The use of Montgomery salivary bypass tubes and pharyngocutaneous fistula following salvage laryngectomy.

Objectives: Pharyngocutaneous fistula (PCF) is the most common complication to follow total laryngectomy (TL) and is associated with increases in length of hospital stay and with a need for revision surgery or readmission, as well as with delays in return to oral diet. Patients who require salvage TL (STL) or primary (chemo)radiation therapy are at higher risk for developing PCF. Due to the quality-of-life burden of PCF on patients, limiting this occurrence is crucial. Methods: We conducted a retrospective cohort study of patients undergoing STL with placement of Montgomery salivary bypass tube (MSBT)™ for at least 2 weeks duration between 2013 and 2017 at a single institution. Our patients all underwent free flap reconstruction. Our primary outcome of interest was development of PCF. Secondary outcomes included demographics, previous treatment, base of tongue (BOT) involvement, extent of defect, concurrent neck dissection (ND), and margin status. Univariate χ 2 analysis was used to evaluate factors associated with PCF. Results: Forty-four patients underwent STL with Montgomery tube placement and free flap reconstruction. Eight developed PCF (18.2%). The average age was 61.6 years; 36 patients were male (81.8%), whereas eight patients were female (18.2%). There was no association between PCF and previous chemoradiation versus radiation (15.8% vs. 33.3%, P < 0.30), BOT involvement versus not (11.1 vs. 22.2%, P < 0.38), circumferential versus partial defect (18.8% vs. 17.9%, P < 0.94), ND versus none (10% vs. 25%, P < 0.20), or margin status. Conclusion: PCF complicated 18.2% of STL cases at our institution and was not associated with differences in primary treatment modality, presence of concomitant ND, extent of pharyngeal defect, BOT involvement, or positive frozen or permanent surgical margin.

Head and Neck Ultrasound Utilization Rates: 2012 to 2019.

Objective: We measured utilization of clinician-performed head and neck ultrasound among otolaryngologists, endocrinologists, and general surgeons, using Medicare Provider Utilization and Payment Data. Study Design: Retrospective analysis of Medicare billing database. Setting: University. Methods: For each year, the files were filtered to include 4 provider types: Diagnostic Radiology (DR), Endocrinology (ENDO), General Surgery (GS), and Otolaryngology (OTO). Billable procedures are listed by Healthcare Common Procedure Coding System code and a filter was applied to include 76536 Ultrasound, soft tissues of the head and neck. Results: In 2019, OTOs submitted charges for 2.1% of all head and neck diagnostic ultrasounds (76536) performed on Medicare beneficiaries. For each year 2012 to 2019, DRs submitted the most charges, followed by ENDOs, and then OTO and GS. Charges for all groups increased in a proportional manner across the 8-year period. 14.5% of OTOs submitted more than 100 charges apiece during 2019, that is, "super users." The percentage of super users within each specialty increased from 2012 to 2019. Overall, the data support an ever-increasing use of head and neck ultrasound (HNUS) among all provider types. Conclusion: Even with increased use among OTOs, this specialty only accounted for a small percentage of head & neck diagnostic ultrasounds performed on Medicare beneficiaries in 2019. Changes in volume of nonradiology point-of-care HNUS was not associated with changes in DR volume. A greater proportion of OTOs than DRs are "super users" among the ultrasound users within their specialty, performing more than 100 exams/year. Level of Evidence: V.

Oropharyngeal Squamous Cell Carcinoma Outcomes by p16INK4a Antigen Status in a Veteran Population.

