Early outcomes of osteofascial versus osteocutaneous fibula free flap mandibular reconstruction.

BACKGROUND: This study compares early outcomes of osteofascial fibula free flap (OF-FFF) with donor-site primary closure and osteocutaneous (OC) FFF with donor-site skin grafting in segmental mandibular reconstruction. METHODS: A retrospective chart review of FFF mandibular reconstruction patients (2006-2022) divided into OF-FFF and OC-FFF groups. Clinical data, operative parameters, and early postoperative outcomes (≤ 90 days) were analyzed. RESULTS: The study included 67 patients (39 OF-FFF, 28 OC-FFF). OF-FFF had significantly lower donor-site complications (12.8% vs. 53.6%, p < 0.001) and revision surgeries (7.7% vs. 35.7%, p = 0.004) compared to OC-FFF. Recipient-site (28.2% vs. 25%, p = 0.77) and flap (15.4% vs. 17.9%, p > 0.99) complications were comparable. CONCLUSIONS: OF-FFF mandibular reconstruction with donor-site primary closure is a safe and reliable technique associated with superior donor-site and comparable flap and recipient-site outcomes to OC-FFF, thus may be considered as a viable alternative to OC-FFF for selected patients.

Impact of pretreatment body mass index on the survival of head and neck cancer patients.

BACKGROUND: Differences in pretreatment body mass index (BMI) have been associated with survival in squamous cell carcinoma of head and neck (SCCHN). We examined effects of BMI on survival in SCCHN patients after stratifying patients by tumor human papillomavirus (HPV) status and subsite. METHODS: Totally 2204 SCCHN patients in a prospective study were included in this secondary analysis. Multivariable Cox models were used to evaluate associations between pretreatment BMI and overall survival, disease-specific survival, and disease-free survival. RESULTS: BMI was significantly higher among patients with HPV-positive tumors than HPV-negative tumors. BMI >25 kg/m2 was associated with improved survival, while BMI <18.5 kg/m2 was associated with reduced survival, particularly in patients with HPV-positive oropharyngeal cancer tumors. CONCLUSIONS: This exploratory analysis suggests that pretreatment BMI could be an independent prognostic factor of survival outcomes in SCCHN patients, particularly in patients with HPV-positive oropharyngeal cancer tumors. Further prospective investigations are warranted.

The Feasibility and Outcome of Integra® Bilayer Matrix in the Reconstruction of Oral Cavity Defects.

OBJECTIVE: To evaluate the feasibility, safety, and failure rate of Integra® Bilayer Wound Matrix (Integra) in the reconstruction of oral cavity defects. STUDY DESIGN: Retrospective cohort study. SETTING: All study information was collected from a single academic tertiary care hospital. METHODS: Subjects included adult patients who underwent oral cavity resection and immediate subsequent reconstruction with Integra® Bilayer Wound Matrix at MD Anderson Cancer Center between the years 2015 and 2020. The following variables were collected: patient's demographics, comorbidities, disease stage, treatment and reconstruction modalities, and surgical outcome from the medical records. Statistical analysis included distribution analysis for all collected parameters and Pearson's χ2 tests to find correlation between variables and take rate of Integra. RESULTS: Eighty-three patients underwent reconstruction with Integra® Bilayer Wound Matrix dressing. Average age was 66 years old. Thirty-nine patients (47%) had history of previous resections for oral cavity tumors. Fourteen patients (17%) had history of radiation therapy to the Head and Neck region. Most common pathology was invasive squamous cell carcinoma (75%) followed by dysplasia (12%). Complete wound healing with good cellular integration occurred in 83 patients (96%) with only 3 failures requiring additional surgery. Reconstruction of mandibulectomy defects was associated with increased risk of dehiscence and bone exposure (0.66, P = .03). CONCLUSION: This study shows promising results with high take rate of Integra® Bilayer Wound Matrix dressing in the reconstruction of various oral cavity defects. We encourage surgeons to adopt this technique as a viable and versatile option into the reconstruction ladder of oral cavity defects.

