Ultrasonic Shears Decrease Postoperative Hematomas in Head and Neck Microvascular Reconstruction.

OBJECTIVE: To evaluate postoperative hematoma and takeback rates in a large series of microvascular reconstructions. We sought to determine whether the use of ultrasonic shears reduced these rates. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral hospital. METHODS: A total of 2288 patients undergoing free flap reconstruction for head and neck defects between 1995 and 2022 were reviewed. Patients undergoing dissection with and without ultrasonic shears were compared to determine postoperative hematoma and takeback rates. RESULTS: The overall hematoma rate was 1.3% (29/2288) for the entire cohort. The postoperative hematoma rates with and without ultrasonic shears were 0.63% (9/1418) and 2.3% (20/870), relative risk = 0.28, P = .0015. Of 870 patients undergoing surgery without ultrasonic shears, 14 (1.61%) were taken back to the operating room for control of bleeding compared to 8 of 1418 (0.56%) in the ultrasonic shears cohort. CONCLUSION: Our large series of patients undergoing microvascular reconstruction shows a decrease in postoperative hematoma rate and takeback for bleeding with the adoption of ultrasonic shears. Ultrasonic shears are an effective tool that can help decrease perioperative morbidity secondary to hematoma after head and neck tumor resection and microvascular reconstruction.

Diferentes técnicas para colocação de enxerto de extensão caudal em rinoplastia / Different techniques for caudal extension graft placement in rhinoplasty

Resumo Introdução: O enxerto de extensão caudal é geralmente um enxerto de cartilagem que se sobrepõe à margem caudal do septo nasal. Uma combinação do enxerto de extensão caudal e a técnica de tongue-in-groove é usada para estabilizar a base nasal, definir a projeção da ponta e refinar a relação alar-columelar. Objetivo: Apresentar algumas novas modificações na colocação dos enxertos de extensão caudal na rinoplastia. Método: Revisão retrospectiva de um banco de dados prospectivamente coletado de 965 pacientes que se submeteram a rinosseptoplastia de junho de 2011 a julho de 2015. Desses, 457 pacientes necessitaram de enxerto de extensão caudal e foram incluídos no estudo. O seguimento mínimo foi de 13,2 meses, com tempo médio de seguimento de 17,4 meses. Resultados: Na maioria dos casos, a comparação das fotografias antes e após a cirurgia foi satisfatória e apresentou melhora do contorno. Pequenas deformidades foram detectadas em 41 pacientes e 11 pacientes necessitaram de cirurgia de revisão. Conclusão: Com essas modificações, o cirurgião pode usar o enxerto de extensão caudal mesmo em desvios angulares do septo caudal. Vários métodos têm sido propostos para correção do desvio septo-caudal.

The Effectiveness of Skeletal Reconstruction in Severe Post-Rhinoplasty Nasal Deformity.

BACKGROUND: Revision rhinoplasty in patients with multiple prior surgeries is among the most challenging procedures in facial plastic surgery. Evaluating patient satisfaction in this unique patient population is important in determining which technique is effective. OBJECTIVES: The aim of this study was to determine the outcomes of total nasal skeletal reconstruction in patients with severe post-rhinoplasty deformity due to multiple previous revision surgeries. METHODS: A retrospective medical record analysis of ambulatory surgery and hospital databases was performed relating to rhinoplasty patients between April 2014 and December 2018. Patient demographics, surgical technique, and functional and aesthetic outcome assessment data were retrieved. Patients' functional satisfaction was measured with the Nasal Obstruction Symptom Evaluation (NOSE) instrument, and the Rhinoplasty Outcome Evaluation (ROE) instrument was used to evaluate cosmetic results. RESULTS: A total of 253 revision rhinoplasties were extracted. Of these, 25 patients were revision cases with total skeletal reconstruction. The patients had undergone a mean of 3.2 previous rhinoplasties. Mean [standard deviation] preoperative ROE and NOSE scores were 6.36 [3.69] and 80.33 [12.02], respectively. Septum, tip, dorsum, and side walls were reconstructed in all cases. The mean postoperative ROE and NOSE scores after 1 year were 17.27 [4.67] and 53.33 [19.80], respectively, which represented a statistically significant improvement (P < 0.001). CONCLUSIONS: Having the knowledge and experience to perform total nasal skeletal reconstruction by rebuilding an unsalvageable nose leads to long-standing satisfactory functional and aesthetic results.

