Microvascular reconstruction of midface osteoradionecrosis.

BACKGROUND: Head and neck osteoradionecrosis (ORN) of the midface requiring free flap (FF) reconstruction is uncommon. This multi-institutional study was designed to review outcomes for this rare patient population. METHODS: Retrospective multi-institutional review of FF reconstruction for midface ORN (2005-2022; n = 54). RESULTS: The FF survival rate was 87% (n = 54). Patients were less likely to be tolerating a regular diet at 3 months postoperative if they had a preoperative history of prior head and surgery (80% vs. 95%; p = 0.02), a pathologic fracture (50% vs. 90%; p = 0.04), exposed bone intraorally (43% vs. 94%; p = 0.002), or a fistula (67% vs. 96%; p = 0.03). Mean albumin was higher in patients whose FF survived (3.6 ± 0.5 vs. 2.7 ± 1.4; p = 0.03). Patients with low prealbumin were more likely to undergo a hematoma evacuation (27% vs. 0%; p = 0.02). CONCLUSION: In this series of midface ORN requiring FF reconstruction preoperative nutritional status impacted postoperative complications. Preoperative occurrence of a fistula, pathologic fracture, and intraoral bone exposure correlated with decreased tolerance of a regular diet following reconstruction.

Early and Late Complications of Mandibulectomy Free Flap Reconstruction: Does the Selective Use of Soft Tissue Only Flaps Reduce Complications?

PURPOSE: This study aims to evaluate the factors most associated with early and late complications following microvascular free tissue transfer (MVFTT) after mandibulectomy. METHODS: A retrospective review of patients undergoing MVFTT after segmental mandibulectomy from September 2016 to February 2021 was performed across a single academic institution. Surgical variables were collected, including the location of the resultant mandibular defect (anterior vs posterior) and flap type (osseous or non-osseous). The primary outcome variables included postoperative complications (early, <90 days; and late, >90 days) and the patients' functional status (return to oral intake). Descriptive statistics, chi-square test, Fischer's exact test, and 2-sample t tests were used to analyze differences among variables. RESULTS: We analyzed a cohort of 114 consecutive patients with mandibular defects, comprising 57 anterior and 57 posterior defects. Bony free flaps with hardware were used to reconstruct 98% of anterior defects compared to 58% of posterior defects (P < .001). All soft tissue only flaps did not utilize any hardware during the reconstruction. Anterior defects demonstrated more late complications requiring additional surgery (30% vs 9%, P = .04). A secondary analysis of posterior mandibular reconstructions compared soft tissue only flaps and bony free flaps with hardware and showed equivalent rates of early (12% vs 13%, P > .99) and late (9% vs 8%, P > .99) complications requiring additional surgery while demonstrating a similar return to full oral competence (55% vs 46%, P = .52) and recovery of a 100% oral diet (67% vs 54%, P = .53). CONCLUSION: Osseous free tissue transfer for segmental mandibular defects remains the gold standard in reconstruction. In our patient cohort, anterior mandibular defects are associated with greater late (>90 day) complications requiring additional surgery. Comparable outcomes may be achieved with soft tissue only versus osseous free flap reconstruction of posterior mandibular defects.

A novel risk score for predicting prolonged length of stay following pediatric kidney transplant.

BACKGROUND: Kidney transplants (KT) are accepted as the kidney replacement therapy of choice for children with kidney failure. The surgery itself may be more difficult especially in small children, and often leads to significant hospital stays. There is little research on predicting prolonged length of stay (LOS) in children. We aim to examine the factors associated with prolonged LOS following pediatric KT to help clinicians make informed decisions, better counsel families, and potentially reduce preventable causes of prolonged stay. METHODS: We retrospectively analyzed the United Network for Organ Sharing database for all KT recipients less than 18 years old between January 2014 and July 2022 (n = 3693). Donor and recipient factors were tested in univariate and multivariate logistic analysis using stepwise elimination of non-significant factors to create a final regression model predicting LOS longer than 14 days. Values were assigned to significant factors to create risk scores for each individual patient. RESULTS: In the final model, only primary diagnosis of focal segmental glomerulosclerosis, dialysis prior to KT, geographic region, and recipient weight prior to KT were significant predictors of LOS longer than 14 days. The C-statistic of the model is 0.7308. The C-statistic of the risk score is 0.7221. CONCLUSIONS: Knowledge of the risk factors affecting prolonged LOS following pediatric KT can help identify patients at risk of increased resource use and potential hospital-acquired complications. Using our index, we identified some of these specific risk factors and created a risk score that can stratify pediatric recipients into low, medium, or high risk groups. A higher resolution version of the Graphical abstract is available as Supplementary information.

