing of a novel nanostructured surface-enhanced Raman catheter device is reported for rapid detection, classification, and grading of normal, premalignant, and malignant tissues with high sensitivity and accuracy. The sensor part of catheter is formed by a surface-enhanced Raman scattering (SERS) substrate made up of leaf-like TiO2 nanostructures decorated with 30 nm sized Ag nanoparticles. The device is tested using a total of 37 patient samples wherein SERS signatures of oral tissues consisting of malignant oral squamous cell carcinoma (OSCC), verrucous carcinoma, premalignant leukoplakia, and disease-free conditions are detected and classified with an accuracy of 97.24% within a short detection-cum-processing time of nearly 25-30 min per patient. Neoplastic grade changes detected using this device correlate strongly with conventional pathological data, enabling correct classification of tumors into three grades with an accuracy of 97.84% in OSCC. Thus, the potential of a SERS catheter device as a point-of-care pathological tool is shown for the rapid and accurate detection, classification, and grading of solid tumors.

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2019

S. Murthy, Low, T. - H. Hubert, Subramaniam, N., Deepak Balasubramanian, Sivakumaran, V., Anand, A., Vijayan, S. Nalumackal, Nambiar, A., Thankappan, K., and Dr. Subramania Iyer K., “Validation of the Eighth Edition AJCC Staging System in Early T1 to T2 Oral Squamous Cell Carcinoma”, J Surg Oncol, vol. 119, no. 4, pp. 449-454, 2019.[Abstract]


BACKGROUND: To validate the newly proposed American Joint Committee on Cancer (AJCC) eighth edition staging in early T1 and T2 oral cavity cancers and its effect in predicting tumour control.

METHODS: Retrospective analysis of treatment outcomes of 441 T1 to T2 oral squamous cell carcinoma (OSCC). Overall survival (OS), disease-specific survival (DSS), and tumour control were calculated and compared between the AJCC 7 and 8 staging systems.

RESULTS: The 5-year OS was 78% and 61% for T1 and T2 tumours, respetively (P < 0.001) (AJCC 7) vs 87% and 67% (P < 0.001) (AJCC 8). The 5-year DSS was 78% and 61% for T1 and T2, respectively (P < 0.001) (AJCC 7) vs 89% and 71% (P < 0.001) (AJCC 8). For stages I and II tumours the 5-year OS was 81% and 76%, respectively (P < 0.302) (AJCC 7) vs 87% and 73% (P < 0.017) (AJCC 8). The 5-year DSS was 83% and 82% (P < 0.222) vs 89% and 77% (P < 0.016). With the AJCC eighth edition the 5-year local, regional, and distant control rates for T1 vs T2 tumours were 85% vs 74% (P = 0.003), 95% vs 77% (P = 0.001), and 95% vs 80% (P = 0.014), respectively.

CONCLUSION: The AJCC 8th staging system provided for more accurate prediction of OS, DSS, and disease control in early oral cavity cancers.

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2018

Deepak Balasubramanian, Subramaniam, N., Rathod, P., Murthy, S., Sharma, M., Jimmy Mathew, Thankappan, K., and Dr. Subramania Iyer K., “Outcomes Following Pharyngeal Reconstruction in Total Laryngectomy - Institutional Experience and Review of Literature”, Indian J Plast Surg, vol. 51, no. 2, pp. 190-195, 2018.[Abstract]


Background: Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction.

Materials and Methods: Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction.

Results: Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap ( = 29), anterolateral thigh flap ( = 8), gastric pull-up ( = 13) and free jejunal flap ( = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis ( = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour ( = 0.003).

Conclusion: Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.

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2018

Manju V., Anitha A., Dr. Deepthy Menon, Dr. Subramania Iyer K., Shantikumar V Nair, and Dr. Manitha B. Nair, “Nanofibrous yarn reinforced HA-gelatin composite scaffolds promote bone formation in critical sized alveolar defects in rabbit model”, Biomedical Materials, vol. 13, no. 6, p. 065011, 2018.[Abstract]


Alveolar ridge resorption and crestal bone loss necessitate the use of bone graft substitutes for dental rehabilitation. The aim of this study was to compare the bone regenerative property of nanofibre incorporated two composite matrices (nanofibrous sheet layered matrix (CS-S) and nanofibrous yarn reinforced matrix (CS-Y)) in critical sized mandibular defect in a rabbit model (under load bearing scenario). Histological evaluation revealed continuous bone formation in the defect implanted with fibre reinforced scaffolds than those without fibres as well as commercial nanoHA-collagen graft. Interestingly, the mineralisation and the mineral density were significantly higher with nanoyarn reinforced scaffolds. Moreover, the compressive strength of new bone formed from CS-Y scaffolds was almost similar to that of native rabbit mandible. It can be concluded that the mechanical strength provided by three-dimensionally reinforced nanoyarns in the matrix could promote bone formation in load bearing mandibular region, and these can be proposed as a scaffold of choice for alveolar bone augmentation and dental rehabilitation.