Different techniques for caudal extension graft placement in rhinoplasty.

INTRODUCTION: The caudal extension graft is usually a cartilage graft that overlaps the caudal margin of the nasal septum. A combination of the caudal extension graft and the tongue-in-groove technique is used to stabilize the nasal base, set tip projection, and refine the alar-columellar relationship. OBJECTIVES: In this study we present some new modifications to the placement of caudal extension grafts in rhinoplasty. METHODS: This study is a retrospective review of a prospectively collected database of 965 patients who underwent septorhinoplasty from June 2011 to July 2015. Of these, 457 patients required a caudal extension graft and were included in the study. Minimum follow-up was 13.2 months with a mean follow-up time of 17.4 months. RESULTS: In most cases, comparison of photographs before and after surgery were satisfactory and showed improved contour. Minor deformity was detected in 41 patients and 11 patients needed revision surgery. CONCLUSION: With these modifications the surgeon can employ the caudal extension graft even in angulated caudal septal deviations. A variety of methods have been proposed for correction of caudal nasal deviation.

Outcome of rhinoplasty in patients undergoing autospreader flaps without notable dorsal hump reduction: A clinical trial.

BACKGROUND: Reconstruction of the nasal midvault is an important component of successful rhinoplasty outcomes. Use of the autospreader flap is a beneficial technique for preserving the middle vault. In the present study, we evaluated the esthetic and functional outcomes of this technique in patients without notable dorsal hump reduction. METHODOLOGY: A nonrandomized clinical trial was performed from December 2017 to April 2018 with a minimum follow-up time of 6 months. From among patients seeking rhinoplasty, 38 were eligible for inclusion in the study. The autospreader flap was used to recreate the middle vault in patients undergoing open rhinoplasty, with up to 2 mm bony and cartilaginous dorsal hump removal. Preoperative and postoperative standard photographs were obtained. Assessment of patients was based on Rhinoplasty Outcome Evaluation (ROE) and Nasal Obstruction Symptom Evaluation Scale (NOSE) scores. Objective assessment included quantitative analysis of anthropometric angles, mean dorsal width, nasal length, and projection which was performed on standard pre- and postoperative photos. RESULTS: Overall, the patients had statistically significant improvement in their postoperative NOSE scores (9 vs. 6.92, p = 0.0001). The majority of patients were satisfied with the postoperative appearance of their noses. The mean nasal dorsal width (NDW) decreased postoperatively (43% vs. 36%). No difference was found between the mean height of the nose and projection pre- and postoperatively. There was a significant postoperative increase in the nasolabial angle and reduction in nasal length. CONCLUSIONS: The autospreader flap is an effective technique for preservation and restoration of the middle vault and dorsal esthetic line in cases of less than 2 mm dorsal hump reduction. Nasal function can be improved while achieving good cosmetic outcomes.

The Bony Cartilaginous Unit.

To achieve an acceptable result in septorhinoplasty, sufficient septal cartilage is needed. There are many cases in which septal cartilage is insufficient, especially in revision surgery or in some races such as Asian. To obtain an ideal outcome, a bony cartilaginous unit (septal cartilage/ethmoid bone composite graft) is proposed as a versatile graft for different purpose such as caudal extension graft.

Dynamic Optical Contrast Imaging.

The variable location and indistinct features of parathyroid glands can make their intraoperative identification challenging. Currently, there exists no routine use of localization methods during surgery. Dynamic optical contrast imaging (DOCI) leverages a novel realization of temporally dependent measurements of tissue autofluorescence that allows the acquisition of specific tissue properties. A prospective series of patients with primary hyperparathyroidism was examined. Parathyroid lesions and surrounding tissues were collected; fluorescence decay images were acquired via DOCI. Ex vivo samples (81 patients) were processed for histologic assessment. DOCI extracts relative fluorescence decay information in a surgically relevant field of view with a clinically accessible acquisition time <2 minutes. Analysis of DOCI revealed microscopic characterization sufficient for tissue type identification consistent with histology ( P < .05). DOCI is capable of efficiently distinguishing parathyroid tissue from adjacent tissues. Such an intraoperative tool would be transformative, helping surgeons to identify lesions, preserve healthy tissue, and improve patient outcomes.