Enhanced recovery after surgery, current, and future considerations in head and neck cancer.

Objectives: Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods: Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results: A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion: Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence: 2a.

Opioid versus non-opioid postoperative pain management in otolaryngology.

BACKGROUND: The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC). METHODS: A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017-2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups. RESULTS: The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (p < 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (P < 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (P < 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (P < 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (p < 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (p < 0.0001). Dipyrone was prescribed to 78% of patients in Israel. CONCLUSIONS: HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.

The Prognostic Value and Clinical Utility of the 40-Gene Expression Profile (40-GEP) Test in Cutaneous Squamous Cell Carcinoma: Systematic Review and Meta-Analysis.

BACKGROUND: The current tumor staging systems for cutaneous squamous cell carcinoma (cSCC) are considered inadequate and insufficient for evaluating the risk of metastasis and for identifying patients at high risk of cSCC. This meta-analysis aimed to assess the prognostic significance of a 40-gene expression profile (40-GEP) both independently and integrated with clinicopathologic risk factors and established staging systems (American Joint Committee on Cancer, eighth edition (AJCC8) and Brigham and Women's Hospital (BWH)). METHODS: Electronic databases, including PubMed (MEDLINE), Embase, the Cochrane Library, and Google Scholar, were systematically searched to identify cohort studies and randomized controlled trials on evaluations of the prediction value of 40-GEP in cSCC patients up to January 2023. The metastatic risk analysis of a given 40-GEP class combined with tumor stage and/or other clinicopathologic risk factors was based upon log hazard ratios (HRs) and their standard error (SE). Heterogeneity and subgroup analyses were performed, and data quality was assessed. RESULTS: A total of 1019 patients from three cohort studies were included in this meta-analysis. The overall three-year metastatic-free survival rates were 92.4%, 78.9%, and 45.4% for class 1 (low risk), class 2A (Intermediate risk), and class 2B (high risk) 40-GEP, respectively, indicating a significant variation in survival rates between the risk classification groups. The pooled positive predictive value was significantly higher in class 2B when compared to AJCC8 or BWH. The subgroup analyses demonstrated significant superiority of integrating 40-GEP with clinicopathologic risk factors or AJCC8/BWH, especially for class 2B patients. CONCLUSIONS: The integration of 40-GEP with staging systems can improve the identification of cSCC patients at high risk of metastasis, potentially leading to improved care and outcomes, especially in the high-risk class 2B group.

Comparison of lateral neck X-ray to neck CT in patients with suspicious bone impaction: "Old habits die hard".

OBJECTIVE: Bone impaction (BI) is a common cause for emergency room visits. Among foreign bodies, fish bone is considered the most common. The sensitivity of symptoms in predicting BI is relatively low, making imaging a central tool to aid diagnosis. Current imaging practices include both neck plain film radiography and none-contrast CT scans of the neck. We evaluated the accuracy of neck plain film radiography and CT scans of the neck for the diagnosis of BI. METHODS: Retrospective review of all patients who presented to the emergency room between 2009 and 2016 with a suspicious history of BI whom underwent plain film neck radiography or CT. All Images were reviewed by two neuro-radiologist blinded to the clinical symptoms and findings. Symptoms, clinical findings and images results were compared to the final diagnosis. RESULTS: 89 patients (30.7%), out of 290 patients who presented with complaints of BI, were diagnosed with BI. Mean age was 44.7 years old. Plain film neck radiography failed to predict BI (sen. 14.4%, spe 89.8% accuracy 63.2%), neck CT has an improved accuracy and sensitivity in locating BI (sen. 83.3%, spe. 94.1% accuracy 92.5%). Interobserver agreement between the two neuro-radiologists was moderate (0.46) and substantial (0.77) in neck radiography and CT images, respectively. Neck radiography missed 60 (out of 61) oropharyngeal BI's. CONCLUSION: Neck radiography has high inter-observer variability and low sensitivity for the diagnosis of BI. Neck CT should be the first imaging modality in patients with suspicious complaints for BI and negative physical exam.

