Contemporary Management of Microtia.

Microtia techniques have evolved to improve esthetic outcomes, reduce donor site morbidities, and reduce complications. Patients with microtia commonly have aural atresia associated with conductive hearing loss. We present the evolution of our technique for microtia reconstruction and considerations for hearing management in these patients.

Management of patients with unilateral microtia and aural atresia: recent advances and updates.

PURPOSE OF REVIEW: The management of patients with unilateral microtia and aural atresia is complex. Recent literature suggests significant strides in hearing habilitation and ear reconstruction. RECENT FINDINGS: Several options of hearing management are available and are associated with improved outcomes. Timelines for hearing habilitation and ear reconstruction vary by institution. We offer our timeline as a reference. Three dimensional (3D) printed models are increasingly used for training and reconstruction. Bioprinting is on the horizon, though safety and effectiveness studies are pending. Lastly, application of qualitative methods has provided a foundation on which to improve communication between physicians and patients and their families. Better understanding of the patient and family experiences will provide opportunities to target interventions to improve care. SUMMARY: Current developments include expanding options for hearing management, changing approaches to timing of atresiaplasty, utilization of 3D printed models, and focus on patient and family experience to improve reconstructive outcomes.

Ophthalmic Changes Following Maxillectomy With or Without Postoperative Radiation Therapy.

PURPOSE: To evaluate ophthalmic complications and quantitatively assess anatomic changes following maxillectomy with or without adjuvant radiotherapy in patients with midface malignancy. METHODS: Twenty-four patients who underwent maxillectomy for sinus and/or paranasal cancer were included for retrospective review. Patients with complete ophthalmic examinations were evaluated for postoperative findings corresponding to sequelae of treatment. When available, anatomical changes including eyelid position were quantified from preoperative and postoperative full-face photos using computer software. RESULTS: The most common complications identified in patients after maxillectomy were retraction/ectropion (50%), epiphora (29%), and exposure keratopathy/dry eye syndrome (25%). Patients treated with maxillectomy with adjuvant radiation therapy were more frequently found to have ophthalmic complications following treatment. In patients with available postoperative photos (n = 10), the mean ipsilateral margin reflex distance (MRD)2 and inferior scleral show were 8.4 mm and 2.4 mm, respectively. In patients with available preoperative photos (n = 5), the mean change in MRD2 and inferior scleral show following maxillectomy was 3.4 mm and 2.8 mm, respectively. CONCLUSION: Patients undergoing maxillectomy for the treatment of head and neck malignancy may be at significant risk for development of specific periocular complications. Lower eyelid malposition was the most significant postoperative quantitative eyelid change following maxillectomy, which may be exacerbated by adjuvant radiotherapy and inferior orbital rim removal.

Educational Exposure to Transgender Patient Care in Otolaryngology Training.

OBJECTIVE: Gender dysphoria is estimated to occur in over 1 million people in the United States. With decreasing stigma regarding the transgender population, it is likely more patients will seek medical and surgical gender transition as parts of their treatment. However, otolaryngologists may lack training in gender-confirming surgery. This study aims to determine the current state of transgender-related education in the United States otolaryngology training programs and to evaluate trainee perceptions regarding the importance of such training. METHODS: A cross-sectional survey was performed among the United States otolaryngology training programs. A representative sample of 22 training programs divided within 4 US Census regions completed a cross-sectional 9-question survey between March and May 2017. Respondents were queried regarding demographics, transgender curricular exposure (didactic and/or clinical), and perceived importance of training in transgender patient care. RESULTS: A total of 285 trainees responded (69.3% response rate). Thirty percent of respondents reported education on or direct exposure to transgender care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to facial (masculinization or feminization) or pitch alteration surgery. Overall, the majority of respondents believed training in gender-confirming surgery is somewhat important and 63.2% supported incorporation of transgender patient care in existing subspecialty fellowship training. CONCLUSION: Less than one-third of otolaryngology trainees are exposed to transgender patient care. The majority of trainees endorsed the importance of residency and subspecialty fellowship training in gender-confirming surgery. To better serve the transgender population, formal didactics on gender-confirming surgery should be offered.