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2018

N. Subramaniam, Deepak Balasubramanian, Low, T. - H., Murthy, S., Clark, J. R., Thankappan, K., and Dr. Subramania Iyer K., “Factors Affecting Survival in Surgically Salvaged Locoregional Recurrences of Squamous Cell Carcinoma of the Tongue”, Journal of Oral and Maxillofacial Surgery, 2018.[Abstract]


Purpose: To determine the factors affecting outcomes in surgically salvaged, locoregionally recurrent squamous cell carcinoma of the tongue (SCCT). Materials and Methods: In a retrospective cohort of patients who underwent successful salvage of locoregionally recurrent SCCT, we performed this observational analytical study to determine survival and its determinants. Details extracted from our database were patient characteristics (age, gender, tobacco use), treatment characteristics, and characteristics of recurrent disease (stage and adverse pathologic features [APFs] such as grade, perineural invasion, and lymphovascular invasion). Overall survival (OS) curves were plotted using the Kaplan-Meier method. A Cox proportional hazards model was used to determine the impact of patient, disease, and treatment characteristics on OS. Results: Of 52 patients with locoregional recurrences of surgically treated SCCT, 25 (48.1%) underwent surgical salvage with curative intent. The median overall OS for this cohort was 26 months. Factors predictive of worse OS were previous adjuvant therapy (P = .016) and increasing APFs in recurrent tumor histology (P = .008). Lymphovascular invasion in recurrent tumor histology and patients with a disease-free interval of less than 6 months showed worse survival (P = .008 and P = .058, respectively). Conclusions: Among patients with locoregional recurrence, the number who are eligible for curative-intent surgical salvage is small. Those who received previous adjuvant therapy and those with increasing APFs in recurrent tumors had poor outcomes despite attempts at surgical salvage, particularly patients with early recurrence. © 2018 American Association of Oral and Maxillofacial Surgeons.

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2016

Dr. Subramania Iyer K., Thankappan, K., and Balasubramanian, D., “Early detection of oral cancers: Current status and future prospects”, Current Opinion in Otolaryngology and Head and Neck Surgery, vol. 24, pp. 110-114, 2016.[Abstract]


Purpose of review: This article reviews the current literature and summarizes the latest developments in screening and early detection of oral cancers and looks at the future possibilities. Recent findings: Oral cancer is the best model for screening and prevention. The screening for oral cancer can be population based, opportunistic, or targeted. A long-term 15-year follow-up data of a randomized controlled study from a developing country setting indicated a sustained reduction in oral cancer mortality in high-risk individuals. Visual oral examination remains the mainstay in the screening. Several adjunctive techniques have been described to aid in the clinical examination of these lesions. A Cochrane review revealed that there is no evidence to recommend these adjuncts in clinically visible lesions. Salivary biomarkers seem to be promising as a tool for screening in the future. A Targeted Evidence Update for the US Preventive Services Task Force found no evidence on screening either in the general or selected high-risk population for oral cancer in the United States or on benefit of any adjunctive device affecting the performance of the screening examination. Summary: Current evidence shows that community based screening has a value in reducing the oral cancer mortality in high-risk group of population. But this evidence may not be universally applicable. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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2014

S. Vidhyadharan, Augustine, I., Kudpaje, A. S., Dr. Subramania Iyer K., and Dr. Krishnakumar T., “Site-wise Differences in Adequacy of the Surgical resection Margins in Head and Neck Cancers”, Indian journal of surgical oncology, vol. 5, no. 3, pp. 227–231, 2014.[Abstract]


Adequacy of surgical resection decided by the margin status is important in attaining a good local control and better survival in Head and neck Cancers. Conventionally, a measured distance between the tumor edge and the cut edge of the specimen is taken as the margin. A margin more than 5 millimeter (mm) is considered clear, less than 5 mm is close and less than one mm is denoted as involved. The concept of this adequacy varies between the different sites and subsites in head and neck. The purpose of this paper is to review the current evidence that describes the adequacy of surgical margin status and their variability among the sites and sub-sites in the head and neck. More »»

2013

D. Balasubramanian, Dr. Subramania Iyer K., and Thankappan, K., “Tracheoesophageal puncture site closure with single perforator-based deltopectoral flap”, Head and Neck, vol. 35, pp. E60-E63, 2013.[Abstract]


Background Tracheoesophageal puncture (TEP) combined with a voice prosthesis is commonly used for voice production in postlaryngectomy patients. In certain cases, however, leakage occurs around the prosthesis. Many techniques have been described to correct this problem. Surgical closure of the puncture site has to be done if the conservative techniques fail. We present the use of the pedicled deltopectoral flap on the basis of a single perforator in the closure of these fistulae. Methods The reported technique was used in 6 patients over a period 8 years from 2004 to 2011. Results The technique was successful in 5 patients. In 1 case there was dehiscence at the leading edge of the flap because of severe local wound infection. Conclusion The novel technique described by us avoids the need for layered closure or dissection of the trachea and esophagus. It is simple and reliable and provides durable results. © 2011 Wiley Periodicals, Inc.