Dynamic optical contrast imaging as a novel modality for rapidly distinguishing head and neck squamous cell carcinoma from surrounding normal tissue.

BACKGROUND: Head and neck squamous cell carcinomas (HNSCCs) are debilitating diseases for which a patient's prognosis depends heavily on complete tumor resection. Currently, the surgeon's fingers determine the location of tissue margins. This study evaluated the diagnostic utility of a novel imaging modality, dynamic optical contrast imaging (DOCI), in the detection of HNSCC. This system generates contrast by illuminating the tissue with pulsed light and detecting variations in endogenous fluorophore lifetimes. METHODS: A total of 47 fresh ex vivo samples from 15 patients were imaged with the DOCI system immediately after surgical resection. DOCI maps were analyzed to determine the statistical significance of contrast between tumors and adjacent nonmalignant tissue. Pilot intraoperative clinical data were also acquired. RESULTS: Statistical significance (P < .05) between muscle and tumor was established for 10 of 10 emission wavelengths, between collagen and tumor for 8 of 10 emission wavelengths, and between fat and tumor for 2 of 10 wavelengths. The system extracted relative fluorescence decay information in a surgically relevant field of view in <2 minutes. CONCLUSIONS: This study demonstrates the feasibility of using DOCI to rapidly and accurately distinguish HNSCC from surrounding normal tissue. An analysis of DOCI images revealed microscopic characterization sufficient for tissue-type identification consistent with histology. Such an intraoperative tool would be transformative by allowing the rapid delineation of tumor tissue from nontumor tissue and thus maximizing the efficacy of resection and improving patient outcomes. Cancer 2017;123:879-86. © 2016 American Cancer Society.

IMRT for head and neck cancer: Cost implications.

OBJECTIVES: Intensity-modulated radiotherapy (IMRT) is a dose-delivery technology allowing for a reduction in radiotherapy side effects. It has been rapidly adopted despite the lack of prospective studies showing improved outcomes. We sought to compare the cost through Medicare reimbursement patterns of surgery, IMRT, and conventional XRT in treating head and neck cancer. We then identified factors that correlate with these differences. METHODS: Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data were examined to determine treatment patterns for 47,237 patients with head and neck carcinoma from 2000 to 2007. We identified 14,748 patients that met our inclusion criteria. We then compared cost related to head and neck cancer treatments on the basis of Medicare payments. RESULTS: From 2000 to 2007, the usage of IMRT increased from 1.5% to 48.6% while the usage of conventional XRT decreased from 98.5% to 51.4% (p<0.0001). During this time, patients undergoing IMRT had a mean cost of $101,099 compared to $42,843 for XRT. For patients with early stage tumors, surgery alone cost $18,140, traditional XRT $32,296 while IMRT cost $95,047 (p<0.0001). When removing patients who underwent concomitant chemotherapy, patients treated with IMRT cost $67,576 compared to $24,955 for non-IMRT patients (p<0.0001). CONCLUSIONS: IMRT has become widely adopted as a primary treatment modality in head and neck cancer. We demonstrated that IMRT is significantly more costly than traditional treatment for head and neck cancers. Prospective studies investigating the comparative efficacy of IMRT will be needed in order to determine if this increased cost correlates with patient outcomes. LEVEL OF EVIDENCE: 2b.

Facial Paralysis Reconstruction.

Facial nerve paralysis is a devastating condition arising from several causes with severe functional and psychological consequences. Given the complexity of the disease process, management involves a multispecialty, team-oriented approach. This article provides a systematic approach in addressing each specific sequela of this complex problem.

Microvascular reconstruction of segmental mandibular defects without tracheostomy.