Background: The correlation between head and neck squamous cell carcinoma (SCC) and human papillomavirus (HPV) has been of great interest. We aimed to study immunoexpression of the p16INK4a (p16) antigen, a surrogate marker for high-risk HPV infection, in oropharyngeal SCC among veterans to estimate HPV-related cancer and survival. Secondary aims included stratification of race and ethnicity, degree of tobacco and alcohol use, tumor location, stage, and age at diagnosis. Methods: A retrospective electronic health record review was performed between January 1, 2000, and December 31, 2008, at a tertiary-level US Department of Veterans Affairs (VA) medical center for veterans who were treated for oropharyngeal SCC, had follow-up for a minimum of 2 years, and for whom paraffin-embedded tissue was available. Paraffin-embedded tissue was analyzed for p16 expression. Results: We identified 66 veterans who met the inclusion criteria. p16 expression was observed in 29% of the patients. All patients were male with no difference in age at diagnosis between the groups. Among patients with p16-negative status, 60% were African American, whereas among patients with p16-postive status, 32% were African American (P = .04). Among patients with p16-postive status, 22% were tobacco-naïve, and 18% were alcohol-naïve vs 0% and 4%, respectively, of patients with p16-negative status (P = .005 and P = .12, respectively). Two-year survival was the same for both groups (P = .52). Conclusions: We observed p16 expression in 29% of VA patients with oropharnygeal SCC, which was less than observed in non-VA populations. At presentation, both groups demonstrated a predilection for tonsil location and late stage without significant difference in age or disease-specific survival. Disparities in racial distribution and tobacco use between patients with and without p16-positive status appear like that reported in non-VA populations; however, the frequently reported younger age at presentation, lower stage, and improved prognosis were not observed.

Calcinosis of the internal jugular vein: Interesting presentation of tertiary hyperparathyroidism.

Tumoral calcinosis is a severe complication of hemodialysis. A 49-year-old male on dialysis for end-stage renal disease developed a large calcified retropharyngeal mass. This caused stridor and dyspnea, necessitating an emergency awake tracheostomy. This is the first report of internal jugular vein calcinosis. Surgery is recommended.

Is there Really a Lump in My Throat? The Incidence and Implication of Vocal fold Abnormalities in Patients Presenting with Globus.

OBJECTIVE: To identify the prevalence of vocal fold abnormalities in patients with a primary complaint of globus sensation. Secondly, to determine the relationship between globus, vocal fold abnormality, and patient-reported quality of life questionnaire score. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was performed to identify all new patients evaluated at a tertiary academic care laryngology practice between January 2018 and December 2018 presenting with a chief complaint of globus. Variables of interest include age, gender, laryngeal symptoms, self-reported quality-of-life questionnaire results, and laryngostroboscopy findings. Questionnaires selected for this investigation include the reflux symptom index (RSI), eating assessment tool-10 (EAT-10), and voice handicap index-10 (VHI-10). RESULTS: Two hundred twenty-eight subjects with an average age of 54 ±17 years, were categorized based on one of three laryngostroboscopic findings: absence of vocal fold abnormality, vocal fold paresis/paralysis (motion abnormality), or a vocal fold mass lesion. Fifty percent of patients reporting globus had a normal laryngeal exam, and 50% had a mass lesion or motion abnormality. Twenty five percent had vocal fold motion abnormality (paresis, paralysis, or supraglottic squeeze); 19% had a mass lesion; and 3% had both a lesion and motion abnormality. The average self-reported survey scores were compared among the three groups. Patients with dysphonia had a significantly higher VHI-10 (P = 0.00), and a significantly higher RSI (P =  0.00) than those without dysphonia. Those patients with dysphagia had significantly higher EAT-10 (P = 0.00) and RSI (P = 0.02) scores than those who did not have dysphagia. Patients with vocal fold motion abnormality had significantly higher VHI-10 than those with normal vocal fold mobility (P = 0.02) CONCLUSIONS: Identifying the etiology of globus presents a significant challenge to laryngologists. Data presented here suggest that vocal fold abnormalities may contribute to the sensation of globus and should therefore be considered in the differential when managing these patients.

Blue man: Ochronosis in Otolaryngology.

Blue discoloration of the skin and cartilage, or ochronosis, is a rare physical examination finding. We present two cases of childhood onset ochronosis, one exogenous and one endogenous in etiology. The first was caused by minocycline use for severe acne, and the second was caused by congenital alkaptonuria.