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2013

D. Balasubramanian, Thankappan, K., Shetty, S., Jayaprasad, K., Mathew, J., and Dr. Subramania Iyer K., “Cricotracheal reconstruction with free radial forearm flap and titanium mesh”, Head and Neck, vol. 35, pp. E178-E180, 2013.[Abstract]


Background Reconstruction after partial cricotracheal resection is technically demanding and is seldom reported in literature. The purpose of this study was to report a technique of reconstruction of such a defect with a radial forearm flap supported by a titanium mesh. Methods A 75-year-old man who was diagnosed with a case of papillary carcinoma thyroid, underwent excision of the tumor with a partial cricotracheal resection. The defect was reconstructed with a free radial forearm flap with fascia suspended on a titanium mesh. Results At a follow-up of 6 months after treatment, the patient has normal nasal breathing and an acceptable voice. Conclusion This reconstructive technique enabled us to maintain the integrity of the subglottic airway. Our technique was unique in that we used the skin-lined part of the radial forearm flap to line the airway and the fascia to cover the titanium mesh outside, thereby preventing plate exposure. © 2012 Wiley Periodicals, Inc.

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2013

M. Sharma, Balasubramanian, D., Thankappan, K., Sampathirao, C. L., Mathew, J., Chavre, S., and Dr. Subramania Iyer K., “Propeller flaps in the closure of free fibula flap donor site skin defects”, Annals of Plastic Surgery, vol. 71, pp. 76-79, 2013.[Abstract]


The free fibula is a versatile and commonly used free flap in microvascular reconstruction. It allows for reconstruction of both bone and soft tissue defects. In head and neck reconstruction, the skin paddle harvested along with the flap allows for the reconstruction of skin or oral mucosal defects. After skin paddle harvest, the donor site can be closed primarily or with skin grafts. Grafting the donor area is the common method used. However, this could lead to delayed healing because of the poor graft over the area of peroneal tendons. Propeller flaps have been extensively reported for closure of leg skin defects. We report a series of 10 patients in whom we used a local propeller flap for the closure of the fibula flap skin donor site. The donor defects could be satisfactorily closed without the need of a skin graft in 9 patients. This method is simple, reliable, and suitable for closing small to medium defects. Copyright © 2013 by Lippincott Williams & Wilkins.

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2012

Dr. Subramania Iyer K., Chatni, S., and Kuriakose, M. A., “Free tensor Fascia Lata-Iliac crest osteomusculocutaneous flap for reconstruction of combined maxillectomy and orbital floor defect”, Annals of Plastic Surgery, vol. 68, pp. 52-57, 2012.[Abstract]


Reconstruction of maxillectomy with extensive orbital rim and floor excision defects is a challenging problem. The goal of reconstruction here is to provide adequate orbital support to prevent enophthalmos and diplopia as well as obturation of the palatal defect. The existing methods of the reconstruction fail to simultaneously address these 2 goals of reconstruction. A new method of reconstruction of these defects using tensor fascia lata-iliac crest flap was used in 7 cases of cancers of the maxilla, which necessitated extensive resection of the orbital floor along with the maxillectomy. The flap was raised as a muscle and bone flap in 5 cases and in 2, a skin paddle was included. The immediate and delayed outcome at 6-month follow-up was analyzed. The functional outcome with regards to the ocular position and function, palatal obturation, speech, and swallowing were recorded. The bone viability at 6 months was assessed by computed tomography scan. The flap was successful in all the 7 cases. The delayed outcome assessment showed that the orbital support was excellent with no diplopia in all the cases. The palatal defect could be covered successfully in all the cases, resulting in normal speech and swallowing. The computed tomography scan showed excellent integration of the bone. The free tensor fascia lata-iliac crest flap is a reliable and safe method of reconstruction of the orbitomaxillary defects, addressing the issues of both orbital support and palatal obturation. © 2012 by Lippincott Williams & Wilkins.

