Idiopathic Subglottic Stenosis: Long-Term Outcomes of Open Surgical Techniques.

Objectives Idiopathic subglottic stenosis (iSGS) is rare, and its cause remains elusive. Treatment options include empiric medical therapy and endoscopic or open surgery. We present our results for open surgical technique. Study Design Case series with chart review (1978-2015). Setting Tertiary academic center. Subjects/Methods Thirty-three patients (32 female; median age, 51 years) met inclusion criteria and underwent cricotracheal resection with thyrotracheal anastomosis, tracheal resection with primary anastomosis, or laryngotracheoplasty with rib grafting. Continuous variables were summarized using medians and ranges while categorical features are presented using frequency counts and percentages. Results Sixteen patients (48%) underwent a single-stage approach with immediate extubation or temporary intubation following surgery (median, 1 day; range, 1-3 days). Seventeen patients (52%) underwent a double-staged approach with a median time to decannulation of 35 days (range, 13-100 days). Twenty-four (73%) patients underwent a previous intervention. Median stay in the intensive care unit was 1 day (range, 0-3 days), with a median hospital stay of 4 days (range, 2-7 days). Recurrence requiring further surgical intervention was observed in 12 patients (36%). The median time to recurrence was 8 years over an average follow-up of 9.7 years. The most common complaint following surgery was change in voice quality (fair to poor; n = 10; 30%). Conclusions Open surgery should be reserved for refractory cases of iSGS; cricotracheal resection with thyrotracheal anastomosis is the preferred open technique. Recurrence may occur after open treatment, highlighting the importance of long-term follow-up. Patients should be counseled about the potential for worsening voice quality with the open approach.

Scapular flap for maxillectomy defect reconstruction and preliminary results using three-dimensional modeling.

OBJECTIVES/HYPOTHESIS: Discuss current techniques utilizing the scapular tip and subscapular system for free tissue reconstruction of maxillary defects and highlight the impact of medical modeling on these techniques with a case series. STUDY DESIGN: Case review series at an academic hospital of patients undergoing maxillectomy + thoracodorsal scapula composite free flap (TSCF) reconstruction. Three-dimensional (3D) models were used in the last five cases. METHODS: 3D modeling, surgical, functional, and aesthetic outcomes were reviewed. RESULTS: Nine patients underwent TSCF reconstruction for maxillectomy defects (median age = 43 years; range, 19-66 years). Five patients (55%) had a total maxillectomy (TM) ± orbital exenteration, whereas four patients (44%) underwent subtotal palatal maxillectomy. For TM, the contralateral scapula tip was positioned with its natural concavity recreating facial contour. The laterally based vascular pedicle was ideally positioned for facial vessel anastomosis. For subtotal-palatal defect, an ipsilateral flap was harvested, but inset with the convex surface facing superiorly. Once 3D models were available from our anatomic modeling lab, they were used for intraoperative planning of the last five patients. Use of the model intraoperatively improved efficiency and allowed for better contouring/plating of the TSCF. At last follow-up, all patients had good functional outcomes. Aesthetic outcomes were more successful in patients where 3D-modeling was used (100% vs. 50%). There were no flap failures. Median follow-up >1 month was 5.2 months (range, 1-32.7 months). CONCLUSIONS: Reconstruction of maxillectomy defects is complex. Successful aesthetic and functional outcomes are critical to patient satisfaction. The TSCF is a versatile flap. Based on defect type, choosing laterality is crucial for proper vessel orientation and outcomes. The use of internally produced 3D models has helped refine intraoperative contouring and flap inset, leading to more successful outcomes. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:E8-E14, 2017.

Surgical management of lateral skull base defects.

