Interpreting Lower Trapezius Musculocutaneous Flap Skin Paddle Perfusion with Indocyanine Green Angiography.

Background: The lower trapezius myocutaneous flap (LTF) is a pedicled flap with clinically significant variability of distal skin flap perfusion. Objective: To compare the incidence of partial flap necrosis before and after the institution of routine intraoperative laser-assisted indocyanine green (ICG) angiography. Methods: This is a retrospective review of all LTF performed between November 2021 and July 2022. The outcomes measured in this study are the distance distal to the inferior border of the trapezius muscle with adequate perfusion, and incidence and degree of partial flap necrosis. Results: Sixteen patients met inclusion criteria with a median age of 64.5 years, and a median defect size of 147 cm2. Most patients (11/16) had undergone previous treatment for malignancy. Before utilizing ICG angiography, 40% (2/5) had partial flap necrosis, whereas after utilizing ICG angiography, 9% (1/11) of patients had partial flap necrosis. Seventy-three percent (8/11) of cases who underwent ICG angiography demonstrated a portion of the skin paddle with inadequate perfusion. The range of skin perfusion distal to the inferior border of the trapezius muscle was 0-7 cm (median, 4). Conclusions: The incidence of partial flap necrosis decreased after institution of routine ICG angiography.

Utility of CT in the workup of adults with sore throat in the emergency department.

OBJECTIVE: The goal of this study was to determine if computed tomography (CT) added any clinical information that was incorporated into the decision regarding treatment for patients who presented to the Emergency Department (ED) with sore throat. METHODS: A retrospective chart review of adult patients who presented to the ED with a chief complaint of sore throat who subsequently underwent CT during that ED visit between 1/1/18 and 12/31/18 at our tertiary academic health center was performed. The association between palatal bulge on Otolaryngology physical exam with successful drainage procedure was examined. The mean Hounsfield units (HU) and maximum dimension of measurable fluid collection on CT were compared between patients who underwent a successful drainage procedure and those who did not undergo a drainage procedure or attempted drainage was unsuccessful. RESULTS: Ninety-four patients met inclusion criteria, with 53% (50/94) men. Of the 22 patients with a palatal bulge on physical examination by Otolaryngology, 86% (19/22) underwent a successful drainage procedure (p < 0.001) when compared to those not undergoing successful drainage. Notably, 56% (53/94) of CT scans were interpreted as normal or tonsillitis. The mean HU was 42.0 in those patients who underwent a successful drainage procedure and 74.1 in those who did not undergo a drainage procedure (p < 0.001). Overall, 21/35 fluid collections had a palatal bulge (p < 0.001). CONCLUSION: Palatal bulge is a reliable finding in identifying patients with a drainable peritonsillar abscess, and CT scans could largely be avoided in patients without physical exam findings suggestive of more extensive deep neck space abscesses. If a CT scan is obtained, HU should be measured and incorporated into the shared decision-making process with the patient.

Orthognathic Surgery of the Mandible.

Orthognathic surgery performed in conjunction with orthodontic treatment is commonly performed to correct skeletal irregularities and realign the maxillomandibular relationship to improve occlusal function and facial esthetics. A thorough understanding of soft tissue esthetics, skeletal and occlusal relationships, and surgical techniques is required to obtain successful results. Surgical techniques have evolved greatly throughout history, as technological advances such as virtual surgical planning have become available and widely used to obtain predictable movements with minimized complications. The aim of this article is to review the orthognathic surgical procedures of the mandible, with particular attention to the indications, contraindications, preoperative assessment, surgical technique, and possible complications encountered.

Bony Orbital Surgery for Graves' Ophthalmopathy.

The majority of Graves' ophthalmopathy, or thyroid eye disease, can be managed medically; however, in refractory or severe cases, surgical intervention with orbital decompression may be necessary. The majority of the published literature is retrospective in nature, and there is no standardized approach to orbital decompression. The purpose of this review is to evaluate the various surgical approaches and techniques for orbital decompression. Outcomes are ultimately dependent on individual patient factors, surgical approach, and surgeon experience.

Cranioplasty.

Calvarial defects are commonly encountered after neurosurgical procedures, trauma, and ablative procedures of advanced head neck cancers. The goals of cranioplasty are to provide a protective barrier for the intracranial contents, to restore form, and prevent syndrome of the trephined. Autologous and alloplastic techniques are available, each with their advantages and drawbacks. A multitude of materials are available for cranioplasty, and proper timing of reconstruction with attention to the overlying skin envelope is important in minimizing complications.

Tracheotomy Outcomes in the Medical Intensive Care Unit.