The submental flap: Be wary.

The submental island flap (SIF) is as an alternative to free flaps in head and neck reconstruction. 10 patients underwent submental flaps. All ten patients suffered failure of SIF as the definitive reconstructive procedure. Despite comparing favorably to free tissue transfer in published reports, our SIF had high failure rate.

Factors predictive of an academic otolaryngologist's scholarly impact.

OBJECTIVES: Describe the h index as a bibliometric that can be utilized to objectively evaluate scholarly impact. Identify which otolaryngology subspecialties are the most scholarly. Describe if NIH funding to one's choice of medical school, residency, or fellowship has any impact on one's scholarly output. Determine other factors predictive of an academic otolaryngologist's productivity. STUDY DESIGN: Analysis of bibliometric data of academic otolaryngologists. METHODS: Active grants from the National Institutes of Health (NIH) to otolaryngology departments were ascertained via the NIH Research Portfolio Online Reporting Tools Expenditures and Reports database. Faculty listings from these departments were gleaned from departmental websites. H index was calculated using the Scopus database. RESULTS: Forty-seven otolaryngology programs were actively receiving NIH funding. There were 838 faculty members from those departments who had a mean h index of 9.61. Otology (h index 12.50) and head and neck (h index 11.96) were significantly (P < 0.0001) more scholarly than the rest of subspecialists. H index was significantly correlative (P < 0.0001) with degree of NIH funding at a given institution. H index was not significantly higher for those that attended medical school (P < 0.18), residency (P < 0.16), and fellowship (P < 0.16) at institutions with NIH funding to otolaryngology departments. CONCLUSIONS: H index is a bibliometric that can be used to assess scholarly impact. Otology and head and neck are the most scholarly subspecialists within otolaryngology. NIH funding to an individual's medical school, residency, or fellowship of origin is not correlative with one's scholarly impact, but current institutional affiliation and choice of subspecialty are.

Contained hypopharyngeal and cervical esophageal perforation masquerading as retropharyngeal abscess.

It is possible to have a spontaneous hypopharyngeal and cervical esophageal perforation following yelling. We believe our case is the first study showing such an event, which can become catastrophic if not addressed in a timely manner.

The utility of intraoperative nerve monitoring in secondary and tertiary Hyperparathyroid surgery.

OBJECTIVES: Recurrent laryngeal nerve (RLN) injury is a well-known complication of parathyroid surgery. Despite ample data, there is still uncertainty about the role of intraoperative monitoring (IONM) in mitigating RLN damage. STUDY DESIGN: A retrospective review. METHODS: We included all patients presenting for total, subtotal, or completion parathyroidectomy at a tertiary referral hospital from 2013 to 2018. Information about demographics, previous neck surgery, perioperative data, pathology, and possible RLN injury was collected. Two groups were formed for analysis: IONM vs. nonmonitored (NM). RESULTS: 105 patients underwent 107 surgeries with IONM utilized in 71 cases. The groups were similar in demographics, but significantly differed (all P < 0.05) in preincision parathyroid hormone level (IONM = 2091.44 vs NM = 1334.87), surgery type (IONM = 62.9% vs NM = 27.8% subtotal), and surgery length in minutes (IONM = 155.21 vs NM = 182.22). We observed six cases (6/71 = 8.45%) of persistent RLN complaints (three or more weeks postoperatively) and four cases (4/71 = 5.63%) of temporary complaints with the use of IONM compared with only one temporary complaint (1/36 = 2.78%) in unmonitored procedures (P = 0.129). CONCLUSIONS: These results suggest that the use of IONM does not provide a protective effect on the RLN in patients with secondary or tertiary hyperparathyroidism undergoing total, subtotal, or completion parathyroidectomy. Prospective, randomized studies with pre- and postoperative flexible laryngoscopy are needed to explore the use of IONM in this patient population further.

Awake ECMO without anticoagulation for nearly completely obstructive squamous cell carcinoma of the trachea.

