Bilateral Inferior Turbinate Flaps for Salvage Reconstruction after Proton Beam Radiotherapy for Clival Chordoma.

Clival chordoma is a rare, aggressive, notochord-derived tumor primarily managed with surgery via an endoscopic endonasal approach (EEA) and adjuvant proton beam radiotherapy. Reconstruction is commonly performed with a nasoseptal flap (NSF) at the time of initial surgery. While failures of the NSF are rare, they can occur following the initial surgery or in the setting of osteoradionecrosis. Salvage repair typically requires transfer of alternative vascularized tissues outside of the previously radiated field including regional scalp flaps such as pericranial or temporoparietal fascial flaps, or free vascularized tissue transfer. Here we describe the case of a 29-year-old woman with a history of clival chordoma with widespread skull base osteomyelitis secondary to NSF necrosis after proton beam radiotherapy. We describe successful skull base reconstruction with intranasal bilateral inferior turbinate flaps based on the sphenopalatine artery with lateral nasal wall extension, despite prior proton beam therapy and a failed prior vascularized intranasal reconstruction.

Race and sex demographics in the surgical management of facial nerve palsy.

Objective: Facial palsy affects patients of all backgrounds, yet no existing studies describe differences in its treatment patterns between demographic groups. Methods: We used the National Surgical Quality Improvement Project database to investigate whether race and sex disparities exist in facial reanimation surgery. Patients were identified using CPT codes corresponding to facial-nerve procedures. Results: Seven hundred sixty-one patients met criteria; 681 self-identified as White (89.5%), 51 as Black (6.7%), 43 as Hispanic (5.6%), 23 as Asian (3.0%), and 5 patients as other (0.61%). White patients were more than twice as likely to undergo brow ptosis repair than Non-White patients (OR 2.49, 95% CI 1.16-6.15, p = .03). After controlling for malignancy, men had longer operative times than women (480.2 vs. 413.9 min, p = .04) and higher likelihood of free tissue transfer (OR 4.1, 95% CI 1.9-9.8), fascial free tissue transfer (OR 10.7, 95% CI 2.1-195), and ectropion repair (OR 1.8, 95% CI 1.2-2.8). Conclusion: Most patients undergoing facial reanimation surgery in the United States are White. Men have longer operative times and a higher likelihood of undergoing free fascial grafts and cutaneous and fascial free tissue transfer than women regardless of malignancy status. Level of Evidence: 2c.

Reducing Surgical Risks in the Rhinoplasty Patient.

Reducing complications after rhinoplasty is critical to ensuring optimal functional, aesthetic, and patient satisfaction outcomes. Many of the most frequent complications of rhinoplasty are technical in nature and can be prevented with meticulous attention to detail and preservation of critical nasal support structures. In this article, the authors review many of the common pitfalls of rhinoplasty and discuss preventative measures that can be used by the competent rhinoplasty surgeon.

Identification of Degenerated Murine Facial Nerves With Fluorescence Labeling After Transection Injury.

OBJECTIVE: Delayed peripheral nerve repair is complicated by nerve degeneration and atrophy that can prevent identification. We use a murine facial nerve transection model to demonstrate the efficacy of ALM-488 (bevonescein) in labeling degenerated facial nerves with quantitative image analysis and qualitative survey data. STUDY DESIGN: Prospective cohort study. SETTING: Laboratory. METHODS: Ten wild-type mice underwent transection of the lower facial nerve division with subsequent degeneration. Either 9 (n = 5 mice) or 12 (n = 5 mice) weeks later, mice underwent intravenous infusion of ALM-488 with in vivo real-time fluorescence imaging (FL) of the facial nerve. Using ImageJ, the mean gray value of each nerve segment under white light reflectance (WLR) and FL was compared to that of adjacent soft tissue to calculate the signal-to-background ratio (SBR). A survey was distributed to evaluate the perceived utility of ALM-488 in surgeon identification of degenerated nerves. RESULTS: The mean SBR of degenerated nerves was 1.08 (standard deviation [SD]: 0.07) under WLR and 2.11 (SD: 0.31) under FL (p < 0.001). In mice with degenerated nerves, survey participants identified on average 3.01 (SD: 1.84) nerve branches under WLR and 5.73 (SD: 1.88) under FL (p < 0.0001). Under FL, 47 of 48 survey responses correctly identified isolated, degenerated nerves; in contrast, only 12 responses identified degenerated nerves under WLR (p < 0.0001). CONCLUSION: Preoperative intravenous infusion of ALM-488 with FL improves the identification of degenerated facial nerves. ALM-488 also improves surgeon confidence in nerve identification, particularly in degenerated nerve branches that are not visible with WLR.

