The influence of perioperative enoxaparin on bleeding after TORS oropharyngectomy.

Perioperative enoxaparin is often avoided in patients undergoing transoral robotic (TORS) oropharyngectomy. Our goal was to quantify the risk of postoperative hemorrhage (POH) in patients receiving enoxaparin after TORS oropharyngectomy. This was a retrospective database cohort study set up in 89 separate healthcare organizations. The TriNetX electronic database was queried for patients with OPSCC who underwent TORS oropharyngectomy. Propensity-score matching was used to create two cohorts, one receiving and one not receiving perioperative enoxaparin. Outcome measures were the POH rate within 1 day of surgery ("primary") and POH rate within 2-30 days of surgery ("secondary"). 1109 patients undergoing TORS for OPSCC were identified, 400 of which received perioperative enoxaparin. One-to-one propensity score matching resulted in 310 patients per cohort. After matching, the primary POH rates between patients receiving and not receiving enoxaparin were 3.23% for both cohorts (OR 1.000, 95% CI 0.410 to 2.438). The secondary POH rates between those receiving and not receiving enoxaparin were 5.47% vs. 3.54% (OR 1.577, 95% CI 0.726 to 3.424). The number needed to harm (NNH) with perioperative enoxaparin use for secondary POH after TORS was 53; no difference was found in primary POH rates. While not statistically significant, the use of perioperative enoxaparin after TORS is associated with increased odds of secondary POH with a NNH of 53; no difference was found in rates of primary POH. For patients undergoing TORS, enoxaparin use requires careful weighing of the risks and benefits.

Effect of perioperative ketorolac on postoperative bleeding after pediatric tonsillectomy.

INTRODUCTION: Ketorolac is a frequently used anesthetic pain agent which is traditionally avoided during tonsillectomy due to concern for postoperative hemorrhage. Our goal was to assess the degree of risk associated with the use of Ketorolac following pediatric tonsillectomy. METHODS: The TriNetX electronic health records research database was queried in January 2024 for patients undergoing tonsillectomy with or without adenoidectomy under the age of 18 years and without a diagnosed bleeding disorder. Patients were separated into two cohorts either having received or not having received ketorolac the same day as surgery. Propensity score matching was performed for age at the time of surgery, sex, race, ethnicity, and preoperative diagnoses. The outcomes assessed were postoperative hemorrhage requiring operative control within the first day (primary hemorrhage) and within the first month after surgery (secondary hemorrhage). RESULTS: 17,434 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had received ketorolac the same day as surgery. 290,373 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had not received ketorolac the same day as surgery. 1:1 propensity score matching resulted in 17,434 patients within each cohort. Receipt of ketorolac the same day as surgery resulted in an increased risk of primary hemorrhage OR 2.158 (95 % CI 1.354, 3.437) and secondary hemorrhage OR 1.374 (95 % CI 1.057, 1.787) requiring operative control. CONCLUSION: Ketorolac use during pediatric tonsillectomy with or without adenoidectomy was associated with an increased risk of postoperative primary and secondary bleeding requiring surgery.

Metastatic Esophageal Adenocarcinoma Presenting as Neck Dermal Metastasis.

Dermal metastasis is a rare manifestation of visceral disease, and esophageal adenocarcinomas represent around only 1% of primaries that present with cutaneous metastasis. In this case, we discuss a patient who presented with a painless submental mass and extensive right neck cutaneous induration and erythema. Core needle biopsy demonstrated poorly differentiated adenocarcinoma. Blood testing also demonstrated elevated carbohydrate antigen 19-9, carcinoembryonic antigen, and alkaline phosphatase. PET/CT followed by esophagoscopy led to the diagnosis of esophageal signet-cell adenocarcinoma primary with isolated dermal metastasis. The patient was started on palliative radiotherapy and passed away two months later from a suspected thoracic fistula and hydropneumothorax.

Excision of massive left branchial cleft cyst with secondary hypertension.

Branchial anomalies are heterogeneous congenital malformations that form secondary to incomplete closure of pharyngeal clefts and pouches. There have been no reports of branchial cleft cysts causing carotid artery compression and hypertension. We report a large branchial cleft cyst causing suspected secondary hypertension from carotid artery compression.

Effect of 2 Teams and Operative Time on Complications After Oral Cavity Free Flap Reconstruction.