OBJECTIVE: To report our experience with mandibular resection and reconstruction using vascularized bone-containing free flaps without an elective tracheostomy. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral hospital center. SUBJECTS AND METHODS: Sixty-six patients undergoing mandibular reconstruction with vascularized bone-containing free flaps without an elective tracheostomy were identified between 1995 and 2013. We describe patient, tumor, and surgical factors and report perioperative outcomes in this population. RESULTS: Most patients underwent fibula free flap reconstruction (n = 61, 92.44%). The 4 most frequent indications for resection were osteoradionecrosis, parotid carcinoma, oral squamous cell carcinoma, and osteomyelitis. Bone defects ranging from 4.0 to 13.0 cm were reconstructed, and associated soft-tissue defects were reconstructed with skin paddle sizes ranging from 24.0 to 450.0 cm(2). There was only 1 patient with a bilateral central mandibular defect, and there were no tongue/pharyngeal soft-tissue defects or bilateral neck dissections. One case required emergent tracheostomy on postoperative day 1, and 2 more patients developed respiratory complications. There were no cases of perioperative death or flap failure. CONCLUSION: Mandibular free flap reconstruction is feasible without an elective tracheostomy in a subset of carefully selected patients without bilateral central mandibular defects, tongue/pharynx defects, or bilateral neck dissection.

Oncologic and functional outcomes of partial laryngeal surgery for intermediate-stage laryngeal cancer.

OBJECTIVE: To evaluate the oncologic and functional outcomes of partial laryngeal surgery (PLS) using transoral laser microsurgery (TLM) and supracricoid laryngectomy (SCL) in patients with intermediate-stage laryngeal squamous cell carcinoma (LSCC). STUDY DESIGN: Historical cohort study. SETTING: Single tertiary care center. SUBJECTS AND METHODS: Retrospective review of oncologic and functional outcomes in intermediate-stage (T2-3/N0-1, stage II and III) LSCC patients who underwent TLM or SCL from 1998 to 2010. RESULTS: Sixty patients were included, of whom 28 (47%) underwent TLM and 32 (53%) underwent SCL. For the entire cohort, 2- and 5-year probabilities were 86.2% (95% confidence interval [CI], 73.0%-93.2%) and 72.9% (95% CI, 52.4%-85.6%), respectively, for overall survival (OS) and 79.3% (95% CI, 65.6%-88.0%) and 62.4% (95% CI, 41.9%-77.4%), respectively, for recurrence-free survival (RFS). There was no difference between the TLM and SCL cohorts in OS (P = .542) or RFS (P = .483). More than 75% of patients avoided adjuvant therapy. Communication Scale and Functional Outcome Swallowing Scale scores at median follow-up of 33 months were 2 or better in 97% and 91% of patients, respectively, reflecting functional voice and swallowing postoperatively. Eighty-eight percent of patients retained a functional larynx. CONCLUSION: PLS provides excellent oncologic and functional outcomes for intermediate-stage LSCC and should be considered an alternative to chemoradiation or total laryngectomy in selected patients.

Prevention and management of dysphonia during anterior cervical spine surgery.

OBJECTIVES/HYPOTHESIS: Dysphonia is a common postoperative complaint following anterior cervical spine surgery (ACSS). The purpose of this study was to analyze voice outcomes following ACSS, to identify risk factors predicting vocal cord impairment, and to develop an algorithm for postoperative management of dysphonic patients. STUDY DESIGN: Retrospective cohort study. METHODS: This was a retrospective review of 815 consecutive patients undergoing ACSS from January 2000 to January 2009. All cases were performed using a team approach with a neurosurgeon and head and neck surgeon. Factors associated with voice change and vocal cord motion impairment were analyzed. RESULTS: The mean age of the cohort was 53 years (range, 13-88 years), with a male-to-female ratio of 1.2. There were 32 of 815 available patients (3.9%) who developed dysphonia following ACSS. Fiberoptic laryngoscopy demonstrated that only nine (1.1%) of these patients had ipsilateral vocal fold motion impairment. Of these nine patients, only one (0.1%) was found to have permanent vocal fold paralysis at 1-year follow-up. Factors that correlated significantly with voice change included kyphosis, revision surgery, and level C6-C7 surgery. Kyphosis was the only independent factor correlating with voice change. CONCLUSIONS: ACSS is a safe surgical procedure with a low incidence of postoperative dysphonia when exposure is provided by a head and neck surgeon. Team performance of ACSS appears to reduce laryngeal complications and optimize the management of temporary or permanent postoperative dysphonia.