OBJECTIVES/HYPOTHESIS: We sought to analyze key factors that influence the management of lateral skull base defects and implement an algorithm to improve outcomes of reconstruction. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary academic referral center. METHODS: Adults who underwent temporal bone resection were included. Variables included tumor characteristics, ablative procedure, reconstructive method, and wound complications. RESULTS: Seventy-one patients were studied. Lateral temporal bone resection was performed in 55 patients (77%), subtotal temporal bone resection in 14 (20%), and total petrosectomy in two (3%). Primary closure was achieved in 46 patients (35%), with rotational muscle flaps in 21 (46%). The pectoralis major myocutaneous flap (PMMF) was used in nine patients (13%) without major complications. Single-stage free tissue transfer was undertaken in 10 patients (14%) with no flap failures. Primary closure was achieved in 16 of 32 of previously untreated cases (50%) compared to nine of 39 cases of previously treated disease (23%) (P = 0.03). Pedicled or free flaps were used in 18 of 39 cases of previously treated disease (46%) compared to three of 32 previously untreated cases (9%) (P < 0.001). Pedicled or free flaps were used in 13 of 22 cases (59%) in which partial or total auriculectomy was performed, whereas primary closure was achieved in 39 of 49 cases (80%) in which the pinna was preserved (P < 0.001). CONCLUSION: Advanced tumors that require adjuvant therapy, revision cases for recurrent disease, and cases involving auriculectomy warrant free flap or PMMF reconstruction, with the latter preferred in poor free flap candidates. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1911-1917, 2016.

Langerhans cell histiocytosis of the temporal bone: A review of 29 cases at a single center.

OBJECTIVES/HYPOTHESIS: Evaluate presentation, management, and clinical outcomes of patients with temporal bone Langerhans cell histiocytosis (LCH). STUDY DESIGN: Retrospective chart review. METHODS: Reviewed all patients with temporal bone LCH at a tertiary academic referral center between 1978 and 2014. Presentation, disease course, intervention, and clinical outcomes were analyzed. RESULTS: Between 1978 and 2014, 29 temporal bones in 20 patients (12 males; median age 32 years, range 1.3-88 years) were diagnosed with temporal bone LCH, representing 4% of all patients diagnosed with LCH at our institution during that time. Twelve (60%) patients presented purely with head and neck disease, nine (45%) with bilateral temporal bone involvement, seven (35%) with intracranial spread, and eight (40%) with multisystem disease. The most common presenting symptoms were otorrhea (n = 11; 55%) and subjective hearing loss (n = 10; 50%). Treatment included primary chemotherapy or radiation alone(n = 7; 35%), local resection alone (n = 2; 10%), and chemotherapy or radiation with surgery(n = 11; 55%). Ten patients suffered local or systemic relapse (50%; median 12 months). Median follow-up for patients was 31 months. One patient died secondary to pulmonary complications of multisystem LCH. CONCLUSIONS: LCH is an uncommon histiocytic disorder with a range of clinical manifestations and disease severity. Otologic involvement is rare, and frequently manifests with symptoms similar to otomastoiditis. Evaluation and close follow-up of both ears is important. Bilateral simultaneous or sequential LCH can be seen in up to 45% of cases. Patients with temporal bone LCH should be managed by a multidisciplinary team with treatment tailored to the patient. Relapse is more common in patients with multisystem involvement. Even in subjects with isolated otologic involvement, long-term follow-up is critical, with relapses occurring years beyond treatment. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1899-1904, 2016.

Occult Temporal Bone Facial Nerve Involvement by Parotid Malignancies with Perineural Spread.