Awake veno-venous ECMO without anticoagulation is a safe and successful way to remove a significantly obstructive malignancy in the trachea.

Chyloma formation after anterior cervical disc fusion.

Chyle leak from iatrogenic thoracic duct injury is a rare but serious complication of head and neck surgery. The chyloma in this case took months to recognize and required open thoracic ligation. He fully recovered.

False Identity: Lymphoid Hyperplasia Imitating a Large Paraganglioma.

The danger of the parapharyngeal space mass comes from the small space and vital neighboring structures. Its differential diagnosis is broad, however benign lymphoid hyperplasia in this region has not been previously reported. The clinical presentation, imaging, surgical findings and pathology slides were reviewed in an adult patient with a parapharyngeal space mass. The literature on somatostatin-positive parapharyngeal space lesions was reviewed. A 51-year old male with otalgia for 3 months, hearing loss, and tinnitus underwent audiogram, revealing asymmetric hearing loss. Laryngoscopy demonstrated a paretic true vocal cord. Subsequent MRI demonstrated 4.5 cm post-styloid parapharyngeal space mass displacing the carotid artery anterolaterally. Octreoscan scan showed significant uptake of the somatostatin analog. Angiogram showed prominent vascular blush. The mass was excised transcervically and histopathology demonstrated lymphoid hyperplasia. This case demonstrates that post-styloid parapharyngeal masses may be lateral retropharyngeal nodes. An octreotide-positive lymphoid hyperplasia has never been previously reported.

The effect of intrathyroidal versus intraperitoneal bevacizumab on thyroid volume and vasculature flow in a rat model.

BACKGROUND: Several clinical conditions increase thyroid gland vascularity, impacting surgical blood loss. Bevacizumab has been observed to reduce thyroid function, possibly through its effect on gland angiogenesis. This study aimed to determine if bevacizumab has any effect on thyroid vascularity as measured by gland volume and superior thyroid artery (STA) flow velocity in the normal rat thyroid. METHODS: Sixteen adult female Sprague-Dawley rats were placed under general anesthesia to measure baseline thyroid gland characteristics. A Vevo 2100 high-frequency ultrasound with 40 mHz transducer was used to obtain STA flow measurements and thyroid gland dimensions. Four rats served as controls. Six rats received intrathyroidal (IT) injections and 6 received intraperitoneal (IP) injections of bevacizumab (4-5 mg/kg). After two weeks ultrasound measurements were repeated. RESULTS: Pretreatment animals displayed similar thyroid volume and vascularity. Thyroid volume decreased (62.583 vs. 42.161, P=0.004) after IP administration of bevacizumab, and blood flow measurements did not change [peak velocity 75.896 vs. 76.7, P=0.96, average velocity 45.748 vs. 43.867, P=0.88, or resistivity index (RI) 30.345 vs. 25.32, P=0.60]. IT bevacizumab did not change thyroid volume (55.229 vs. 58.16, P=0.64). The average peak (73.191 vs. 100.589 cm/s, P=0.03) and mean (45.047 vs. 62.843 m/s, P=0.03) velocities were increased, but did not differ in the RI (0.619 vs. 0.632, P=0.82). No differences were noted on VEGF or CD 31 immunohistochemical analysis. CONCLUSIONS: Single systemic administration of bevacizumab appears to decrease thyroid volume without an effect on STA flow, VEGF or CD31 staining. These preliminary findings support further study of pharmacologic intervention in thyroid conditions characterized by increased angiogenesis and vascularity, such as iodine deficiency, Graves disease, and hypothyroidism.

An Unusual Cause of Epistaxis: Paranasal Sinus Myeloid Sarcoma.