Factors Impacting Discharge Destination Following Head and Neck Microvascular Reconstruction.

OBJECTIVE: Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction. STUDY DESIGN: Retrospective review of prospectively collected databases. METHODS: Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n = 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death). RESULTS: The mean age of patients discharged home was lower (60 SD ± 13, n = 1450) compared to those discharged to an SNF (68 SD ± 14, n = 168) or a rehabilitation facility (71 SD ± 14, n = 200; p < 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p < 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p < 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p = 0.006), thromboembolism (59% vs. 80%; p = 0.001), a pulmonary complication (46% vs. 81%; p < 0.0001), a cardiac complication (46% vs. 80%; p < 0.0001), or a cerebral vascular event (25% vs. 80%; p < 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty-day readmission rates were similar when stratified by discharge destination. CONCLUSION: There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:95-104, 2023.

Age and Comorbidities Impact Medical Complications and Mortality Following Free Flap Reconstruction.

OBJECTIVE: Determine if age correlated with surgical or medical complications following head and neck free flap reconstruction. STUDY DESIGN: Retrospective review of prospectively collected databases. METHODS: Patients undergoing head and neck free flap reconstruction at three tertiary care institutions were included (n = 1972). Cohorts were based on age (<65, 65-75, 75-85, and >85). Outcomes reviewed operative duration, length of stay, surgical complications (free flap failure, fistula, hematoma, dehiscence, and infection), and medical complications (thromboembolism, stroke, cardiac, and pulmonary). RESULTS: Anatomic site (P < .0001) and donor site varied by age (P < .0001). There was no difference in operative duration (P = .3) or length of hospitalization (P = .8) by age. The incidence of medical complications increased with increasing age. Pulmonary complication rates: <65 (3.9%), 65 to 75 (4.8%), 75 to 85 (7.1%), and >85 (11%) (P = .02). Cardiac complication rates: <65 (2.0%), 65 to 75 (7.3%), 75 to 85 (6.1%), and >85 (16.4%) (P < .0001). Mortality increased with age: <65 (0.4%), 65 to 75 (0.8%), 75 to 85 (1.1%), and >85 (4.1%) (P < .003). Medical complications correlated with mortality rates: pulmonary (3.5% vs. 0.6%; OR: 5.5; 95% CI: 1.5-20.0; P = .004); cardiac (3.3% vs. 0.6%; OR: 6.0; 95% CI: 1.6-21.8; P = .002); thromboembolism (4.6% vs. 0.7%; OR: 7.3; 95% CI: 1.6-33.6; P = .003); stroke (42% vs. 0.5%; OR: 149; 95% CI: 40-558; P < .0001); and sepsis (5% vs. 0.7%; OR 7.5; 95% CI: 1.0-60.5; P = .03). Age did not correlate with free flap success (P = .5), surgical complications (hematoma, P = .33; fistula, P = .23; infection, P = .07; and dehiscence, P = .37), or thirty-day readmission (P = .3). CONCLUSION: Following free flap reconstruction, patient age did not correlate with development of a surgical complication. Patient age did correlate with development of a medical complication. Postoperative medical complications were found to correlate with perioperative mortality. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:772-780, 2022.

Impact of preoperative and intraoperative management on outcomes in osteoradionecrosis requiring free flap reconstruction.

BACKGROUND: Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and outcomes. METHODS: Multi-institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n = 260). RESULTS: Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p = 0.03) and 30-day readmission (p = 0.04). Patients with FF compromise had higher TSH (p = 0.04) and lower albumin levels (p = 0.005). Prealbumin levels were lower in patients who required neck washouts (p = 0.02) or a second FF (p = 0.03). TSH levels were higher in patients undergoing postoperative debridement (p = 0.03) or local flap procedures (p = 0.04). CONCLUSION: Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.

