Outcomes After Tracheostomy for Patients With Respiratory Failure due to COVID-19.

OBJECTIVE: To evaluate the utility and safety of tracheostomy for patients with respiratory failure from COIVD-19 and describe patient clinical characteristics and process of management. METHODS: Case series of the first 24 COVID-19 patients who underwent tracheostomy at our institution, a single-center tertiary care community hospital intensive care/ventilator weaning unit. The patients all had respiratory failure from COVID-19 and required endotracheal intubation and mechanical ventilation. Outcomes reviewed include mortality, percent discharged, percent liberated from mechanical ventilation, percent decannulated, time from tracheostomy to ventilator liberation and discharge, and number of staff infected with COVID-19 during tracheostomy and management. RESULTS: Of the 24 patients who underwent tracheostomy, 21 (88%) of 24 survived. Twenty (83%) were liberated from mechanical ventilation, and 19 (79%) were discharged. Fourteen (74%) of the discharged had been decannulated. The average (± SD) time from tracheostomy to ventilator liberation was 9 ± 4.3 days and from tracheostomy to discharge 21 ± 9 days. All discharged patients had been liberated from mechanical ventilation. No health care workers became infected with COVID-19 during the procedure or subsequent patient management. CONCLUSION: Patients with respiratory failure from COVID-19 who underwent tracheostomy had a high likelihood of being liberated from mechanical ventilation and discharged. Tracheostomy and subsequent ventilator weaning management can be performed safely. Tracheostomy allowed for decompression of higher acuity medical units in a safe and effective manner.

Thromboprophylaxis in Head and Neck Microvascular Reconstruction.

Head and neck patients undergoing microvascular reconstruction are at high risk for thromboembolism. While the prevention of thromboembolism has become an essential aspect of care, within the field of microsurgery, concern for anastomotic complications have hindered the creation of an accepted regimen. The aim of this review was to evaluate the risks and benefits of prophylactic agents for thromboprophylaxis. A literature search was conducted in MEDLINE, Cochrane Library, and PubMed/NCBI databases. Articles discussing thromboprophylaxis in otolaryngology, head and neck surgery, or microvascular reconstruction were considered in the review from the past 30 years. The majority of patients undergoing microvascular surgery have multiple risk factors for thrombus formation. Several consensus guidelines exist for the prophylaxis in patients who are critically ill, undergoing surgery, or with malignancy. Significant evidence supports the routine use of mechanical means, such as early mobilization and pneumatic compression along with subcutaneous heparin. Low-molecular-weight heparin is also frequently utilized, although results are largely divided. Data on aspirin remain equivocal. Studies on microvascular failure and flap loss have demonstrated little to no association with chemoprophylaxis. The evidence for postoperative thromboprophylaxis regimens in patients undergoing head and neck free tissue transfer is variable. Multiple studies have supported the use of unfractionated heparin or low-molecular-weight heparin. There appears to be an expert consensus for the combined use of mechanical prophylactic methods and chemical prophylaxis. Prospective randomized trials are required to validate the most effective combination of chemoprophylaxis agents.

Multiflap closure of scalp defects: Revisiting the orticochea flap for scalp reconstruction.

Reconstruction of the scalp following oncologic resection is a challenging undertaking owing to the variable elasticity of the soft tissue overlying the calvarium and the limited amount of tissue available for recruitment. Defect size, location, and skin characteristics heavily influence the reconstructive options available to the surgeon. Reconstruction options for scalp defects range from simple direct closure, to skin grafting, to adjacent tissue transfer with local flaps, and ultimately to free tissue transfer. Dermal regeneration templates have also gained popularity in the recent past. Often times a primary closure with multiple local flaps can be a prime choice in these scenarios. One such modality of multi-flap closure, the Orticochea flap, is an excellent option for scalp reconstruction as it decreases operative time, may provide hair-bearing skin, and potentially avoids the risks of general anesthesia in debilitated patients. We present an interesting case of a patient with a large scalp defect following melanoma excision that was successfully reconstructed with an Orticochea flap. A review of scalp reconstruction and uses of the Orticochea flap will follow the case presentation.

VEGFR-2 expression in human melanoma: revised assessment.