OBJECTIVE: Evaluate the effects of operative time and 2 team approach on complications after soft tissue free flap reconstruction for oral tongue cancer. METHODS: Patients with oncologic glossectomy with myocutaneous or fasciocutaneous free flap reconstruction were included from the 2015 to 2018 American College of Surgery National Surgical Quality Improvement Program. The primary predictive variables assessed were operative time and 2 team approach; control variables included age, sex, body mass index (BMI), 5-question-modified frailty index (mFI-5), American Society of Anesthesiologists (ASA) class, and total work relative value units (wRVU). Outcomes assessed included 30-day mortality, 30-day reoperation, hospital length of stay beyond 30 days, readmission, medical and surgical complications, and non-home discharge. Multivariable logistic/linear regression models were used to predict surgical outcomes. RESULTS: Microvascular soft tissue free flap reconstruction of the oral cavity after glossectomy was performed on 839 patients. Operative time was independently associated with readmission, prolonged length of stay, surgical complications, medical complications, and non-home discharge. A 2-team approach was independently associated with prolonged length of stay and medical complications. The mean operative time of the 1-team and 2-team approach was 8.73 and 9.13 hours. The 1-team approach did not significantly increase operative time (P = .16). CONCLUSIONS: In the largest study to date of operative time on post-surgical outcomes after glossectomy and soft tissue free flap reconstruction, we found longer operative times increased rates of postoperative complications and non-home discharge. The 1-team approach is non-inferior to the 2-team approach with respect to operating time and complications.

Rhinogenic Optic Neuropathy with No Light Perception Secondary to Onodi Cell Mucocele with Visual Recovery after Optic Nerve Decompression.

Rhinogenic optic neuropathy (RON) results from ethmoid or sphenoid sinus inflammation or infection causing optic nerve impairment.1 Treatment often requires endoscopic surgery and vision restoration occurs in select cases. There is no clear evidence for the benefit of optic nerve decompression (OND) in these situations. We present a unique case of RON caused by an Onodi cell mucocele for which isolated endoscopic mucocele drainage was not enough and further OND was needed to improve vision.

Endoscopic Endonasal Orbital Apex Decompression for Carotid Cavernous Fistula.

SIGNIFICANCE STATEMENT: This case report demonstrates a novel approach to treating a rare indirect carotid cavernous fistula (CCF) and associated abducens palsy. Although endovascular treatment is the standard of care in the management of CCFs, it was contraindicated in this patient. Instead, she underwent an endoscopic endonasal approach (EEA) with decompression of the medial orbital apex, including the cavernous sinus and optic nerve, with complete resolution of headache, lateral gaze palsy, and diplopia within 2 months.

Effects of Soft Tissue Sleep Surgery on Morbidly Obese Patients.

INTRODUCTION: Morbidly obese patients with obstructive sleep apnea (OSA) are often intolerant of continuous positive airway pressure (CPAP). The effects of sleep surgery in this population is not well documented, and sleep surgery is generally avoided due to the expectation of poor outcomes, leaving these patients untreated. METHODS: This retrospective study included 42 patients with a body mass index (BMI) ≥40.0 and OSA with a preoperative apnea hypopnea index (AHI) ≥5. Preoperative BMI ranged from 40.0 to 69.0 kg/m2. Preoperative AHI ranged from 7.2 to 130.0. Of 42 patients, 12 (28.6%) underwent concurrent pharyngeal and retrolingual surgery. Subgroup analysis of change in AHI was measured with respect to preoperative OSA severity, change in preoperative BMI, and BMI severity. Univariate linear and logistic regression was performed assessing change in AHI and surgical success with respect to age, sex, preoperative AHI, preoperative BMI, change in BMI, total procedures, palatal procedure, retrolingual procedure, nasal procedure, and multilevel procedures. RESULTS: The mean AHI improved from 45.9 ± 31.8 to 31.9 ± 31.6 (P = .007). Epworth sleepiness score (ESS) improved from 13.2 ± 5.5 to 9.6 ± 5.4 (P = .00006). Lowest oxygen saturation (LSAT) improved from 74.4 ± 10.7 to 79.9 ± 10.4 (P = .002). About 33.3% of patients had surgical success (AHI < 20 with at least 50% reduction in AHI). Preoperative AHI was the most significant factor for change in AHI in univariate and multivariate models (P = .015). CONCLUSION: Sleep surgery is effective in reducing OSA burden in most morbidly obese patients and can result in surgical cure for a third of patients.

Botulinum toxin A for the treatment of first bite syndrome-a systematic review.