OBJECTIVE: To characterize disease presentation and outcomes following surgical treatment of parotid malignancies with occult temporal bone facial nerve (FN) involvement. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic referral center. SUBJECTS AND METHODS: Thirty consecutive patients (mean age 58 years; 77% men) who underwent surgery for parotid malignancies with occult perineural involvement of the intratemporal FN were included. Primary outcome measures included margin status and recurrence. RESULTS: The mean duration of clinical follow-up was 49 months, and the most common presenting symptom was FN paresis (n = 23; 77%) followed by pain (n = 15; 50%). To obtain a proximal FN margin, 27 patients (90%) underwent mastoidectomy, and 3 patients (10%) had lateral temporal bone resection. The intratemporal FN margin was cleared in 26 patients (87%), most commonly in the mastoid segment (60%). Adjuvant therapy was given in 25 patients (83%). Ten patients (33%) experienced locoregional (4; 13%) and/or distant (8; 27%) recurrence at a median of 19 months (mean 26, 2-54 months) following surgery. Locoregional failure was significantly more common in cases with a positive intratemporal FN margin (66% vs 8%; P = .045). Overall 1-, 3-, and 5-year disease-specific survival rates were 83%, 79%, and 72%, respectively. CONCLUSIONS: Perineural invasion of the intratemporal FN by parotid malignancy is uncommon. Normal preoperative FN function does not preclude histopathologic involvement. Temporal bone FN exploration should be considered when a positive margin is encountered at the stylomastoid foramen, as failure to do so is associated with an increased rate of locoregional recurrence.

Cochlear Implantation in Patients With Superficial Siderosis: Seven Cases and Systematic Review of the Literature.

OBJECTIVE: To date, there have been less than 30 cases of cochlear implantation (CI) in patients with superficial siderosis (SS) reported in the literature. The primary objective of the current study is to evaluate CI outcomes in six additional patients (seven ears) with SS and sensorineural hearing loss (SNHL) and to perform a systematic review of the literature. STUDY DESIGN: Case series and systematic review of the literature. SETTING: Two tertiary academic CI centers. PATIENTS: All patients with SS who underwent CI between 2007 and 2014. INTERVENTION(S): Cochlear implantation. MAIN OUTCOME MEASURES: Pre- and post-implantation speech perception scores and durability of benefit. RESULTS: A total of seven ears (four males; median age 52 yr) with SS and SNHL met inclusion criteria. All patients developed progressive bilateral SNHL that was no longer amenable to conventional hearing aids. Additional presenting symptoms included vestibulopathy (n = 4), cerebellar ataxia (n = 3), mild dementia (n = 1), and myelopathy (n = 1). All patients underwent uncomplicated CI, and intraoperative device telemetry revealed normal responses in all electrodes. The median postoperative auditory threshold average was 32.5 dB HL (range 16-36 dB) and the median postoperative CNC word score was 51% (range 46-64%). The median duration of follow-up was 15.5 months (range 3-64 mo). All patients demonstrated initial improvement in speech perception testing. Two patients had performance decline and worsening dementia resulting from progressive SS. CONCLUSION: Cochlear implantation is a viable strategy for auditory rehabilitation in patients with SS and associated SNHL. Most individuals enjoy benefit from CI; however, patients should be counseled regarding the risks of performance decline with progressive SS.

Inverting papilloma of the temporal bone: Report of four new cases and systematic review of the literature.

OBJECTIVES/HYPOTHESIS: Inverting papillomas (IPs) are benign locally invasive tumors that most commonly present within the sinonasal cavity. Temporal bone involvement is exceedingly rare, with fewer than 30 cases reported within the English literature to date. STUDY DESIGN: Case series and systematic review of the literature. METHODS: Four consecutive subjects with temporal bone inverting papilloma (TBIP) were treated, and an additional 28 previously published cases were identified in the literature. Main outcome measures were disease presentation, diagnostic evaluation, management strategy, and outcome. RESULTS: A total of 32 cases were analyzed. The median age at diagnosis was 54 years (mean 54.1; range 19-81 years). Nineteen (59%) patients had synchronous or metachronous sinonasal IP, whereas 13 (41%) had isolated temporal bone disease without sinus involvement. Over half of the patients undergoing microsurgical resection experienced at least one recurrence. Compared to patients with a history of sinus IP, subjects with primary TBIP were younger at time of presentation (44 vs. 58 years; P=0.012); were more commonly female (62% vs. 32%; P=0.15); and were less likely to have intracranial spread (8% vs. 26%; P=0.36), cranial neuropathy (8% vs. 26%; P=0.36), human papillomavirus positivity (11% vs. 57%; P=0.11), or associated carcinoma (0% vs. 47%; P=0.004). CONCLUSIONS: Inverting papilloma of the lateral skull base is rare and can pose a significant therapeutic challenge. Primary lesions of the temporal bone appear to follow a less aggressive clinical course when compared to those arising in association with sinonasal disease. Gross total resection is the preferred method of treatment, when feasible, given the high rate of recurrence with subtotal resection and risk of associated malignancy. LEVEL OF EVIDENCE: 4.