We report a case of a 65-year-old female who presented with right-sided headaches, blurring of vision in the right eye, cold-induced epistaxis, and facial numbness in the trigeminal nerve distribution. Laboratory studies revealed a significant number of myeloblasts on peripheral smear with granulated cytoplasm, irregular nuclei, and prominent vacuoles. Magnetic resonance imaging (MRI) of the brain demonstrated a T1-enhancing 1.5 cm right-sided dural-based lesion involving the medial sphenoid wing, cavernous sinus, infratemporal fossa, and sphenoid sinus region. An endoscopic biopsy of the lesion within the sphenoid sinus confirmed the diagnosis of myeloid sarcoma, with myeloblasts comprising 30% of cellularity by flow cytometry. A subsequent bone marrow biopsy revealed a hypercellular marrow with 23% blasts by flow cytometry that demonstrated a similar immunophenotypic pattern to those seen in the sinus mass. Fluorescence in situ hybridization (FISH) testing revealed the balanced translocation t(8;21)(q22;q22.1), consistent with a diagnosis of acute myeloid leukemia with RUNX1-RUNX1T1-balanced translocation by WHO 2016 criteria. Myeloid sarcoma represents a rare extramedullary presentation of acute myeloid leukemia (AML), either alone or in conjunction with blood or bone marrow involvement. This case emphasizes the need for a broad differential diagnosis and an aggressive work-up for any unusual paranasal sinus mass.

Validation of ultrasound as a diagnostic tool to assess vocal cord motion in an animal feasibility study.

BACKGROUND: Post-thyroidectomy dysphonia can result from recurrent laryngeal nerve (RLN) injury. Confirmation of postoperative recurrent nerve function has prompted many surgeons to advocate laryngoscopic examination. Indirect and flexible laryngoscopy permit visualization of vocal cord motion, but not all thyroid surgeons are skilled in these techniques. Indirect laryngoscopy has a significant failure rate due to gag reflexes or anatomical obstruction. Flexible fiberoptic laryngoscopy, the current gold standard, allows reliable visualization of the cords, but perioperative examination is not always feasible for lack of equipment or training. Recent studies suggest vocal fold ultrasound as an alternative to flexible laryngoscopy. It offers the advantages of being non-invasive and painless without radiation exposure or sedation. Whereas ultrasound has been compared to laryngoscopy in the clinical setting, there remains a need for correlation of laryngeal ultrasound results with known neurophysiology in the normal and injured state. An animal model was proposed that reproduces neck surgery-associated recurrent nerve injury. The model allowed simultaneous recording of laryngeal endoscopy and transcutaneous high-resolution ultrasound during stimulation of intact and injured RLNs. METHODS: One RLN was injured in each of 4 rats. Rats were kept anesthetized during the fiberoptic examination and laryngeal ultrasound procedures. Following surgery and subsequent imaging the rats were given a lethal anesthetic dose. Results of both imaging modalities were compared to the presence or absence of neuromuscular action potential following stimulation of the recurrent nerve. RESULTS: The investigators observed a 100% correlation between endoscopic and ultrasonographic assessments. CONCLUSIONS: This study validated the clinical use of diagnostic ultrasound in vocal cord dysfunction in a rodent model.

Anterior skull base duplication requiring delivery via EXIT procedure: A case report.

Duplication of the anterior skull base structures is an extremely rare malformation of failed midline blastogenesis. We present the case of a child with an obstructive oral cavity mass diagnosed on prenatal imaging. The child was successfully delivered by EXIT procedure, a tracheotomy was performed, and postnatal imaging demonstrated an array of craniofacial malformations, including complete duplication of the maxilla, pituitary glands, aqueducts of Sylvius, and basilar arteries. The child underwent excision of the duplicate maxilla, resulting in a wide cleft palate that will be repaired at a future date.

Management protocol for primary hyperparathyroidism in a single institution: utility of surgeon performed ultrasound.