Vascular endothelial growth factor (VEGF) is an angiogenic factor that also functions as an autocrine growth factor for VEGF receptor (VEGFR)-2(+) melanomas. In multiple studies, VEGFR-2 was detected by immunostaining in 78-89% of human melanoma cells, suggesting that most patients with melanoma would benefit from anti-VEGF therapy. Here, we evaluated 167 human melanoma specimens in a tissue microarray to verify the presence of VEGFR-2, but found disparities in staining with commercial antibodies A-3 and 55B11. Antibody A-3 stained melanoma cells in 79% of specimens, consistent with published results; however, we noted extensive nonspecific staining of other cells such as smooth muscle and histiocytes. In contrast, antibody 55B11 stained melanoma cells in only 7% (95% confidence interval: 3.3-11.5) of specimens. As an internal positive control for VEGFR-2 detection, vascular endothelial cells were stained with antibody 55B11 in all specimens. We compared VEGFR-2(+) and VEGFR-2(-) melanoma cell lines by immunoblotting and immunohistochemistry after small interfering RNA (siRNA) knockdown and transient overexpression of VEGFR-2 to validate antibody specificity. Immunoblotting revealed that A-3 primarily cross-reacted with several proteins in both cell lines and these were unaffected by siRNA knockdown of VEGFR-2. In contrast, 55B11 staining of VEGFR-2(+) cells was mostly eliminated by siRNA knockdown of VEGFR-2 and increased in VEGFR-2(-) melanoma cell lines following transfection to express ectopic VEGFR-2. Our results show that relatively few melanoma cells (<10%) express detectable levels of VEGFR-2, and therefore, the majority of patients with melanoma are unlikely to benefit from antiproliferative effects of anti-VEGF therapy.

Steroid injection for sinonasal polyps: the University of Virginia experience.

BACKGROUND: Sinonasal polyps are treated with topical steroids, systemic oral steroids, surgical excision, and intrapolyp steroid injection. Use of steroid injection is not widespread because of reported complications. The objective of this study was to evaluate the complications of intrapolyp steroid injections and compare it to the complications of surgical removal of polyps. METHODS: All patients seen between 1994 and 2003 with a diagnosis of nasal polyps were reviewed retrospectively. Demographics, complications, follow-up, and comorbidities were collected. Frequency of each treatment modality used and complications of each treatment were compared. RESULTS: Three hundred fifty-eight patients were in the study with a mean follow-up of 30 months. Respiratory comorbidities were asthma alone (35%), aspirin triad (16%), and cystic fibrosis (15%). Other comorbidities were smokers (21%). Treatment modalities were medical treatment alone (14%); medical treatment and steroid injections (19%); medical treatment and surgery (33%); and medical treatment, injections, and surgery (34%). Patients who underwent injection had fewer surgeries (p < 0.001). There was 1 minor complication associated with 1495 injections and 11 major and 16 minor complications associated with the 310 surgeries. The differences in complication rates were statistically significant (p < 0.001). There was no significant difference in demographics, follow-up, or comorbidities between patients who received injections and patients who underwent surgery. CONCLUSION: Intrapolyp steroid injection is associated with a significantly lower rate of complication than is surgical excision of sinonasal polyps. Steroid injection also may decrease the need for further surgical intervention of polyps.

Rethinking auricular trauma.

OBJECTIVES/HYPOTHESIS: An unrecognized auricular hematoma can lead to a disfiguring deformity, the cauliflower ear, but it can be prevented with prompt and comprehensive management. Fine needle aspiration with pressure bandages remains the mainstay treatment but will occasionally fail. We review our experience with recurrent or recalcitrant auricular hematomas in terms of their pathophysiology and revision surgery. STUDY DESIGN: Retrospective chart review. METHODS: A review of patients undergoing surgical incision, drainage, and debridement secondary to recurrent auricular hematomas was conducted. Demographic data was collected, intraoperative notes were reviewed, and follow-up results were obtained. Our management included an open incision, aggressive debridement, and long term bolsters to the ear. RESULTS: Ten patients presented with a persistent auricular hematoma and deformity following outpatient management with either incision and drainage or fine needle aspiration. All were male with a mean age of 25 years, presenting for surgery on average 19 days following initial trauma. The location of the hematoma within this group was not limited to the potential space between the cartilage and perichondrium. The hematoma was clearly located within the cartilage itself and it is postulated that this is one of the primary reasons for initial failure. Following surgical incision and drainage there were no recurrences or complications. CONCLUSION: There is a select group of patients with refractory auricular hematomas that require more aggressive treatment over a fine needle aspiration. Open debridement is indicated for this group. The location of the hematoma, granulation tissue, and neo-cartilage is found to be within the cartilage itself rather than between the cartilage and perichondrium, thus explaining why a needle aspiration alone can be ineffective.