This is a retrospective chart review of 161 MICU patients who underwent tracheotomy by the Otolaryngology service at the University of Missouri Hospital from April 2015 through March 2018. The objectives of this study were to describe long term outcomes of patients who underwent tracheotomy, and identify any clinical variables associated with these outcomes. One-year mortality was 37% (50/161), and on multivariate analysis only age (p=0.001) was associated with mortality.

Treatment of Cutaneous Melanoma of the Head and Neck With Wide Local Excision Versus Mohs.

OBJECTIVES: Determine if Mohs micrographic surgery (MMS) is associated with improved overall survival compared to wide local excision (WLE) when treating cutaneous melanoma of the head and neck (CMHN) and to report the proportion of patients treated with MMS versus WLE who also underwent sentinel lymph node biopsy (SLNB). METHODS: Retrospective cohort study of the National Cancer Database (NCDB) analyzing the overall survival of patients diagnosed with T1 to T4 CMHN between 2004 and 2016 who were treated with either WLE or MMS. RESULTS: On multivariable analysis, treatment with WLE versus MMS was not significantly associated with overall survival (HR, 1.094; 95% CI, 0.997-1.201). On multivariable analysis, lower Charlson-Deyo score (HR, 0.489; 95% CI, 0.427-0.560), negative margins (HR, 0.754; 95% CI, 0.705-0.807), and N0 classification (HR 0.698; 95% CI, 0.668-0.730) were associated with improved overall survival. Seventy-seven percent of patients treated with MMS did not undergo SLNB, while 45% of patients treated with WLE did not undergo SLNB (P < .001). CONCLUSIONS: No difference in overall survival between MMS and WLE when treating CMHN. Patients treated with MMS were significantly less likely to undergo SLNB, suggesting an opportunity for enhancement of multidisciplinary care. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2490-2496, 2021.

Scalp and Forehead Injury: Management of Acute and Secondary Defects.

The primary challenges in scalp reconstruction are the relative inelasticity of native scalp tissue and the convex shape of the calvarium. All rungs of the reconstructive ladder can be applied to scalp reconstruction, albeit in a nuanced fashion due to the unique anatomy and vascular supply to the scalp. Important defect variables to incorporate into the reconstructive decision include site, potential hairline distortion, size, depth, concomitant infection, prior radiation therapy, planned adjuvant therapy, medical comorbidities, patient desires, and potential calvarium and dura defects.

Positive Margins in Cutaneous Melanoma of the Head and Neck: Implications for Timing of Reconstruction.

OBJECTIVE: The aim of this study is to identify clinicopathologic features associated with positive margins after surgical treatment of cutaneous melanoma of the head and neck (CMHN). STUDY DESIGN: Retrospective cohort study. SETTING: National Cancer Database. METHODS: A retrospective analysis of the National Cancer Database was performed of patients diagnosed with CMHN between 2004 and 2016. Univariate and multivariate analyses examining the association of clinicopathologic features with positive margins were performed via logistic regression analysis. RESULTS: A total of 101,560 patients met inclusion criteria. The incidence of positive margins was 5.0% (5128/101,560). Patients were significantly more likely to have positive margins with the following: increasing age (P < .001; odds ratio [OR], 1.028; 95% CI, 1.026-1.031), the lip subsite (P < .001; OR, 1.664; 95% CI, 1.286-2.154), the eyelid subsite (P < .001; OR, 2.380; 95% CI, 1.996-2.838), the face subsite (P < .001; OR, 1.215; 95% CI, 1.133-1.302), the lentigo maligna/lentigo maligna melanoma subtype (P = .019; OR, 1.099; 95% CI, 1.016-1.188), the desmoplastic subtype (P < .001; OR, 1.455; 95% CI, 1.261-1.680), the spindle cell subtype (P = .006; OR, 1.276; 95% CI, 1.073-1.516), and advanced pT classification. Patients with male sex (P < .001; OR, 0.733; 95% CI, 0.687-0.782) and without ulceration (P < .001; OR, 0.803; 95% CI, 0.736-0.876) were significantly less likely to have positive margins. CONCLUSION: The following have been identified as clinicopathologic features associated with positive margins after surgical treatment of CMHN: increasing age, female sex, the lip subsite, the eyelid subsite, the face subsite, ulceration, the lentigo maligna/lentigo maligna melanoma subtype, the desmoplastic subtype, the spindle cell subtype, and increasing pT classification.

Implications of Tumor Size, Subsite, and Adjuvant Therapy on Outcomes in pT4aN0 Oral Cavity Carcinoma.