Malignant Peripheral Nerve Sheath Tumor of the Lower Eyelid: Case Presentation and Literature Review.

Solitary benign neurogenic tumors are common in the orbit, but only rarely arise from peripheral nerves in the eyelids. In contrast, malignant tumors of neural or nerve sheath elements are exceedingly rare in the orbit and, to date, have never been reported in the lower eyelid. The authors report a 55-year-old man with multiple recurrent lower eyelid masses initially treated as chalazia then misdiagnosed as neurotropic malignant melanoma on pathology. Diagnosis of malignant peripheral nerve sheath tumor was ultimately confirmed histopathologically after surgical resection. The patient has since undergone multiple resections and adjuvant radiotherapy. Twenty-two months since the last procedure, the patient remains disease-free.

Microtia Reconstruction.

Microtia reconstruction is a challenging endeavor that has seen significant technique evolution. It is important to educate patients and their families to determine the best hearing rehabilitation and ear reconstructive options. Microtia is often associated with aural atresia, hearing loss, and craniofacial syndromes. Optimal care is provided by multiple disciplines, including a reconstructive surgeon, an otologic surgeon, an audiologist, and a craniofacial pediatrician. Microtia management includes observation, prosthetic ear, autologous cartilage reconstruction, or alloplastic implant placement. Hearing management options are observation, bone conduction sound processor, or atresiaplasty with and without hearing aids. Appropriate counseling should be done to manage expectations.

Complication Rates in Delayed Reconstruction of the Head and Neck After Mohs Micrographic Surgery.

IMPORTANCE: Same-day Mohs reconstructive surgery is not always possible owing to patient factors, scheduling, and complexity of defect, but there is hesitancy in delaying closure of such defects. OBJECTIVE: To describe the frequency of and predictors of complications in patients undergoing delayed facial reconstruction after Mohs micrographic surgery (MMS). DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective, multi-institutional cohort study from February 1, 1989, to December 31, 2012. Data were pooled from 2 institutions: University of Washington Medical Center and Virginia Mason Medical Center. All patients who underwent MMS for facial carcinomas with delayed (non-same-day) reconstruction were included. We excluded those with incomplete medical records and no follow-up. The analysis was performed from June 2014 to March 2016. MAIN OUTCOMES AND MEASURES: Our main outcome measure was postoperative complication, classified as immediate (≤24 hours after surgery) or delayed (>24 hours after surgery). RESULTS: A total of 415 cases in 342 patients were identified. Reconstruction occurred from 1 to 11 days after excision, with 95.4% of repairs occurring within 2 days of MMS. The overall complication rate was 8.2%. The total delayed complication rate was 7.7% (32 of 415 cases). The overall infection rate was 2.4%. In terms of patient characteristics, reconstruction delayed more than 2 days, bone or cartilage exposure, and large defects were associated with complications. In terms of defect location and reconstruction type, complications were associated with composite defects (those that included >1 facial subunit) and use of interpolated flaps with cartilage grafting. We used these variables in a multivariable logistic regression model and found that composite location, use of interpolated flap with cartilage grafting, and reconstruction delayed more than 2 days were associated with postoperative complications. Among the variables in the model, composite location of defects, interpolated flap with cartilage grafting, and delayed reconstruction greater than 2 days were found to have a statistically significant association with a complication (OR, 3.48 [95% CI, 1.16-10.56]; OR, 4.93 [95% CI, 1.44-16.95]; OR, 4.26 [95% CI, 1.24-14.60], respectively). CONCLUSIONS AND RELEVANCE: To our knowledge, this is the largest study to report complication rates in delayed reconstruction of MMS defects in the head and neck, noting a rate that is similar to what has been reported in the literature. We noted a statistically significant increased risk of complications when reconstruction is performed for composite defects, if an interpolated flap with cartilage is performed, and if reconstruction is performed after more than 2 days. LEVEL OF EVIDENCE: 3.