Orbital floor reconstruction via autologous radial forearm free flap with palmaris longus tendon.

We describe reconstruction of the orbital floor following suprastructure maxillectomy for resection of maxillary squamous cell carcinoma utilizing an osteocutaneous radial forearm free flap and palmaris longus tendon.

A Scoping Review of Ongoing Fluorescence-Guided Surgery Clinical Trials in Otolaryngology.

OBJECTIVE: Fluorescence-guided surgery (FGS) is a rapidly developing intraoperative technology, and many contrast agents are currently under investigation. We sought to provide a review of the current state of FGS clinical trials in Otolaryngology, emphasizing its oncologic applications. METHODS: According to the preferred reporting Items for systematic reviews and meta-analyses (PRISMA) workflow for scoping reviews, a clinical trial search was performed across multiple international clinical trials registries, searching for permutations of "fluorescence," "tumor," "surgery," and "nerve" to identify all relevant studies. Studies that were active, enrolling, or soon to be enrolling patients undergoing head and neck surgery were included. RESULTS: Nineteen studies were eligible for inclusion. Seventeen studies are focused on FGS for oncologic resection and lymph node detection. One study assesses peripheral nerve fluorescence, and one evaluates normal parathyroid function after thyroidectomy. Contrast agents under development are conjugated to fluorophores that excite in the 800 nm (indocyanine green), 410 nm (5-aminolevulinic acid), 700 nm (Cyanine 5.5), and 525 nm ranges (fluorescein derivatives). CONCLUSION: Presently, there are 19 ongoing trials investigating novel FGS contrast agents for their safety, efficacy, and utility in Otolaryngology-Head and Neck Surgery. These agents rely on unique fluorophores and absorption ranges in the near-infrared and visible light spectra. FGS studies are expanding within Otolaryngology-Head and Neck Surgery with profound implications in oncologic surgery, lymph node detection, and anatomic and functional assessment. Laryngoscope, 132:36-44, 2022.

Race, Income, and the Timeliness of Cleft Palate Repair in the United States.

Objective To determine if differences exist in the timing of cleft palate repair with respect to sex, race, income, and geographical location within the United States. Design Retrospective cross-sectional study using the Kids' Inpatient Database (KID) from 1997 to 2009. Setting Inpatient. Patients Children with cleft palate with or without cleft lip undergoing inpatient cleft palate repair. Main outcome measures Age at the time of palatoplasty (in months) by sex, race, income quartile, and geographic location. Results A total of 7,218 children with cleft palate underwent repair at a mean age of 12.1 months (95% CI 12.0-12.3). Females underwent palatoplasty at an older age (13.6 months) than males (13.2 months), a difference of 0.47 months (SE: 0.19, p=0.015). White children underwent surgery at an earlier age (12.1 months) than Black (12.9 months) (difference: 0.73 months, SE: 0.37, p=0.045), Hispanic (12.7 months) (difference: 0.57 months, SE 0.25, p=0.025), and Asian children (15.7 months) (difference: 3.60 months, SE 0.49, p<0.0001). Asian children were also found to undergo repair later than Hispanic (difference 3.03 months, SE 0.51, p<0.0001) and Black (difference: 2.87 months, SE 0.59, p<0.0001) children. Patients born into the highest income brackets were repaired 0.75 months earlier than those in the lowest bracket (SE: 0.26, p=0.005). Patients in the Midwest underwent palatoplasty later (14.3 months) than in the Northeast (12.9 months) (difference: 1.36 months, SE: 0.31, p<0.0001), South (13.2 months) (difference: 1.05 months, SE: 0.36, p=0.004), and West (13.2 months) (difference: 1.09 months, SE: 0.32, p=0.0007). Conclusions After controlling for confounding factors, our results suggest that in recent history, Black, Hispanic, and Asian children with cleft palate were repaired later than their White counterparts. In addition, children of affluent families were repaired earliest, and economically disadvantaged children were repaired later than their peers.

Rate and Factors Associated With Change in Surgeon for Revision Endoscopic Sinus Surgery.