OBJECTIVE: To determine if tumor size, subsite, and adjuvant radiation therapy (AXRT) are associated with overall survival (OS) in patients with pT4aN0 oral cavity squamous cell carcinoma (OSCC) who underwent mandibulectomy with negative surgical margins (NSMs). STUDY DESIGN: Retrospective cohort study. SETTING: National Cancer Database (NCDB). SUBJECTS AND METHODS: Retrospective analysis of the NCDB that included patients diagnosed with pT4aN0 OSCC who underwent mandibulectomy with NSMs between 2004 and 2015. The association of age, Charlson-Deyo score (CDS), tumor size, subsite, and AXRT with OS was analyzed. The cases were divided into 3 subgroups based on maximal tumor dimension for subgroup analysis; tumors ≤2.0 cm, tumors 2.1 to 4.0 cm, and tumors >4.0 cm. RESULTS: For the entire cohort; age (P < .001; hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.02-1.03), CDS (P = .013; HR, 0.57; 95% CI, 0.37-0.89), tongue subsite (P = .003; HR, 2.01; 95% CI, 1.27-3.40), floor of mouth subsite (P = .001; HR, 1.76; 95% CI, 1.28-2.42), tumor size (P < .001; HR, 0.57; 95% CI, 0.45-0.72), and AXRT (P < .001; HR, 1.46; 95% CI, 1.24-1.72) were associated with OS on multivariate analysis. On subgroup analysis, AXRT not significantly associated with OS in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm (P = .323; HR, 1.29; 95% CI, 0.78-2.15). CONCLUSIONS: In patients with pT4aN0 OSCC who underwent mandibulectomy with NSMs, age, CDS, tongue subsite, floor of mouth subsite, tumor size, and AXRT are associated with OS. AXRT was not significantly associated with overall survival in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm.

Variability in pathologic interpretation of mandibular invasion.

OBJECTIVES/HYPOTHESIS: Our objective was to identify the accuracy, sensitivity, and specificity of pathological interpretation of mandibular invasion by oral cavity squamous cell carcinoma (SCC) and compare the sensitivity of detecting mandibular invasion in the erosive versus the infiltrative patterns of invasion. We also aimed to describe the significance of the terminology the carcinoma "abuts the mandible" in pathologic interpretation of mandibular invasion. STUDY DESIGN: Retrospective case series. METHODS: Mandibulectomy specimens from patients who underwent surgical treatment for oral cavity SCC between January 1, 2005 and December 31, 2015 were retrospectively reviewed by a board-certified anatomic pathologist. The accuracy of pathologic interpretation of mandibular invasion was calculated using the retrospective interpretation of bone invasion as the true interpretation, which was compared to the interpretation on the original pathology report. Incidence of encountering the terminology the carcinoma "abuts the mandible" in the pathology report was calculated. RESULTS: A series of 108 consecutive mandibulectomy specimens were reviewed. Sixty-nine percent (74/108) of cases were interpreted as having mandibular invasion. The accuracy of interpreting mandibular invasion was 84%. The sensitivities for interpretation of mandibular invasion for the erosive and infiltrative patterns of invasion were 77% (30/39) and 91% (32/35), respectively (P = .08). Nine percent (10/108) of pathology reports utilized the terminology the carcinoma "abuts the mandible," and 80% (8/10) of these cases exhibited mandibular invasion. CONCLUSIONS: The accuracy of identifying mandibular invasion is 84%, indicating a certain degree of sampling error and variability in interpretation. A precise pathologic definition of mandibular invasion should be applied during the interpretation of these specimens to minimize variability. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1721-1724, 2020.

Considerations for Timing of Defect Reconstruction in Cutaneous Melanoma of the Head and Neck.

The objective of this study is to identify the incidence and characteristics of cases with positive margins on wide local excision for cutaneous melanoma of the head and neck (CMHN) and therefore provide a potential basis for selectively delaying reconstruction pending final histological clearance of melanoma. A systematic review of English language articles was performed on studies retrieved from PubMed and Web of Science. Original investigations published between July 1999 and June 2018 reporting on margin status of CMHN wide local excision specimens were included in the review. The incidence of positive margins after definitive resection for cutaneous melanoma in the literature ranges from 6 to 20.9%. The incidence is higher in cases of advanced patient age, diagnosis by shave biopsy, lentigo maligna melanoma subtype, desmoplastic subtype, tumor thickness, and ulceration. Delayed reconstruction remains the most oncologically sound decision, allowing for interpretation of margin status on paraffin-embedded tissue sections. However, resection and the resultant defect closure in a single stage is more expedient and potentially a more efficient use of resources. The risk-benefit ratio of immediate versus delayed reconstruction must be considered for each case. The incidence of positive margins is higher in cases of advanced patient age, diagnosis by shave biopsy, lentigo maligna melanoma subtype, desmoplastic subtype, increasing tumor thickness, and the presence of ulceration; delayed reconstruction should be strongly considered in these cases.