Autologous Costochondral Microtia Reconstruction.

Reconstruction with autologous costochondral cartilage is one of the mainstays of surgical management of congenital microtia. We review the literature, present our current technique for microtia reconstruction with autologous costochondral graft, and discuss the evolution of our technique over the past 20 years. We aim to minimize donor site morbidity and create the most durable and natural appearing ear possible using a stacked framework to augment the antihelical fold and antitragal-tragal complex. Assessment of outcomes is challenging due to the paucity of available objective measures with which to evaluate aesthetic outcomes. Various instruments are used to assess outcomes, but none is universally accepted as the standard. The challenges we continue to face are humbling, but ongoing work on tissue engineering, application of 3D models, and use of validated questionnaires can help us get closer to achieving a maximal aesthetic outcome.

Antibiotic Prophylaxis in Patients Undergoing Head and Neck Free Flap Reconstruction.

IMPORTANCE: Evidence supports short courses of perioperative antibiotics for patients receiving minor head and neck procedures. Few studies have addressed antibiotic prophylaxis for patients undergoing free flap reconstruction of head and neck defects. OBJECTIVE: To determine ideal antibiotic prophylaxis in patients undergoing head and neck free flap reconstruction. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 427 adults receiving free flap reconstruction of head and neck defects at 2 affiliated tertiary care academic hospitals between January 1, 2006, and January 28, 2013. EXPOSURES: Prophylactic antibiotic type and duration were recorded from patient records. MAIN OUTCOMES AND MEASURES: Outcome data were abstracted from patients' medical records including infection at the surgical sites and distant nonsurgical sites and flap site complications including flap compromise, dehiscence, or fistula. Multivariate logistic regression was used to determine the association of risk factors with the primary outcome of any infection within 30 days of surgery. RESULTS: Ninety-six patients (22.5%) received prophylactic antibiotics for 24 hours or less, and 331 patients received prolonged courses of prophylactic antibiotics. The majority of patients received ampicillin-sulbactam alone for prophylaxis (53.2%), while 36.5% received clindamycin alone and 10.3% received an alternative regimen. Postoperative infections occurred in 46% of patients, and 22% of patients had an infection at the flap inset site or neck incision. The use of clindamycin (odds ratio [OR], 2.54; 95% CI, 1.25-5.14 [P = .01]) was associated with an increased risk of postoperative infection; extended duration of antibiotics (OR, 0.63; 95% CI, 0.34-1.19 [P = .18]) was not associated with increased risk of postoperative infection. By multivariate analysis, use of clindamycin (OR, 6.71; 95% CI, 1.83-24.60 [P = .004]) and oral tobacco use (OR, 1.20; 95% CI, 1.04-1.39 [P = .02]), but not extended course of prophylactic antibiotics (OR, 0.75; 95% CI, 0.30-1.86 [P = .53]), were associated with a higher risk of postoperative flap or neck infections. CONCLUSIONS AND RELEVANCE: The choice of antibiotic appears to affect the rate of all postoperative infections and flap site infections more than the duration of antibiotics following head and neck free flap reconstruction. At our institutions, ampicillin-sulbactam is the preferred prophylactic antibiotic for major clean-contaminated head and neck procedures when possible.

Head and neck free flap reconstruction in patients older than 80 years.