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2011

B. Murali, Vijayaraghavan, S., Kishore, P., Dr. Subramania Iyer K., Jimmy, M., Sharma, M., Paul, G., and Chavare, S., “Cross-chest liposuction in gynaecomastia”, Indian Journal of Plastic Surgery, vol. 44, pp. 81-86, 2011.[Abstract]


Background: Gynaecomastia is usually treated with liposuction or liposuction with excision of the glandular tissue. The type of surgery chosen depends on the grade of the condition. Objective: Because gynaecomastia is treated primarily as a cosmetic procedure, we aimed at reducing the invasiveness of the surgery. Materials and Methods: The technique complies with all recommended protocols for different grades of gynaecomastia. It uses liposuction, gland excision, or both, leaving only minimal post-operative scars. The use of cross-chest liposuction through incisions on the edge of the areola helps to get rid of all the fat under the areola without an additional scar as in the conventional method. Results: This is a short series of 20 patients, all with bilateral gynaecomastia (i.e., 40 breasts), belonging to Simon′s Stage 1 and 2, studied over a period of 2 years. The average period of follow-up was 15 months. Post-operative complications were reported in only two cases, with none showing long-term complications or issues specifically due to the procedure. Conclusions : Cross-chest liposuction for gynaecomastia is a simple yet effective surgical tool in bilateral gynaecomastia treatment to decrease the post-operative scars. The use of techniques like incision line drain placement and post-drain removal suturing of wounds aid in decreasing the scar. More »»

2010

Dr. Subramania Iyer K. and Kuriakose, M., “Tensor Facia Lata-iliac crest osteocutaneous flap for orbitomaxillary reconstruction: A preliminary report”, Indian Journal of Plastic Surgery, vol. 43, pp. 8-13, 2010.[Abstract]


Tensor Fascia Lata muscle and musculocutaneous flap has been used in the past for reconstruction of trunk defects and also as a free flap for soft tissue reconstruction elsewhere in the body. Transferring the iliac crest along with the muscle as a free flap has been described earlier, reported for bridging calcaneal defect and small mandibular defects. The use of this flap as a source of free vascularised bone has not been widely practised since these initial few reports. Anatomical studies were carried out to assess the feasibility of using this flap for reconstructing maxillary and other head and neck defects, following which it was successfully used for these indications. The preliminary report describes the flap anatomy, method of harvest and its potential uses in head and neck reconstruction. More »»

2008

N. P. Trivedi, Swaminathan, D. K., Thankappan, K., Chatni, S., Kuriakose, M. A., and Dr. Subramania Iyer K., “Comparison of quality of life in advanced laryngeal cancer patients after concurrent chemoradiotherapy vs total laryngectomy”, Otolaryngology - Head and Neck Surgery, vol. 139, pp. 702-707, 2008.[Abstract]


Objective: To compare quality of life (QOL) of patients with advanced laryngeal cancers treated by total laryngectomy with those who received concurrent chemoradiotherapy. Study Design: This is a cross-sectional study of the patients treated in our institution who have completed one year of follow-up and were disease-free at the time of evaluation. Subjects and Method: Forty patients treated for advanced cancer of the larynx (stage III/IV), either by concurrent chemoradiation (11) or total laryngectomy and postoperative radiation (29), have been included in this study. The Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) version 4 questionnaire was used. Results: Total scores for overall QOL are equal in both treatment groups (P = 0.69). Scores for individual components are similar in both treatment groups. However, dryness of mouth is significantly worse in the chemoradiotherapy group (P = 0.01) and ability to communicate with others is poorer in the laryngectomy group (P = 0.03). Conclusion: Long-term overall QOL remains similar in all the patients treated for advanced carcinoma of the larynx irrespective of treatment modality. © 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation. More »»

Publication Type: Book

Year of Publication Title

2018

K. Thankappan, Dr. Subramania Iyer K., and Menon, J. R., Dysphagia Management in Head and Neck Cancers A Manual and Atlas: A Manual and Atlas. 2018.[Abstract]


Dysphagia and problems related to swallowing are common following treatment for head and neck cancers. Though there are books available on dysphagia management and associated neurological conditions, this is the only atlas that comprehensively discusses dysphagia related to the head and neck cancers. It comprises of 33 chapters divided into five sections. The initial chapters present the anatomy and physiology of swallowing and the pathophysiology of the dysphagia-related structures. It discusses assessment of dysphagia in detail, highlighting clinical and instrumental evaluations. Swallowing dysfunction related to common sub-site cancers and chemo-radiotherapy related dysphagia are explored individually. The book addresses direct and indirect swallowing therapy methods involving postures and exercises in a detailed yet simple manner to enable them to be incorporated in routine practice. It also covers topics like nutritional management, alternative feeding methods and unique problems associated with tracheostomy that have a great bearing on the day-to-day management of patients with dysphagia. The current status of the research and evidence- based management updates are also included. Additionally, where appropriate videos are included for a better understanding of the subject. 

Written and edited by experts in the field, the book is intended for clinicians treating head and neck cancer, head and neck surgeons, radiation oncologists, speech and swallowing therapy specialists and trainees in these fields

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