A cross-sectional survey of patient attitudes towards telemedicine in head and neck surgical oncology.

OBJECTIVE: To investigate patient attitudes towards desire for and barriers to utilizing telemedicine visits for head and neck oncology care. METHODS: This is a retrospective analysis of data from cross-sectional survey responses collected via prospectively administered questionnaire to 616 adult patients during their clinical visit to a tertiary care head and neck surgical oncology clinic. Responses to questions investigating interest in telemedicine and potential barriers were collated with patient demographics, measures of rurality, and insurance status. Interest in telemedicine appointments was the assessed primary outcome. RESULTS: Of 616 survey respondents, 315 (51 %) indicated interest in telemedicine visits. Limitations in access to technology (17.5 %) and lack of reliable internet connection (13.14 %) were identified as key barriers to telemedicine use. Lack of interest in telemedicine was associated with older age (OR 0.97 [95%CI 0.96-0.98]), governmental insurance (0.43 [0.31-0.60]) and, retired work status (0.48 [0.33-0.69]). Women (1.43 [1.04-1.97]) and patients who reported access to compatible electronic devices (41.05 [14.88-113.20]) and reliable internet connection (20.94 [8.34-52.60]) were more likely to be interested in telemedicine appointments. Respondents also indicated preference for a "hands on" examination over telemedicine appointments. CONCLUSION: Nearly 1 in 2 patients evaluated in a tertiary care head and neck surgical oncology clinic expressed reticence regarding telemedicine for clinical visits. Limited access to technology platforms and unreliable internet remain key concerns for these patients. Understanding the needs and attitudes of specific patient populations may be important for organizations pivoting to telemedicine platforms to ensure equity in healthcare access. LEVEL OF EVIDENCE: Retrospective analysis of prospectively collected cross-sectional survey.

Development of the Head and Neck Cancer Caregiving Task Inventory.

PURPOSE: Family caregivers provide vital support for patients with head and neck cancer (HNC), yet few studies have focused on HNC caregiving. Our objective was to develop and conduct initial validation of the HNC Caregiving Task Inventory, an instrument to characterize caregiving task burden in the HNC population. METHODS: This 5-phase instrument development project involved the conceptualization of caregiving task burden (Phase 1), initial instrument development (Phase 2), assessment of content validity through expert panel review (Phase 3), assessment of face validity through family caregiver review (Phase 4), and preliminary validation in a sample of 106 family caregivers (Phase 5). RESULTS: We identified 11 domains of the HNC caregiving role and caregiving tasks for each domain. In Phase 3, the experts deemed all tasks relevant to HNC family caregiving. No tasks were eliminated and 19 were added. In Phase 4, family caregiver feedback indicated that the tasks were comprehensive and relevant. Wording and formatting changes were made and one task was added. In Phase 5, we evaluated discrimination of responses to derive a final version comprised of 58 tasks in 11 domains. Kuder-Richardson values for domains with ≥3 items ranged from 0.65 to 0.94. Associations were generally high with the Caregiving Burden Scale, moderate with the Caregiver Reaction Assessment and Profile of Mood States-Short Form, and low or non-existent with the Preparedness Scale. CONCLUSION: Convergent and divergent validity were supported. The HNC Caregiving Task Inventory can be used to evaluate caregiving task burden across the treatment trajectory and identify targets for intervention.

AlloDerm with split-thickness skin graft for coverage of the forearm free flap donor site.

OBJECTIVE: Major causes of donor site morbidity after free flap harvest are lack of split-thickness skin graft (STSG) take and tendon exposure. Long-term cosmesis remains poor. AlloDerm has shown cosmetically better donor site healing, albeit prolonged healing. We sought to evaluate the use of STSG with AlloDerm compared with STSG alone. STUDY DESIGN: Case series with chart review. SETTING: Academic tertiary care medical center. METHODS AND SUBJECTS: Institutional review board-approved study. Microvascular database queried from 2002 to 2012. Subjects with forearm free flaps and either AlloDerm + STSG or STSG alone for donor site reconstruction were included. Morbidity outcomes were compared. RESULTS: Eighty patients (50 male, 30 female) received AlloDerm + STSG at the donor site. Major and minor donor site complications were 15.0% and 18.8% in the AlloDerm + STSG group compared with 10.2% and 16.9% in the STSG-only group (P = .30 and P = .72), respectively. Complete STSG loss (5.0% vs 3.0%, P = .48), tendon exposure (5.0% vs 5.4%, P = 1.0), functional impairment (2.5% vs 1.8%, P = .66), infection (8.8% vs 9.6%, P = 1.0), hematoma/seroma (5.0% vs 3.6%, P = .73), and paresthesia (1.3% vs 3.6%, P = .43) were not significant. No patients required a second STSG after loss in the AlloDerm + STSG group compared with 60% (P = .17). Cosmetic results were superior in the AlloDerm + STSG group as rated by the surgeon (3.5 vs 2.6, P = .03) and patients (3.7 vs 2.9, P = .05) on a scale of 1 to 5. CONCLUSION: Our results suggest that the use of AlloDerm with STSG can provide thicker coverage of the forearm defect, with minimal donor site morbidity and superior cosmetic results compared with STSG alone.