BACKGROUND: Free tissue transfer is a reliable method for reconstruction of head and neck defects. With the growing number of octogenarians in the population, it is important to understand how these patients respond to these procedures. METHODS: Through a retrospective chart review of patients who underwent a free-flap reconstruction from 2000 to 2010 at an academic medical center, 48 patients, aged 80 years and older, were compared with a control group consisting of 97 similar patients, aged younger than 80 years. We compared the intensive care unit (ICU) length of stay, overall hospital stay, and the incidence of perioperative complications between the cohorts. RESULTS: The average length of stay in the ICU was significantly longer for the octogenarian group as compared with the younger group (101 vs. 41 hours, p-value = 0.007). The average length of hospital stay was not significantly different between the two groups (difference = 40 hours, p-value = 0.102). The incidence of perioperative complication was 75% in the octogenarian group and 60% in the younger group (p-value = 0.095). There were two flap failures in the younger group, and none in the octogenarian group. There was a significantly higher rate of death within 30 days in the octogenarian group. CONCLUSIONS: Microvascular free tissue transfer is a reliable and safe method of reconstruction of head and neck defects in patients over 80 years of age. Patients should be counseled about the potential risks of increased incidence of medical complications, ICU length of stay, and rate of perioperative death when recommended to undergo free tissue transfer reconstruction.

Fast neutron radiotherapy for primary mucosal melanomas of the head and neck.

BACKGROUND: Primary head and neck mucosal melanomas (HNMMs) are rare tumors managed with surgery and/or radiotherapy and associated with poor outcomes. Given their radioresistance, high linear energy transfer radiotherapy with neutrons may improve local control. METHODS: We conducted a retrospective review of 14 patients with HNMM treated with neutrons at the University of Washington from 1990 to 2012. Five patients had T3 disease, 9 had T4 disease, 3 had regional nodal disease, and 4 had distant metastases at diagnosis. Primary sites were sinonasal (n=10), lip (n=2), and palate (n=2). Ten patients had initial surgical resection/debulking. RESULTS: Nine patients had gross residual disease, 6 had complete response, and 3 had partial response. Local control was achieved in 79% until death or last follow-up, and 50% developed distant metastases. Kaplan-Meier 5-year local control was 66% and overall survival was 21%. CONCLUSION: High rates of locoregional control were achieved with neutrons, despite the presence of gross disease. Survival was limited by early distant metastases.

Robotic surgery for primary head and neck squamous cell carcinoma of unknown site.

IMPORTANCE: Identification of the primary site in head and neck squamous cell carcinoma (HNSCC) is crucial because it improves the patient's prognosis and minimizes morbidity from treatment. OBJECTIVES: To determine the efficacy of transoral robotic surgery (TORS) in identifying unknown primary sites of head and neck squamous cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, multi-institutional case series from January 1, 2010, to February 28, 2013, in which data were pooled from the following 6 institutions: University of Washington Medical Center, The University of Texas MD Anderson Cancer Center, University of Alabama-Birmingham Hospital, The University of Texas Medical School at Houston, Johns Hopkins Hospital, and Oregon Health Sciences University. All patients diagnosed as having HNSCC of an unknown primary site who underwent TORS to identify the primary site were included in the study. We excluded those with recurrent disease, a history of radiation therapy to the head and neck, or evidence of a primary tumor site based on previous biopsy results. MAIN OUTCOME AND MEASURE: Identification of the primary tumor site. RESULTS: Forty-seven patients were eligible for the study. The tumor site was identified by TORS in 34 of 47 patients (72.3%). The primary site was located in the base of tongue for 20 patients (58.8%) and the palatine tonsil for 13 patients (38.2%), with 1 patient having a primary site in both the base of tongue and the palatine tonsil. Suspicious physical examination findings were present in 23 of 47 patients (48.9%), with positive and negative predictive values of 56.5% and 25.0%, respectively. Of those who underwent any imaging, 16 patients had suspicious findings, with positive and negative predictive values of 50.0% and 16.7%, respectively. In 18 of 47 patients (38.3%), both preoperative radiographic and physical examination failed to suggest a primary site. Of these 18 patients, 13 (72.2%) were identified after undergoing TORS. CONCLUSIONS AND RELEVANCE: We demonstrate that TORS is a useful approach to identify and treat the primary site in patients with HNSCC who present with an unknown primary site.

Ocular protection in facial paralysis.