OBJECTIVES/HYPOTHESIS: A subset of patients will undergo revision endoscopic sinus surgery (ESS) with a different otolaryngologist than the one who performed their primary surgery. The purpose of this study is to report the incidence of and clinicodemographic factors associated with a change in surgeon for revision ESS. STUDY DESIGN: Retrospective cohort study. METHODS: Adult patients who underwent at least two outpatient ESS procedures between 2009 and 2014 using the State Ambulatory Surgery Database for Florida were included in the study. Change in surgeon was defined by a change in a unique provider identifier for the revision procedure. Multivariable regression analysis was used to determine characteristics associated with a change in surgeon. RESULTS: A total of 2,963 patients were included. For the revision procedure, 47.7% of patients changed their surgeon. On multivariable logistic regression, a medium- (odds ratio [OR]: 0.64; 95% confidence interval [CI]: 0.53-0.77) or high-volume (OR: 0.50; 95% CI: 0.42-0.61) surgeon performing the index surgery and advanced age (≥65 years) (OR: 0.79; 95% CI: 0.63-0.99) were associated with decreased odds of surgeon change for revision ESS. Longer time elapsed between index and revision surgery (OR: 1.15; 95% CI: 1.13-1.17) was associated with increased odds of surgeon change. CONCLUSIONS: Nearly half of patients who undergo revision ESS select a surgeon other than the one who performed their primary procedure. Surgeon volume, age, and time between surgeries affect the likelihood of a change in surgeon for revision ESS. These findings may provide introductory insights into patient preferences and decision making in the surgical management of recalcitrant chronic rhinosinusitis. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1049-E1053, 2021.

Prophylactic Flexible Bronchoscopy Immediately following Open Airway Reconstruction in Children.

OBJECTIVES: Prophylactic flexible bronchoscopy immediately following open airway reconstruction allows for directed clearance of the distal airways, potentially reducing the rate of certain postoperative respiratory complications. In this investigation, we sought to determine if prophylactic flexible bronchoscopy at the conclusion of pediatric open airway reconstruction has any benefit over blind flexible suctioning of the trachea. METHODS: A retrospective, single-center study at an urban tertiary care hospital was completed. From January 2010 to April 2013, patients underwent open airway reconstruction, immediately followed by blind flexible suctioning of the trachea for distal airway clearance. From May 2013 through December 2016, sequential patients underwent prophylactic flexible bronchoscopy immediately following airway reconstruction. RESULTS: A total of 29 patients (age: 3.6 months-6.2 years) met inclusion criteria. Sixteen sequential patients underwent simple blind flexible suctioning and 13 sequential patients underwent directed, prophylactic flexible bronchoscopy. Demographics and comorbidities between the groups were equivalent other than slightly older age in the prophylactic bronchoscopy group. All clinical outcomes analyzed were equivalent other than faster time to room air (P < .002) and a decrease in the number of chest physical therapy sessions (P < .02) in a subset of patients who did not undergo prophylactic bronchoscopy. CONCLUSION: This investigation suggests that the use of prophylactic flexible bronchoscopy immediately following open airway reconstruction may not be superior to blind flexible suctioning of the trachea in limiting postoperative pulmonary complications. Further studies of greater power are needed to better elucidate any small differences that may exist between these two interventions.

Change in surgeon for revision rhinoplasty: The impact of patient demographics and surgical technique on patient retention.

OBJECTIVES: A subset of patients who require revision rhinoplasty will change surgeons for their second procedure. We sought to investigate the rate of surgeon change and identify associated predictors using a population-based, ambulatory surgery database. METHODS/STUDY DESIGN: In this retrospective review, 9172 rhinoplasty procedures over a 5-year period were analyzed using the Healthcare Cost and Utilization Project (HCUP) Florida State Ambulatory Surgery and Services Database (SASD). We identified 380 patients who had at least two rhinoplasty procedures between 2009 and 2014. Logistic regression analysis was used to identify predictors of patients changing surgeons for their second documented rhinoplasty. RESULTS: Among the 380/8531 (4.4%) patients who underwent a revision rhinoplasty, 117/380 (30.8%) patients changed surgeons for their subsequent procedure within a 5-year period. Multivariable logistic regression identified a lower likelihood of surgeon change in patients undergoing functional or cosmetic cartilage grafting procedures (OR 0.342, 95%CI 0.155-0.714, P = .006) and in patients who self-paid for their procedure (OR 0.476, 95%CI 0.225-0.984, P = .048). One hundred twenty-four patients underwent a cosmetic revision rhinoplasty and were twice as likely to change surgeons as those who underwent functional revision rhinoplasty (OR 2.042 95%CI 1.046-4.050, P = .038). Time elapsed (>2 years) was positively correlated with likelihood of surgeon change (OR 1.236, 95%CI 1.153-1.333, P < .001). CONCLUSION: In our analysis, 30.8% of patients changed surgeons for their revision rhinoplasty. Cartilage grafting at the time of index procedure and cash payment correlated with a decreased likelihood of surgeon change. Patients were more likely to change surgeons with increased time elapsed or for an aesthetic revision. Clarifying features associated with surgeon change may help improve patient satisfaction and retention.