Targets for improving disparate head and neck cancer outcomes in the low-income population.

Low-income patients have worse head and neck cancer outcomes than those with high-income. Yet, few targets have been identified to specifically improve outcomes in the low-income population. Here, we conduct a review on the current literature on head and neck cancer outcomes in the low-income population and identify targets for intervention. The degree of disparity is in the range of 20%-90% worse overall survival in the low-income population. Eliminating smoking would have the greatest effect on head and neck cancer mortality rates in the low-income population. Additionally, access to oral cancer exams, assistance with transportation, and continued expansion of telemedicine would facilitate early diagnosis and timely treatment in patients who develop head and neck cancer.

Elective neck dissection versus observation in patients with head and neck cutaneous squamous cell carcinoma.

BACKGROUND: The survival benefit of elective neck dissection (END) for patients with cutaneous squamous cell carcinoma (cSCC) of the head and neck and no evidence of regional metastasis (cN0) has never been reported. The aim of this study was to determine the effect of END on patient survival. METHODS: The authors included patients with head and neck cSCC who had undergone primary surgery from 1995 to 2017. The primary end point was survival, and the secondary end points were the incidence of occult regional disease and regional disease control. To assess the impact of END on survival, the authors used multivariable Cox proportional hazards models with propensity score and matching techniques for internal validation. RESULTS: A total of 1111 patients presented with no evidence of nodal disease; 173 had END, and 938 were observed. Adjuvant radiotherapy to the neck was administered to 101 patients (9%). END resulted in a 5-year overall survival rate of 52%, whereas the rate was 63% in the observation group (P = .003 [log-rank]). The 5-year disease-free survival rate for patients undergoing END was similar to that for the observation group (73% vs 75%; P = .429). A multivariate regression model showed that the performance of END was not associated with improved rates of overall, disease-specific, or disease-free survival; similarly, among patients with advanced disease (T3-4), those who underwent END did not have improved survival rates. CONCLUSIONS: Among patients with cSCC of the head and neck, observation of the neck nodes resulted in noninferior survival rates in comparison with END at the time of primary surgery. Further studies are required to elucidate the role of END in patients with advanced disease.

Early vs. late tracheostomy in ventilated COVID-19 patients - A retrospective study.

BACKGROUND: Tracheostomy is one of the most common surgical procedures performed on ventilated COVID-19 patients, yet the appropriate timing for operating is controversial. OBJECTIVES: Assessing the effect of early tracheostomy on mortality and decannulation; elucidating changes in ventilation parameters, vasopressors and sedatives dosages immediately following the procedure. METHODS: A retrospective cohort of 38 ventilated COVID-19 patients, 19 of them (50%) underwent tracheostomy within 7 days of intubation (early tracheostomy group) and the rest underwent tracheostomy after 8 days or more (late tracheostomy group). RESULTS: Decannulation rates were significantly higher while mortality rates were non-significantly lower in the early tracheostomy group compared with the late tracheostomy group (58% vs 21% p < 0.05; 42% vs 74% p = 0.1, respectively). Tidal volume increased (446 ml vs 483 ml; p = 0.02) while PEEP (13 cmH20 vs 11.6 cmH2O, p = 0.04) decreased at the immediate time following the procedure. No staff member participating in the procedures was infected with SARS-CoV-2 virus. CONCLUSION: Early tracheostomy might offer improved outcomes with higher decannulation rates and lower mortality rates in ventilated COVID-19 patients, yet larger scale studies are needed. Most likely, early exposure to COVID-19 patients with appropriate personal protective equipment during open tracheostomy does not put the surgical team at risk.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Imaging of the age-related anatomical relationship between the innominate artery and the trachea.