Efficacy of free flap reconstruction of the head and neck in patients 90 years and older.

OBJECTIVE: To determine the efficacy of free flap reconstruction in patients 90 years and older. DESIGN: Retrospective medical chart review. SETTING: Academic medical center. PATIENTS: Patients 90 years and older who underwent a free flap reconstruction from 2002 through 2011 were identified. MAIN OUTCOME MEASURES: Clinical, demographic, and procedural data were recorded. Complications of surgery were either medical or flap related. Long-term follow-up was recorded to determine late flap complications, donor site morbidity, and functional outcomes. RESULTS: Of 847 free flaps, 10 (1.2%) were performed in patients 90 years and older, with a median follow-up time of 8.5 months. Four medical complications (40%) occurred (1 case of pneumonia and 3 cases of arrhythmia). There were no mortalities. Two recipient site complications (20%) occurred (1 infection and 1 fistula). The flap failure rate was 0%. One late complication developed 7 months postoperatively involving infection and nonunion of the mandibular reconstruction. There was donor site morbidity in 1 patient. Functional status returned to baseline in 8 patients (80%) at the last follow-up visit. CONCLUSIONS: Medical and flap-related complications in patients 90 years and older are consistent with rates previously reported in elderly patients. Furthermore, patients 90 years and older can tolerate free flap reconstruction with favorable long-term outcomes.

Immunoglobulin G4-related sclerosing disease of the paranasal sinus.

BACKGROUND: Immunoglobulin G4 (IgG4)-related sclerosing disease is a systemic disease characterized by extensive IgG4-positive plasma cells and T-lymphocyte infiltration of various organs. We present a case of a 69-year-old man with maxillary sinus IgG4 sclerosing disease, with orbital invasion treated with rituximab and dexamethasone pulse therapy. Surgery was used as well to debulk the disease and to obtain tissue for diagnosis. METHODS: A PubMed search using the key phrase "IgG4-related Sclerosing Disease" was performed. There were 304 different articles regarding the disease for a multitude of different organ sites. Of the 304 articles, there were 3 articles that reported this disease in the paranasal sinuses. CONCLUSIONS: IgG4-related sclerosing disease is a rare entity in the head and neck. There are documented reports of steroid therapy for this disease, but the patient presented here demonstrated clinical progression of disease with steroids alone. The use of combination therapy of surgery, dexamethasone, and rituximab provided clinical improvement and stable disease determined by radiographic means.

Abnormal anatomy of the superficial branch of the radial nerve.

BACKGROUND: The superficial branch of the radial nerve is frequently encountered when performing the harvest for a radial forearm free tissue transfer. METHODS AND RESULTS: We present an abnormal course of this nerve which has not been described in the literature. During a harvest of a radial forearm free flap, we encountered a nerve that was not deep to the brachioradialis muscle in the proximal arm; rather, the superficial branch of the radial nerve was found to be superficial to this muscle through its entire course. An in-depth literature review was performed, and there was no documented abnormality identified resembling the abnormality we encountered. CONCLUSION: Knowledge of the normal and abnormal anatomy is essential for the microvascular surgeon to assure the safety of this nerve.

Buried free flaps in head and neck surgery: outcome analysis.

BACKGROUND: Over the last several decades, reconstruction of the head and neck oncologic defect has been revolutionized by the use of microvascular free tissue transfer. The majority of these defects can be reconstructed with the ability to visually monitor the flap, to intervene as soon as vascular compromise becomes evident. Occasionally, it is necessary to use a flap that has no visual external monitor: a buried free flap. A belief has circulated within the microvascular community that buried free flaps do not do as well as visible flaps. By our review, there are no recent data in the literature to support this position. We present our data on the outcomes of buried free flaps in microvascular reconstruction. METHODS: A single institutional retrospective review of 1492 flaps was performed between January 1999 and December 2011. A total of 103 free flaps (7.2%) were identified as meeting the criteria for a buried flap. It should be noted that all flaps with or without an external segment were monitored with an implantable Doppler. The flap failure and complications are defined as those failures or complications occurring within 2 weeks of surgery and related to the operation or to the flap itself. RESULTS: In all, 5 of the 103 patients (4.9%) had complications requiring reoperative intervention. There were no instances of flap failure within the first 2 weeks of surgery. CONCLUSION: In our series, there are no differences in flap failure rates comparing buried flaps to externally monitored flaps.