Endonasal transpterygoid approach to the infratemporal fossa: correlation of endoscopic and multiplanar CT anatomy.

BACKGROUND: The infratemporal fossa anatomy, from an endoscopic standpoint, is poorly understood. Our purpose was to design an anatomic model that illustrates the anatomy of the infratemporal fossa from the endoscopic standpoint and serves as a training model for surgeons interested in pursuing this endeavor. METHODS: Red and blue silicone dyes were respectively injected into the great vessels of the neck. Digital data acquired from a high resolution CT scan was imported to a navigational system. An endoscopic endonasal dissection of the infratemporal fossa was completed under conditions that mimicked our operating suite. RESULTS: A detailed anatomic dissection of the infratemporal fossa was correlated to the image guidance (navigation) system. This provided a surgical map highlighting critical neurovascular structures and illustrating the potential surgical corridors. CONCLUSION: A thorough understanding of the anatomy of infratemporal fossa from the endoscopic perspective allows the surgeon to plan an adequate corridor.

Positron emission tomography-computed tomography adds to the management of salivary gland malignancies.

OBJECTIVES/HYPOTHESIS: To evaluate the efficacy of combined positron emission tomography-computed tomography (PET-CT) in identifying salivary gland malignancies and to examine the role of PET-CT in the management of these patients. STUDY DESIGN: Retrospective chart review. METHODS: Fifty-five patients with diagnosed salivary gland cancer who had undergone PET-CT scanning were retrospectively reviewed from January 2000 to October 2008. PET-CT scans using intravenous contrast were correlated with clinicopathological information to determine diagnostic accuracy of disease extent. The impact of PET-CT findings on therapeutic management was analyzed. All histopathologic grades were included in the study. RESULTS: Overall, PET-CT demonstrated a sensitivity of 74.4%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 61.5%. PET-CT also identified unrecognized distant metastases in the following sites: six lung, five bone, two distant lymph nodes, and one liver. PET-CT added to management in 26 patients (47.3%), and it was the deciding diagnostic modality in eight patients (14.5%). Of these 26 patients, 14 patients underwent additional surgery. Three patients with recurrence underwent PET-CT scan-directed radiation and/or chemotherapy, whereas nine patients diagnosed with distant disease received palliative treatment. CONCLUSIONS: PET-CT is useful for planning the most appropriate treatment by identifying clinically unrecognized disease. PET-CT shows a high diagnostic accuracy for detecting disease recurrence and distant metastases, thus helping to determine whether patients are candidates for potentially curative or palliative treatment.

Clinical usefulness of positron emission tomography-computed tomography in recurrent thyroid carcinoma.

OBJECTIVES: To determine the efficacy of combined positron emission tomography-computed tomography (PET-CT) in identifying recurrent thyroid cancer and to elucidate its role in the clinical management of thyroid carcinoma. DESIGN: Retrospective study. SETTING: Tertiary care referral academic center. PATIENTS: One hundred twenty-four patients with previously treated thyroid carcinoma who underwent PET-CT. MAIN OUTCOME MEASURES: PET-CT images were correlated with clinicopathologic information. The influence of PET-CT findings on disease status determination and the treatment plan was evaluated. RESULTS: Among 121 patients undergoing iodine I 131 ((131)I) imaging (an (131)I image was unavailable for 3 patients), 80.6% had negative findings on (131)I imaging before undergoing PET-CT. Among 75 patients who had positive findings on PET-CT, 71 were true positive results. Among 49 patients who had negative findings on PET-CT, 32 were true negative results. Therefore, PET-CT demonstrated a sensitivity of 80.7%, specificity of 88.9%, positive predictive value of 94.7%, and negative predictive value of 65.3%. A significant difference was noted in the mean serum thyroglobulin levels between patients with positive vs negative PET-CT findings (192.1 vs 15.0 ng/mL, P = .01) (to convert thyroglobulin level to micrograms per liter, multiply by 1.0). Overall, distant metastases were detected in 20.2% of patients using PET-CT. There was an alteration of the treatment plan in 28.2% of patients as a result of added PET-CT information, and 21.0% of patients underwent additional surgery. CONCLUSIONS: PET-CT is usually performed in patients with thyroid cancer having elevated thyroglobulin levels but non-(131)I-avid tumors and has high diagnostic accuracy for identifying local, regional, and distant metastases. Additional information from PET-CT in patients with (131)I-negative and thyroglobulin-positive tumors frequently guides the clinical management of recurrent thyroid carcinoma.