Learning Progression in the Use of Sialendoscopy for Sialolithiasis: Effect on Gland Preservation.

OBJECTIVE: Evaluate how learning progression affects outcomes for the use of sialendoscopy for sialolithiasis. STUDY DESIGN: Case series with chart review. SETTING: Academic tertiary care center. SUBJECTS AND METHODS: A retrospective chart review was conducted on 81 patients presenting with sialolithiasis between 2008 and 2012 who underwent surgical intervention on 85 salivary glands. Outcomes compared between the first 43 and subsequent 42 consecutive glands included successful removal, surgical method, and need for further intervention. RESULTS: For the first 43 patients (group A), mean age was 47.3 years (range, 15-77), and 44.2% were male. For the second 38 patients (group B), mean age was 49.9 (range, 23-76), and 50% were male. Mean stone size was similar in both groups; 8.3 versus 7.6 mm, respectively. In cases of stone visualization and removal, complete removal without gland excision was accomplished in 78.4% of cases in group A versus 94.3% in group B (P = .04). Endoscopic removal occurred in 24.3% of patients in group A, versus 45.8% in group B. A combined approach was used in 54.1% of patients in group A versus 48.6% in group B. In group A, 18.9% underwent gland removal as part of initial intervention versus 0% in group B (P = .007). Overall gland preservation was 81.4% in group A versus 97.6% in group B (P = .015). CONCLUSION: This study documents the effect of learning curve on sialendoscopy for the management of sialolithiasis. With experience, the success of sialendoscopy increases with a significant decrease in the number of gland excisions.

Novel irradiated axial rotational flap model in the rodent.

IMPORTANCE: Patients who require extensive surgical resection of head and neck tumors often have a history of treatment with radiation and chemotherapy. Chemoradiation-induced damage to the skin and soft tissues can cause complications following surgical reconstruction. OBJECTIVE: To design an easily reproducible rodent rotational skin flap and to evaluate the effects of radiation exposure on flap viability. DESIGN AND SETTING: Ten rats at a tertiary university medical center received 40-Gy irradiation to the abdominal wall. Following a recovery period of 1 month, a 3 × 8-cm fasciocutaneous flap based axially on the inferior epigastric vessel was raised and rotated 60° into a contralateral deficit. Five nonirradiated rats underwent the identical procedure as a control. Animals were killed 7 days postoperatively, areas of flap necrosis were documented by an observer blinded to the grouping, and histological specimens were taken to compare flap viability and vessel density. MAIN OUTCOMES AND MEASURES: Flap revascularization and microvascular density. RESULTS: Six of 10 rats in the irradiated group had necrosis of the distal flap ranging from 1 to 6 cm from the distal edge, whereas none of the animals in the control group exhibited necrosis (P < .001). Histologic analysis revealed collagen and vascular changes in the irradiated skin. Vascular density analysis revealed a significant difference between radiated and nonradiated flaps; P = .004, .03, and .01 in the distal, middle, and proximal segments of the flap, respectively. CONCLUSIONS AND RELEVANCE: This novel rat axial rotational flap model demonstrates increased flap necrosis and a decrease in vascular density due to the effects of radiation exposure. With use of a linear electron accelerator, a dose of 40 Gy can be delivered to the skin without resulting in devastating gastrointestinal adverse effects. LEVEL OF EVIDENCE: NA.