Patterns of recurrence and retreatment outcomes among clinical stage I and II head and neck melanoma patients.

BACKGROUND: The objective of this study was to determine survival outcomes in patients who underwent retreatment of recurrent cases of cutaneous melanoma of the head and neck (CMHN). METHODS: Retrospective review of all patients who were treated for primary clinical stage I or II CMHN between January 1, 2000 and December 31, 2015. RESULTS: Twenty percent (33/168) of the patients developed a recurrence. Sixty-six percent (4/6) of patients who developed local recurrence first and 50% (3/6) of patients who developed regional recurrence first were alive without evidence (NED) of disease at last follow-up, while 0% (0/21) of patients who developed distant or simultaneous recurrences first were NED at last follow-up. Among the 7 patients who were NED, the mean time from recurrence to last follow-up was 735 days. CONCLUSIONS: Of patients with isolated local or regional recurrences, 58% (7/12) obtained durable curative treatment for recurrent melanoma.

Mandibular Invasion by Oral Squamous Cell Carcinoma: Clinicopathologic Features of 74 Cases.

OBJECTIVES: (1) For patients with oral squamous cell carcinoma (OSCC) and mandibular invasion, to determine whether prior radiation to the head and neck region (PXRTHN) affects the density of osteoblasts, osteoclasts, or fibroblasts along the tumor interface invading the mandible and whether this is significantly associated with overall survival. (2) To identify clinicopathologic features that are associated with overall survival. STUDY DESIGN: Case series with chart review. SETTING: University of Missouri hospital. SUBJECTS AND METHODS: Retrospective review of 74 cases with pathologically confirmed mandible invasion by OSCC and surgical treatment between January 1, 2005, and December 31, 2015. A board-certified anatomic pathologist reviewed the slides from all mandibulectomy cases. RESULTS: The mean density of osteoclasts was 2.0 per linear mm among the patients with PXRTHN and 7.1 among those without PXRTHN ( P < .001). Positive soft tissue frozen section margin was significantly associated with overall survival on univariate analysis ( P < .001; hazard ratio [HR], 0.34; 95% CI, 0.19-0.62) and multivariate analysis ( P = .026; HR, 0.41; 95% CI, 0.19-0.90). Maximum tumor dimension was significantly associated with overall survival on univariate analysis ( P = .021; HR, 1.19; 95% CI, 1.03-1.38) and multivariate analysis ( P = .002; HR, 1.49; 95% CI, 1.16-1.93). Osteoclast, osteoblast, and fibroblast density were not associated with overall survival. CONCLUSIONS: (1) Osteoclast density along the tumor front is significantly lower among patients with PXRTHN. Stromal cell density was not associated with overall survival. (2) Positive soft tissue frozen section margin and maximum tumor dimension are significantly associated with overall survival among patients with mandibular invasion by OSCC.

Impact of Biopsy Modality on the Management of Cutaneous Melanoma of the Head and Neck.

Objective The purpose of this study was to examine how biopsy modality affects the treatment course and outcomes of patients with cutaneous melanoma of the head and neck. Specifically, we investigated if partial biopsy techniques are associated with positive margins on definitive wide local excision (DWLE), the need for early reoperation to obtain adequate margins or sentinel lymph node biopsy, and survival. Study Design Retrospective case series. Setting Tertiary care academic center. Subjects and Methods Subjects (N = 170) included all patients who were surgically treated for primary cutaneous melanoma of the head and neck at the University of Missouri-Columbia between January 1, 2000, and December 31, 2015. For analysis, patients were divided into 4 groups based on biopsy modality: shave (n = 61), excisional (n = 62), punch (n = 33), and incisional (n = 14). Results The shave biopsy group ( P = .0324) and the punch biopsy group ( P = .0479) were significantly more likely to have positive margins on DWLE. The shave biopsy group ( P = .0042) and the punch biopsy group ( P = .0479) were also significantly more likely to need early reoperation. The mean number of sentinel nodes and incidence of positive sentinel nodes detected on pathologic examination did not differ significantly across biopsy modality ( P = .3600). Overall survival ( P = .4605) and disease-free survival ( P = .5011) did not differ significantly among the groups. Conclusions Patients diagnosed with shave and punch biopsy techniques are significantly more likely to have positive margins after DWLE and more frequently require early reoperation. Biopsy modality does not appear to influence the number of sentinel nodes detected, the incidence of detecting regional metastases in sentinel nodes, the overall survival, or the disease-free survival.