PURPOSE OF REVIEW: Facial nerve paralysis has a profound impact on patients' quality of life, of which one of the most important sequelae is a risk of corneal surface disease. Herein, we discuss methods to protect the eye following insult to the facial nerve. RECENT FINDINGS: Protection of the ocular surface in patients with facial nerve injury is of paramount importance to prevent corneal injury and potential blindness. Many interventions on the eye are temporary and therefore easily reversible. A systematic approach to managing the eye is required in these patients. SUMMARY: This article provides a review of current methods used for ocular protection in patients with facial nerve paralysis.

The effects of intensive care unit staffing on patient outcomes following microvascular free flap reconstruction of the head and neck: a pilot study.

OBJECTIVE: To determine if the implementation of the closed intensive care unit (ICU) at our institution altered clinical outcomes in patients who had undergone microvascular free flap reconstruction of the head and neck by the Otolaryngology-Head and Neck Surgery Service. DESIGN: Retrospective medical chart review. SETTING: A single tertiary medical center. PATIENTS: The open ICU cohort had 52 flaps performed on 50 patients, and the closed ICU cohort had 52 flaps performed on 52 patients. MAIN OUTCOME MEASURES: Fifty-two free flap reconstructions of head and neck defects were performed on 50 patients who were admitted to an open ICU. The length of stay (LOS) in the ICU and hospital and incidence of complications were compared with those of 52 patients who underwent 52 free flap reconstructions and were admitted to a closed ICU over a separate period. RESULTS: The mean length of stay in the ICU was 44 and 45 hours in the open and closed ICU cohorts, respectively (P = .90). The incidence of surgical and medical complications was similar in the open and closed ICU cohorts (P > .05). CONCLUSIONS: There does not appear to be a significant difference in patient outcome between open and closed ICU care in our study.

Evaluation of a sphere-templated polymeric scaffold as a subcutaneous implant.

OBJECTIVE: To evaluate the performance of a sphere-templated poly(2-hydroxyethyl methacrylate) (poly[HEMA]) tissue scaffold as a subcutaneous implant by comparing it with widely used high-density porous polyethylene (HDPPE) implant material. DESIGN: We implanted sphere-templated porous poly-(HEMA) and HDPPE disks into the dorsal subcutis of C57BL/6 mice for 4 and 9 weeks. Excisional biopsy specimens of the implants and surrounding tissue were assessed for host inflammatory response, tissue ingrowth, and neovascularization using trichrome, picrosirius red, and anti-endothelial cell antibody staining. RESULTS: The poly(HEMA) and HDPPE implants showed resistance to extrusion and elicited a minimal inflammatory response. Both implants supported cellular and collagen ingrowth, but ingrowth within the HDPPE implant was thicker owing to the larger porous structure (>100 µm) of HDPPE, whereas the poly(HEMA) implant had much thinner collagen fibrils within much smaller (40-µm) pores, suggestive of less scar-type reaction. Neovascularization was supported by both implants. Blood vessels were identified within the fibrous ingrowth of the HDPPE and within individual pores of the poly(HEMA). CONCLUSIONS: Sphere-templated poly(HEMA) implanted as a subcutaneous tissue scaffold stimulates a minimal inflammatory response and supports cellular infiltration, collagen formation, and neovascularization. Because of its tightly controlled porous structure, poly-(HEMA) appears to induce less scar-type ingrowth compared with HDPPE.

Complex nasal reconstruction: a case study: reconstruction of full-thickness nasal defect.

Reconstruction of complex full-thickness nasal defects requires the reconstitution of the mucous internal nasal lining, the cartilaginous framework, and the aesthetic contour of the cutaneous nasal covering. Goals of reconstruction include restoration of a functional nasal airway and redefinition of the contours of the nose as well as its relationship to the cheek and lip with the least amount of morbidity to the patient. This article details a multistaged approach to repairing such a defect using an ipsilateral septal mucoperichondrial flap, multiple cartilage grafts, a paramedian forehead flap, and a cheek flap in a woman who had undergone Mohs surgery.