Incidence and patterns of regional metastasis in early oral squamous cell cancers: feasibility of submandibular gland preservation.

BACKGROUND: We aimed to study the incidence of metastasis to the submandibular gland (SMG) and to establish the oncologic basis of SMG preservation in early-stage cancer of the oral cavity (OSCC). METHODS: This was a retrospective study of 261 patients with OSCC treated primarily with surgery at a tertiary medical center. One hundred thirty-two early-stage (T1-2, N0) OSCCs were further analyzed. RESULTS: The mean age was 59 years with male-to-female sex ratio of 1.4:1. Two hundred sixty-one neck dissections were performed with SMG removal in 253 patients. One patient with an advanced floor of mouth cancer had obvious infiltration of the SMG. Only 2.5% (3 of 116) patients with early-stage OSCC had level I metastasis; none had SMG metastases. CONCLUSION: SMG preservation in early cancers (T1-2, N0) of the oral cavity should be feasible unless there is evidence of direct invasion of the gland or close proximity of the cancer to it.

Ocular outcomes after gold weight placement and facial nerve resection.

OBJECTIVE: To assess the effectiveness of acute gold weight placement after facial nerve resection and to determine the role of concomitant lower eyelid procedures. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: Twenty-two patients who received an upper eyelid gold weight at the time of parotidectomy and facial nerve resection were reviewed to assess ocular outcomes. RESULTS: After gold weight placement, twelve patients (12 of 22, 54.5%) subsequently presented with symptomatic ectropion (n = 9) and/or lagophthalmos (n = 5). Nine patients received a lower eyelid procedure (7 tarsal strips only, 1 tarsal strip combined with a lateral tarsorrhaphy, and 1 lateral tarsorrhaphy only). Six patients, in addition to a gold weight, also underwent a static sling to the midface at the time of facial nerve resection. None of these 6 received a subsequent lower eyelid procedure. Two patients required gold weight upsizing. Two patients required weight removal. CONCLUSIONS: Insertion of 1.2 gm upper eyelid weight with placement of midface sling is recommended at the time of facial nerve resection. Due to the need to tighten the lower eyelid in many of these patients, we now also consider performing a tarsal strip procedure at the time of facial nerve resection in any patient with pre-existing lower lid laxity.

Sialendoscopy and associated complications: a preliminary experience.

OBJECTIVES/HYPOTHESIS: To review our experience with diagnostic and therapeutic sialendoscopy for the management of major salivary gland disorders with respect to complications and also to validate its use in our patient population. STUDY DESIGN: Retrospective chart review. METHODS: We identified 56 consecutive cases of sialendoscopy procedures performed over 2 years in the Department of Otolaryngology at the University of Pittsburgh from July 2005 to August 2007. RESULTS: The mean age of presentation was 43 (range, 7-77) years, with a male to female sex ratio of 1:2. The most common indications included sialolithiasis (52%) followed by salivary gland swelling (16%). The average size of the stones ranged from 2 to 12 mm. The overall success rate for endoscopic stone removal was 74% (14 of 19). Three (3 of 29) patients required a planned combined technique for stone removal. The overall complication rate was 25% (14 of 56). The major and minor complication rates were 2% (1 of 56) and 23% (13 of 56), respectively. CONCLUSIONS: Sialendoscopy is a safe and effective technology for treating major salivary gland disorders. In the early phases of sequential learning, complications rates are significant. However, major complications are infrequent and in general can be salvaged by standard salivary gland surgery.