Microvascular Reconstruction of Osteonecrosis: Assessment of Long-term Quality of Life.

OBJECTIVE: Review long-term clinical and quality-of-life outcomes following free flap reconstruction for osteonecrosis. STUDY DESIGN: Retrospective multi-institutional review. SETTING: Tertiary care centers. METHODS: Patients included those undergoing free flap reconstructions for osteonecrosis of the head and neck (N = 232). Data included demographics, defect, donor site, radiation history, perioperative management, diet status, recurrence rates, and long-term quality-of-life outcomes. Quality-of-life outcomes were measured using the University of Washington Quality of Life (UW-QOL) survey. RESULTS: Overall flap success rate was 91% (n = 212). Relative to preoperative diet, 15% reported improved diet function at 3 months following reconstruction and 26% at 5 years. Osteonecrosis recurred in 14% of patients (32/232); median time to onset was 11 months. Cancer recurrence occurred in 13% of patients (29/232); median time to onset was 34 months. Results from the UW-QOL questionnaire were as follows: no pain (45%), minor or no change in appearance (69%), return to baseline endurance level (37%), no limitations in recreation (40%), no changes in swallowing following reconstruction (28%), minor or no limitations in mastication (29%), minor or no speech difficulties (93%), no changes in shoulder function (84%), normal taste function (19%), normal saliva production (27%), generally excellent mood (44%), and no or minimal anxiety about cancer (94%). CONCLUSION: The majority of patients maintained or had advancement in diet following reconstruction, with low rates of osteonecrosis or cancer recurrence and above-average scores on UW-QOL survey suggesting good return of function and quality of life.

Retro-Auricular Thyroidectomy: An Open Approach.

Distant access robot-assisted thyroidectomy has gained popularity in recent years. Adoption of distant access procedures has been limited by cost, need for specialized training and expertise. We report our preliminary clinical experience with our modification of the retro-auricular thyroidectomy approach that allows adequate exposure for thyroid lobectomy without robotic or endoscopic assistance. This is a retrospective chart review of ten patients who have undergone retro-auricular thyroidectomies in the absence of robotic or endoscopic assistance. Ten patients were identified to have undergone this procedure over an 18-month period. All patients were female with average age 36 years (range 27-52). Six were right sided and 4 were left sided procedures. The average gland size was 4.2 cm (range 3.7-6 cm). The average nodule size was 2.1 cm (range 1.1-3.5 cm). The average operative time was 91 min (range 76-114 min). All patients had benign pathology on final histopathology. There were no conversions to open cervical thyroidectomy. Two patients had vocal cord paresis that resolved spontaneously. The average postoperative follow up was 3 months (range 1-7 months). Our technique for retro-auricular thyroidectomy is a safe, reproducible, and cost effective option for remote access thyroidectomy.

Choices of capture chromatography technology in antibody manufacturing processes.

The capture process employed in monoclonal antibody downstream purification is not only the most critically impacted process by increased antibody titer resulting from optimized mammalian cell culture expression systems, but also the most important purification step in determining overall process throughput, product quality, and economics. Advances in separation technology for capturing antibodies from complex feedstocks have been one focus of downstream purification process innovation for past 10 years. In this study, we evaluated new generation chromatography resins used in the antibody capture process including Protein A, cation exchange, and mixed mode chromatography to address the benefits and unique challenges posed by each chromatography approach. Our results demonstrate the benefit of improved binding capacity of new generation Protein A resins, address the concern of high concentration surge caused aggregation when using new generation cation exchange resins with over 100mg/mL binding capacity, and highlight the potential of multimodal cation exchange resins for capture process design. The new landscape of capture chromatography technologies provides options to achieve overall downstream purification outcome with high product quality and process efficiency.

Secondary tracheoesophageal puncture using transnasal esophagoscopy in gastric pull-up reconstruction after total laryngopharyngoesophagectomy.