Use of nasotracheal intubation in patients receiving oral cavity free flap reconstruction.

BACKGROUND: The aim of this study was to evaluate the effect airway management has on perioperative outcomes of patients undergoing oral cavity free flap reconstruction. METHODS: A retrospective review was performed on patients receiving oral cavity free flap reconstruction between March 2006 and October 2007. Patient, tumor, and treatment variables were recorded. Patients were managed with nasotracheal intubation (NTI) or elective tracheotomy and different perioperative outcomes were measured. RESULTS: Thirty-seven patients received NTI and 21 received tracheotomy. No patients in the NTI group required conversion to tracheotomy or reintubation. The mean total hospital stay was prolonged in the tracheotomy group (12.4 days vs 8.4 days), as was their likelihood of requiring a feeding tube at discharge (76% vs 19%). In multivariate analyses, placement of a tracheotomy was independently correlated with longer hospital stay and feeding tube dependence at discharge. CONCLUSIONS: NTI is a safe alternative to tracheotomy for select patients receiving oral cavity free flap reconstruction and may reduce hospital stay and feeding tube dependence at discharge.

Crosslinking of an oesophagus acellular matrix tissue scaffold.

The oesophagus acellular matrix (EAM) tissue-scaffold has the potential to serve as the foundation for a tissue-engineered oesophagus for repair of ablative defects. Similar to all collagen-based biomaterials, the EAM is subject to enzymatic degradation in vivo. The introduction of exogenous crosslinks to collagen molecules via glutaraldehyde (Glu) is the most accepted method of stabilizing collagen biomaterials, but fixation with Glu incurs adverse effects. Genipin (Gp), a naturally occurring crosslinking agent, has shown to be effective at improving the stability of collagen-based biomaterials with less cytotoxicity and reduced in vivo inflammatory responses than Glu. The aim of this study was to show that crosslinking with Gp improves the stability of the EAM while maintaining minimal biological reactivity and preserving EAM regeneration potential in a rat model. EAMs were crosslinked with Gp and Glu. Uncrosslinked EAMs served as controls. Denaturation temperature measurement and burst-pressure measurement after enzymatic degradation assays were used to determine the effectiveness of crosslinking on in vitro stability. Subcutaneous allograft implantation and oesophageal epithelial cell-seeding studies assessed the crosslinking effects on biological reactivity and regeneration potential, respectively. Both Gp and Glu improved EAM stability. After 30 days of implantation, the EAM elicited a minimal inflammatory response and crosslinking did not increase inflammation. Gp-crosslinked EAMs supported epithelial adhesion and proliferation while Glu-crosslinked EAMs did not. Gp improves the stability of the EAM while maintaining minimal biological reactivity and preserving EAM epithelial proliferation capacity, yielding a tissue scaffold that may form the basis of a durable and biocompatible tissue-engineered oesophagus.

Coronoidectomy for the treatment of trismus in head and neck cancer patients.

OBJECTIVES: Trismus is a common adverse effect of tumor extension or treatment for those with head and neck malignancy. Physical therapy is the mainstay of treatment, but many patients still fail to maintain adequate mouth opening. Coronoidectomy is a treatment option for those with trismus, and the purpose of this study was to evaluate the effectiveness of coronoidectomy in treating trismus refractory to physical therapy. STUDY DESIGN: Prospective case series. METHODS: Eighteen head and neck cancer patients with interincisal distances less than or equal to 20 mm underwent coronoidectomy after failing physical therapy for at least 3 months. All patients had undergone maximal radiation therapy, half after tumor resection. RESULTS: Postcoronoidectomy, mean interincisal distances improved 22.1 mm and 21.8 mm at 6 and 12 months, respectively, with all patients maintaining an interincisal distance greater than or equal to 35 mm. Tumor location, tumor histology, or the addition of surgical resection had no impact on outcome. CONCLUSION: Coronoidectomy is effective at improving trismus refractory to physical therapy in head and neck cancer patients.