PURPOSE: To measure the age-dependent changes of anatomical positions and relations between the trachea, cricoid cartilage (CC), and innominate artery (IA) in adults by computed tomography (CT). METHODS: A retrospective cohort reviewing images of 127 consecutive adult patients who underwent CT angiography (CTA) of the neck. The trachea-to-IA (T-IA) distance was measured as the minimal horizontal distance between them. The vertical distance between the CC and the IA was measured between the axial section, demonstrating the CC's inferior border to the axial section at the level of the T-IA measurement. RESULTS: Images of 125 patients (median age 53 years, range 18-89; 74 males) were reviewed. The mean T-IA distance was 2.3 ± 1.1 mm for males and 1.7 ± 0.9 mm for females (P = 0.002). The vertical C-IA distance was 44.2 ± 11.4 mm and 49.5 ± 12.5 mm for males and females, respectively (P = 0.01). Age correlated negatively with the vertical C-IA distance (P < 0.0001) and positively with the T-IA distance (P < 0.0001). The rate of IA variants was 23.2%, with no significant difference between the measurements of distances among patients with or without IA variants. CONCLUSIONS: This is the first description of the relationships between the trachea, CC, and IA distances in adults as depicted on CTA. The T-IA distance becomes larger while the T-CC distance becomes shorter with age.

Awake Tracheostomy: Indications, Complications and Outcome.

BACKGROUND: Awake tracheostomy (AT) is aimed at securing the airway of patients with upper airway obstruction when other means are not feasible or have failed. Reports on AT in the literature are scarce. The goal of this study was to review our experience with the indications, complications and outcome of AT. METHODS: A retrospective chart review was conducted on all ATs performed between 2010 and 2016 in two university-affiliated, tertiary medical centers. Data on demographics, indications, techniques, urgency and postoperative complications were retrieved from the medical charts. RESULTS: The 37 of the 1023 recorded tracheostomies (3.62%) that were ATs comprised the study group (mean age of the patients 60.3 years, 32 [86.5%] males). The most common indication was head and neck (HN) malignancy (oncologic group, 70.3%), with the larynx (53.8%) being the most commonly involved site. Patients in the non-oncologic group (n = 11) were significantly younger (P = 0.048) and had a significantly higher prevalence of urgent surgery compared to the oncologic group (P = 0.0009). Major postoperative complications included tube dislodgement (n = 2) and pneumothorax (n = 1) that were managed successfully. One of the two patients with severe hypoxia and arrhythmia that necessitated cardiopulmonary resuscitation died. CONCLUSION: Whether the etiology of the AT was related to HN oncological disease or not was the most important clinical factor in our cohort. The non-oncologic group was significantly younger, suffered from more urgent events and tended to have more complications (nonsignificant). ATs had a 97.3% rate of immediate survival, a 5.4% risk of major irreversible complications and a 2.7% risk of mortality.

Recurrent pleomorphic adenoma: is treatment considerably delayed thus affecting surgical morbidity?

OBJECTIVE: To examine the incidence of late presentation of patients with recurrent pleomorphic adenoma (RPA) of the parotid gland. METHODS: This is a retrospective analysis of patients treated in our center. We examined patients demographics, disease characteristics, treatment, and outcome and as well as the time period length from the first discovery of a recurrent mass until seeking treatment at our clinic and its effect on morbidity. RESULTS: A total of 30 patients were included. 26% underwent initial enucleation in other institutions. In eight patients (26%), the recurrence of the mass was second or higher. The patients average time period length until seeking treatment was 2.48 years, with 33% of patients showing a time period length of over three years. Multifocal tumor, tumor diameter larger than 2 cm and facial nerve involvement were found in 15 (50%),16 (53.3%) and seven (25%) patients respectively. Patient's delay of presentation by ≥3 years was associated with a tumor size of ≥2 cm (Relative Risk [RR] = 2, p = .02). Patient's delay of presentation by ≥2 years was also associated with a trend towards a higher rate of post-operative facial nerve palsy (RR = 3.37, p = .07, CI = 0.88-12.85). CONCLUSION: Most patients with RPA were presented late, thus affecting disease extent and surgical morbidity.