BACKGROUND: We aimed to: (I) discover preoperative diagnostic studies, intraoperative techniques, and patient factors most predictive of cure within a single hospital system; (II) establish practice guidelines for surgical treatment of primary hyperparathyroidism to maximize outcomes based on this hospital system's performance. METHODS: A retrospective chart review was undertaken of all parathyroid-related procedures from 01/01/02 to 7/31/15 at the Veteran's Administration Hospital. RESULTS: Seventy-one patients were eligible and charts available for analysis. Preoperative studies most predictive of cure were a combination of sestamibi parathyroid scan and surgeon performed ultrasound (S-US). When studies did not agree, S-US was most often correct. Intraoperative parathyroid hormone (PTH) rapid assay was helpful in predicting cure, but added an average of 33 minutes to operating room time. Patients who had two corroborating preoperative localizing studies, one of which was S-US, that agreed with intraoperative findings, and who did not undergo intraoperative PTH confirmation enjoyed equal cure rates and shorter operating room times. Successful achievement of normal calcium was high at 95.8%. Vitamin D deficiency was prevalent in this patient population, prompting more aggressive preoperative investigation and replacement. CONCLUSIONS: A management protocol was developed based on the findings of this study: (I) obtain two preoperative localization studies, one of which is surgeon-performed ultrasound; (II) obtain preoperative vitamin D levels and supplement as indicated; and (III) in select patients who have two strongly corroborating preoperative localization studies, one of which is surgeon performed ultrasound, and intraoperative findings are consistent with the localizing studies, intraoperative PTH (IOPTH) may not be necessary.

Endovascular Extraction of a Needle from the Internal Carotid Artery: A Novel Approach to a Controversial Dental Misadventure.

Objective To review the literature concerning the management of dental needles broken off into the deep spaces of the neck, to report what we believe is the first case of a fractured dental needle migrating into the jugular foramen, and the unconventional use of endovascular intervention to retrieve the needle fragment. Design Case report with review of literature. Setting Academic tertiary care center. Participants Intervention was performed by the otolaryngology-head and neck surgery, vascular surgery, and neurovascular interventional radiology teams. Results Transoral exploration, including palatal split and exposure of the poststyloid parapharyngeal space with C-arm image guidance, was unable to retrieve the broken needle, which traversed the internal carotid lumen with the distal end entering the jugular foramen. Through endovascular intervention, the neurovascular interventional radiology team captured the proximal end of the needle and retrieved it through the femoral artery. The patient recovered uneventfully. Conclusion Fracture and loss of oral injection needles remain a persistent and preventable problem. This case demonstrates a novel, minimally invasive, well-tolerated, and successful method to extract a fractured needle that migrated into the lumen of the internal carotid artery at the level of the skull base.

Histopathological and postoperative behavioral comparison of rodent oral tongue resection: fiber-enabled CO2 laser versus electrocautery.

OBJECTIVE: To compare operative time and hemostasis of fiber-enabled CO(2) laser (FECL) energy to that of the electrocautery (EC) technique for oral tongue resection, to compare return to oral intake and preoperative weight after FECL and EC resection, and to compare histologic changes in adjacent tissue after FECL and EC resection. STUDY DESIGN: Prospective animal study. SETTING: Research laboratory. SUBJECTS AND METHODS: The CO(2) laser fiber and the Bovie cautery were each used to resect the anterior tongue in 15 adult rats. Fixative perfusion and killing were performed on postoperative day 0 (n = 10), 3 (n = 10), or 7 (n = 10). Body weight, food intake, and water intake were recorded daily for 3- and 7-day survival rats. After preparation for histologic analysis, the tongue tissue was graded with a mucosal wound-healing scale (MWHS). RESULTS: A higher incidence of intraoperative bleeding and shorter operative times were noted in the EC group. No statistically significant difference in postoperative food or water intake between the EC and FECL groups was noted. The FECL group returned to baseline weight by postoperative day 6. MWHS scores were lower in the EC group by postoperative day 3 and lower in the FECL group by postoperative day 7. CONCLUSIONS: Both EC and FECL are effective for resection of the tongue in rats. EC has the advantage of shorter operative time and lower MWHS scores by postoperative day 3; FECL has the advantages of less intraoperative bleeding, faster return to baseline body weight, and lower MWHS score by postoperative day 7.