BACKGROUND: There is debate about the optimal voice restoration method and technique for patients who have undergone total laryngopharyngectomy, esophagectomy, and gastric pull-up. The purpose of this study was to report a series of patients who underwent awake, secondary tracheoesophageal puncture (TEP) after this procedure. METHODS: A retrospective chart review was performed at a tertiary referral center. All subjects who underwent TEP placement under transnasal esophagoscopy guidance between 2003 and 2013 were included. RESULTS: All patients underwent uncomplicated TEP in the clinic. At the time of last follow-up, all patients had functional TEP speech that they were using preferentially over an available electrolarynx. CONCLUSION: In-office placement of secondary TEP using transnasal esophagoscopy is an efficient means of providing a conduit for voice prostheses in patients who have undergone laryngopharyngectomy with gastric pull up reconstruction. This procedure can be performed with minimal complications and with expectation of voice outcomes comparable to that seen with standard laryngectomy.

Mucosal melanoma of the middle ear cavity and Eustachian tube: a case report, literature review, and focus on surgical technique.

OBJECTIVE: To present a case of mucosal melanoma of the Eustachian tube with a focus on surgical technique and to review the literature on treatment of mucosal melanoma of the head and neck, and review cases involving the middle ear and/or Eustachian tube. PATIENT: A 67-year-old man was diagnosed with mucosal melanoma of the middle ear and Eustachian tube. INTERVENTION: The patient underwent primary surgical resection including transtemporal/transpetrosal approach, endoscopic nasopharyngectomy, infratemporal fossa dissection, temporomandibular joint resection, ipsilateral neck dissection (levels II-IV), and superficial parotidectomy. RESULTS: The patient was discharged on postoperative Day 7 with a very good functional status. He did have early dysphagia and dysarthria as a result of the VII to XII anastomosis for facial nerve reconstruction, which did require PEG tube placement. However, at 4 months after surgery, the patient was eating solid foods and returning to normal activities. He received radiation therapy postoperatively. There has been no evidence of tumor recurrence at 8 months after treatment. CONCLUSION: The standard treatment of head and neck mucosal melanoma is primarily surgical. Surgical removal of mucosal melanoma in the Eustachian tube/middle ear can present challenges in achieving microscopically negative margins. However, gross tumor resection with postoperative radiotherapy has been shown to improve locoregional control.

Robotic-assisted transoral removal of a bilateral floor of mouth ranulas.

OBJECTIVE: To describe the management of bilateral oral ranulas with the use of the da Vinci Si Surgical System and discuss advantages and disadvantages over traditional transoral resection. STUDY DESIGN: Case Report and Review of Literature. RESULTS: A 47 year old woman presented to our service with an obvious right floor of mouth swelling. Clinical evaluation and computerized tomography scan confirmed a large floor of mouth ranula on the right and an incidental asymptomatic early ranula of the left sublingual gland. After obtaining an informed consent, the patient underwent a right transoral robotic-assisted transoral excision of the ranula and sublingual gland with identification and dissection of the submandibular duct and lingual nerve. The patient had an excellent outcome with no evidence of lingual nerve paresis and a return to oral intake on the first postoperative day. Subsequently, the patient underwent an elective transoral robotic-assisted excision of the incidental ranula on the left sublingual gland. CONCLUSION: We describe the first robotic-assisted excision of bilateral oral ranulas in current literature. The use of the da Vinci system provides excellent visualization, magnification, and dexterity for transoral surgical management of ranulas with preservation of the lingual nerve and Wharton's duct with good functional outcomes. However, the use of the robotic system for anterior floor of mouth surgery in terms of improved surgical outcomes as compared to traditional transoral surgery, long-term recurrence rates, and cost effectiveness needs further validation.

Diagnostic and interventional sialendoscopy: a preliminary experience.