Traumatic Perforation of the Tympanic Membrane: A Review of 80 Cases.

BACKGROUND: Traumatic perforation of the tympanic membrane (TPTM) is often encountered in primary care or in the emergency department (ED). Several therapeutic interventions have been described, but conservative follow-up until spontaneous complete recovery is the most common choice. OBJECTIVE: Our goal was to analyze the trauma mechanism, perforation characteristics, and outcome of patients with TPTM. METHODS: The study included patients examined in the ED of a tertiary, university-affiliated medical center because of TPTM between 2012 and 2016. Their medical records were retrospectively reviewed for demographics, trauma mechanism, clinical characteristics, and outcome. A phone survey was performed to obtain the missing information of all the patients who did not continue their follow-up in our outpatient clinic. RESULTS: We reviewed the histories of 80 patients with a mean age of 26.7 ± 14.6 years (20 children; 25%). TPTM was caused by blunt trauma in 45 patients (56%) and penetrating trauma in 35 patients (44%). Thirty-five patients (44%) completed their follow-up in the hospital outpatient clinic, with a mean duration of 6.2 weeks. Twenty-five patients (38%) completed their follow-up in a community-based otolaryngology clinic, 6 patients (9%) chose not to complete their follow-up, and 14 patients were lost to follow-up. Of the 60 patients who completed follow-up, 56 patients recovered spontaneously, 3 patients underwent successful tympanoplasty, and 1 patient was referred to surgery but was lost to follow-up. All children healed spontaneously. CONCLUSION: TPTM was more common in young males with main mechanisms of blunt trauma (an assault) or cleaning the ear canal. All children demonstrated complete spontaneous recovery.

Transcanal Endoscopic Ear Surgery for Middle Ear Cholesteatoma.

OBJECTIVE: To evaluate the clinical parameters, outcomes, and complications of transcanal endoscopic ear surgeries for middle ear cholesteatoma. STUDY DESIGN: Retrospective study. SETTING: Tertiary university-affiliated medical center. PATIENTS: Adult patients (age >18) who underwent transcanal endoscopic ear surgeries for cholesteatoma, between March 2009 and March 2015. INTERVENTION: Transcanal endoscopic surgery was indicated when the cholesteatoma did not extend posterior to the anterior limb of the lateral semicircular canal. Rigid endoscopes 4 and 2.7 mm in diameter, 0, 30, 45, and 70 degrees were used with angled picks, suction, and forceps.Preoperative assessment included high-resolution computed tomography of the temporal bones and/or non echo-planar diffusion-weighted magnetic resonance imaging and pure-tone audiometry. MAIN OUTCOME MEASURES: Residual or recurrent disease was diagnosed by clinical examination and/or magnetic resonance imaging findings consistent with cholesteatoma. Intra- and postoperative complications, pre- and postoperative audiometric results were recorded. RESULTS: Sixty operations (56 patients, mean age = 43.6) were included.Six operations (10%) were performed under local anesthesia. The most common sites of cholesteatoma involvement were: posterior epitympanum (n = 51, 91%), anterior epitympanum (n = 19, 33.9%), posterior mesotympanum (n = 13, 23.2%), and sinus tympani (n = 11, 19.6%). Intraoperative ossicular chain reconstruction was performed in 18 (30%) cases.Our overall residual and recurrence rates were 10% (n = 6) and 8.3% (n = 5), respectively, with mean duration of follow up of 35 months. The most common sites of residual disease were the mastoid cavity/antrum (n = 3, 50%), tympanic cavity, and posterior mesotympanum. Overall minor and major complication rates were 16.6 and 6%, respectively. CONCLUSIONS: Transcanal endoscopic ear surgery was found to be an acceptable and safe technique for the exposure and eradication of middle ear and/or attic cholesteatoma.