Association of subjective olfactory dysfunction and 12-item odor identification testing in ambulatory COVID-19 patients.

BACKGROUND: Acute loss of smell and taste are well-recognized symptoms of coronavirus disease 2019 (COVID-19), yet the correlation between self-reported and psychophysical olfactory function remains unclear. Understanding the reliability of self-reported smell loss in ambulatory cases can assess the utility of this screening measure. METHODS: A prospective, longitudinal study evaluating patient-reported and measured olfactory function using the validated 12-item Brief Smell Identification Test (BSIT) was conducted on adult outpatients with COVID-19. Patient-reported olfaction scores using a visual analog scale (VAS) were obtained at baseline, time of COVID-19 testing, and time of BSIT completion. Linear associations between VAS and BSIT were evaluated using Spearman's correlation coefficient and the sensitivity, specificity, and accuracy of VAS scores were calculated. Logistic regression identified characteristics associated with accurate assessment of olfactory function. RESULTS: A total of 81 polymerase chain reaction (PCR)-confirmed COVID-19 positive subjects, of whom 54 self-reported smell loss, were prospectively recruited ≤5 days from diagnosis date between May 8, 2020, and July 8, 2020. Self-reported smell loss had good discriminative ability in identifying abnormal BSIT (area under receiver operating curve [AUC] 0.82, 95% confidence interval [CI], 0.71 to 0.92). A VAS <5 demonstrated sensitivity of 0.62 and specificity of 0.94 for predicting hyposmia (BSIT ≤8) with accuracy of 82.7%, whereas a VAS <9 had highest sensitivity at 0.86. Moderate bivariate linear associations were found between VAS and BSIT scores (rs = 0.59, p < 0.001). CONCLUSION: Self-reported olfactory loss associated with COVID-19 has a strong ability to predict abnormal olfactory function though the 2 measures are moderately correlated. Subjective olfactory assessment is useful in screening olfactory dysfunction at early disease time points when psychophysical testing cannot be conducted.

Elective neck dissection for T3/T4 cN0 sinonasal squamous cell carcinoma.

BACKGROUND: In locally advanced sinonasal squamous cell carcinoma (SNSCC), management of the clinically node-negative (cN0) neck is variable and elective neck dissection (END) remains controversial. METHODS: Patients with surgically treated T3/T4 cN0 M0 SNSCC were identified using the NCDB. Overall survival (OS) was assessed by Cox proportional hazard analysis in propensity score-matched cohorts. Factors associated with END were evaluated with logistic regression. RESULTS: Two hundred twenty patients underwent END (19.6%). END did not correlated with OS in propensity score-matched cohorts (HR 0.971, 95% CI 0.677-1.392), a maxillary sinus tumor subgroup (HR 1.089, 95% CI 0.742-1.599), or by radiation status [radiation: (HR 0.802, 95% CI 0.584-1.102); no radiation: (HR 0.852, 95% CI 0.502-1.445)]. The occult metastasis rate in the END cohort was 12.7%. CONCLUSION: END did not significantly improve OS in this study. Further information on disease-free survival is necessary to determine its role in advanced-stage SNSCC.

Advances in facial nerve management in the head and neck cancer patient.

PURPOSE OF REVIEW: The purpose of this review is to summarize best practices in facial nerve management for patients with head and neck cancer. In addition, we provide a review of recent literature on novel innovations and techniques in facial reanimation surgery. RECENT FINDINGS: Although recommended when tumor ablation surgery requires facial nerve sacrifice, facial reanimation procedures are not always performed. Concurrent dynamic facial reanimation with masseteric nerve transfers and cable graft repair can preserve native facial muscle function. Static suspension can provide facial support and immediate resting symmetry for patients. Eyelid weight and eye care should not be delayed, particularly in patients with trigeminal sensory deficits. Choice of neural source to innervate a gracilis-free muscle transfer for smile reanimation remains controversial; however, new techniques, such as dual innervation and multivector muscle transfer, may improve aesthetic and functional outcomes. SUMMARY: Management of the facial nerve in the setting of head and neck cancer presents unique challenges. When possible, simultaneous oncologic resection and facial reanimation is ideal given the open surgical field, newly dissected and electrically stimulatable facial nerve branches, as well as minimizing postoperative healing time to prevent postsurgical treatment delays. A coordinated approach to facial nerve management with a multidisciplinary surgical team may help provide optimal, comprehensive care.