OBJECTIVES/HYPOTHESIS: To review our preliminary experience with diagnostic and therapeutic sialendoscopy for the management of non-neoplastic disorders of the salivary gland. STUDY DESIGN: Retrospective chart review. METHODS: Thirty-three consecutive patients undergoing 36 sialendoscopy procedures performed at a tertiary medical center from July 2008 to July 2010 were included. RESULTS: The mean age of presentation was 43 years (range, 7-74 years), and 61% of patients were male. Indications included sialolithiasis (47%; 17 of 36), recurrent sialadenitis (44%, 16 of 36), and Sjögren's syndrome (8%; three of 36). Successful endoscopy was performed in 97% (35 of 36). A papillotomy for access was necessary in 25% (nine of 36). In patients with sialolithiasis (n = 17), the mean size of the stones was 7.3 mm (range, 1-20 mm). Complete stone removal was achieved in 76% (13 of 17) of cases. Endoscopic stone removal was possible in 29% (five of 17), and a combined approach technique was required in 47% (eight of 17). Seventy-two percent (26 of 36) of patients had complete resolution of symptoms after sialendoscopy, with 19% (seven of 36) having partial resolution of symptoms. Patients with partial improvement of symptoms had a mean duration of improvement of 4.7 months. The overall complication rate was 22% (eight of 36). The major and minor complication rates were 3% (one of 36) and 19% (seven of 36), respectively. CONCLUSIONS: Sialendoscopy is safe and effective in managing non-neoplastic salivary gland disorders with low rates of major complications. Knowledge of options to navigate the rate-limiting steps, like dilation of the papilla and careful case selection, are key to successful outcomes.

Factors affecting access to head and neck cancer care after a natural disaster: a post-Hurricane Katrina survey.

BACKGROUND: Our aim was to survey the factors affecting access to cancer care in patients with head and neck cancer after Hurricane Katrina. METHODS: In this cross-sectional survey, 207 patients with head and neck cancer were identified post-Hurricane Katrina, but only 83 patients completed the questionnaires and were analyzed. Clinical, demographic, and socioeconomic data were recorded. Chi-square test and t test were used for comparisons. RESULTS: Patients who felt that there was a lack of access to cancer care would have sought treatment earlier had they had better access to cancer care (chi-square[1] = 32; p < .0001). Patients who felt that there was a lack of access to cancer care also had difficulty receiving treatment (chi-square[1] = 48; p < .0001). Availability of transportation affected access to cancer care in patients with early-stage cancers (chi-square[1] = 4; p < .035). CONCLUSION: In the postdisaster environment, patients who felt the lack of access to cancer care post-Hurricane Katrina would have sought treatment earlier with better access to cancer care. These patients also reported difficulty obtaining cancer treatment. Availability of transportation affected access to cancer care in patients with early-stage cancers. Clinical, demographic, and socioeconomic factors did not influence access to cancer care.

Applicability of the pittsburgh staging system for advanced cutaneous malignancy of the temporal bone.

The objectives are to evaluate the applicability of the Pittsburgh staging system (PSS) (designed for primary temporal bone malignancies) to advanced periauricular cutaneous malignancies with temporal bone involvement and to study treatment outcomes and prognostic factors predicting recurrence-free survival. Ten patients with advanced periauricular cutaneous malignancy with temporal bone involvement were identified. Patients with primary temporal bone or parotid gland malignancies were excluded. All patients were clinically T4 at presentation by the American Joint Committee on Cancer (AJCC) staging system. Using Pittsburgh staging, six were T1 (stage I) and four were T4 (stage III). The mean follow-up was 13.6 months (3 to 24 months). Patients with basal cell carcinoma were managed with wide local excision and lateral temporal bone resection (WLE/LTBR) without adjuvant therapy. Two of three (66%) are alive and free of disease; one patient died of other causes. Treatment for squamous cell carcinoma patients involved multimodality therapy. Kaplan-Meier survival curves show a worse prognosis in terms of disease-specific survival for patients with higher-staged PSS tumors. This did not reach statistical significance. The PSS may provide additional prognostic information on advanced cutaneous malignancies of the temporal bone over the more widely used AJCC staging system. However, further prospective multicenter studies with larger sample size are required to validate our findings. Basal cell carcinoma was well controlled with WLE/LTBR alone without adjuvant therapy, whereas squamous cell carcinoma required multimodality therapy: WLE/LTBR and postoperative radiation with or without chemotherapy.