Botulinum Toxin Dosing Trends in Spasmodic Dysphonia Over a 20-year Period.

OBJECTIVES: The study aims to (1) identify the botulinum toxin (BTX) dosing trend in a cohort of patients who received at least 20 injections for the treatment of adductor spasmodic dysphonia (ADSD), (2) describe two distinct BTX dosing trends in treating ADSD (a "classic" dosing trend that initially decreases before stabilizing, and a "fluctuating" dosing trend), and (3) determine if patients with the "classic" dosing trend differed in age or in dosing intervals from those with the "fluctuating" dosing trend. STUDY DESIGN: This is a retrospective case series. METHODS: Of 149 patients who received a total of 2484 BTX injections for the treatment of spasmodic dysphonia in 1993-2013, 49 patients received at least 20 injections. The BTX dose and the interval between doses were recorded. The mean dose of injections 1-20 was determined. The age at initial injection, initial dose, and interval in days between treatments were compared for the "fluctuating" and "classic" groups. RESULTS: The cohort exhibits a significant decrease in dose during the first 10-15 injections. The "fluctuating" group had a significantly shorter interval between injections (mean interval = 97.09 days, SD = 29.41; mean interval = 136.90 days, SD = 43.76, P = 0.002). The mean age at initial dose was not significantly different between the "classic" and "fluctuating" groups. CONCLUSIONS: The average BTX dose of patients with ADSD who receive long-term injections significantly decreases during the initial 10-15 injections before stabilizing. Patients who exhibit the "fluctuating" dosing pattern have a significantly shorter interval between injections than those with the "classic" dosing pattern.

Functional outcomes of sensate versus insensate free flap reconstruction in oral and oropharyngeal reconstruction: A systematic review.

The purposes of this article were to review the literature regarding subjective outcomes, objective functional outcomes, and objective sensation return after sensate and/or insensate free flap reconstruction of the oral cavity and oropharynx. Sensate radial forearm and anterolateral thigh free flaps tend to have better static 2-point discrimination and pressure threshold sensitivity than insensate flaps. There is insufficient evidence to draw conclusions on whether sensate flaps improve functional speech and swallowing outcomes measured by videofluoroscopic swallowing studies and percentage of word intelligibility by a listener blinded to the study. These data highlight the complexity and number of variables affecting functional outcomes in patients who have undergone reconstructive surgery after oral and oropharyngeal cancer ablative operations. A prospective randomized multicenter study that properly and rigidly stratifies patients by defect, flap and recipient nerve choice, adjuvant therapies, and uses widely agreed upon pretreatment and posttreatment evaluation tools could help to answer this important question. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Efficacy of bone marrow cytologic evaluations in detecting occult cancellous invasion.

OBJECTIVES/HYPOTHESIS: Determine the accuracy of bone marrow cytologic evaluations in detecting occult cancellous invasion by squamous cell carcinomas (SCCa) beyond the original margins of bone resection that would have gone undetected without the use of intraoperative bone-marrow margin analysis. STUDY DESIGN: Retrospective single institution cohort study. METHODS: Retrospective chart review of imaging, clinical, pathological, and follow-up data of 51 patients who underwent mandibular resections with intraoperative bone-marrow cytologic evaluation. The accuracy of bone marrow cytologic evaluations to predict final bone margins was calculated. Five-year survival rates were determined. RESULTS: The accuracy of bone marrow cytologic evaluations in detecting occult cancellous invasion by SCCa beyond the original margins of bone resection was 100%. Twelve percent (6/51) were found to have positive bone margins on cytology and were re-resected to obtain clear margins. Patients with a prior history of radiation had a significantly higher incidence of initially positive bone-marrow margins (P = 0.03). The patients with initially positive bone-margins did not have a significantly different prognosis than the patients with initially negative bone-marrow margins. CONCLUSION: 1) The consistent use of intraoperative bone-marrow cytologic evaluation, when applicable, will improve the ability to obtain clear bone margins. 2) Patients with a history of prior radiation therapy have a significantly higher risk of having occult cancellous invasion of SCCa beyond the original margins of bone resection. 3) The prognosis of patients with initially positive bone-marrow margins is not significantly different than patients with initially negative bone-marrow margins. LEVEL OF EVIDENCE: 4.