Background: First bite syndrome (FBS) is a rare post-surgical complication resulting in peri-parotid pain after the first bite of meals. Intra-parotid Botulinum toxin A may offer relief for these symptoms. There is no consensus on the optimal dosage, timing to symptom improvement, need for repeat injections, and safety of this treatment. The objective of this systematic review was to assess the efficacy and safety of intra-parotid Botulinum toxin A injection in treating FBS. Methods: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar were searched from the inception until July 2020. Case reports, case series, prospective and retrospective trials in which patients with post-surgical FBS were treated with intra-parotid botulinum toxin A injection were included. The primary outcome was improvement of FBS symptoms. Secondary outcomes were time to symptom improvement and complications. Risk of bias was assessed with National Institute of Health (NIH) Quality Assessment Tools. Results: Search results yielded 41 studies. Thirty-three articles were excluded after screening titles, abstracts, and full texts, yielding eight studies, from which 22 patients were included. No studies included a control. All studies were of lower quality and had at least moderate risk of bias. The initial botulinum toxin A injection dose ranged from 10-75 U. Time from surgical treatment to injection ranged from 1 month to 3 years. Seven studies, containing 17 patients, reported individual patient outcomes. Clinical improvement was reported in 16 patients lasting between 1-30 months post injection. Eight of 8 (100%) patients receiving at least 40 U botulinum toxin A had symptom improvement. Ten of 22 (45.5%) patients received a second botulinum toxin A injection due to return of pain at a mean of 3.8 months after the first injection. Seven of 22 (38.1%) patients had complete symptom resolution at a mean of 12.1 months. There were no reported injection complications, including: facial paralysis, infection, injection site reaction, and allergic reaction. Discussion: There are no controlled studies comparing intra-parotid botulinum toxin A to observation for FBS. However, botulinum toxin A appears to be a potentially safe, effective treatment.

Treatment Outcomes for Osteoradionecrosis of the Central Skull Base: A Systematic Review.

Objective Osteoradionecrosis (ORN) of the skull base can have catastrophic consequences if not detected early and managed appropriately. This is a systematic review of the different treatment modalities for skull base ORN and their outcomes. Study Design This study is a systematic review. Materials and Methods Two researchers extracted information including patient population, surgical technique, outcomes of interest, and study design. A computerized search of Medline, Embase, and the Cochrane library (January 1990-June 2020) looked for several papers on the subject of skull base ORN. Results A total of 29 studies had met inclusion criteria, including data from 333 patients. Nasopharyngeal carcinoma was the most common primary tumor (85%). Average age at diagnosis of ORN was 55.9 years (range = 15-80 years) and 72.3% of patients were males. The average time to diagnosis of ORN after radiation therapy was 77 months with an average radiation dose of 76.2 Gy (range = 46-202 Gy). Nighty-eight patients (29.4%) also had chemotherapy as part of their treatment regimen. Although all parts of the central skull base were reported to be involved, the clivus and sphenoid bone were the most commonly reported subsites. Trial of medical treatment had a success rate of 41.1%. About 66% of patients needed surgical treatment, either primarily or after failing medical treatment. Success rate was 77.3%. Overall, the surgical treatment was superior to medical treatment ( p < 0.0001). Conclusion ORN is a rare complication of the treatment of skull base tumors. Most cases require surgical treatment, including endoscopic debridement or free flap reconstruction, which has a high success rate. Level of Evidence Level 3 evidence as a systematic review of case studies, case reports, retrospective, and prospective trials with no blinding or controls.

Intraoperative Indocyanine Green Angiography for Assessing Flap Perfusion in Skull Base Reconstruction: A Systematic Review.

Objective This study was aimed to study the current use of intraoperative indocyanine green (ICG) angiography during skull base reconstruction and understand its efficacy in predicting postoperative magnetic resonance imaging (MRI) enhancement and flap. Study Design The Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google Scholar databases were searched from the date of inception until August 2020 for studies of ICG flap perfusion assessment during skull base reconstruction. The primary outcome of interest was the development of cerebrospinal fluid (CSF) leak after skull base reconstruction. Secondary outcomes of interest included postoperative meningitis, flap MRI enhancement, flap necrosis, flap perfusion measurements, and total complications. Results Search results yielded 189 studies, from which seven studies with a total of 104 patients were included in the final analysis. There were 44 nasoseptal flaps (NSF), two lateral nasal wall flaps (LNWF), 14 pericranial flaps (PCF), and 44 microvascular free flaps. The rates of CSF leak and postoperative MRI enhancement were 11 and 94%, respectively. There was one case of postoperative meningitis. Pooled analysis of the available data showed that intraoperative ICG flap perfusion was associated with flap enhancement on postoperative MRI ( p = 0.008) and CSF leak ( p = 0.315) by Fisher's exact test. Conclusion The available literature suggests intraoperative ICG enhancement is associated with postoperative MRI enhancement. Given the small sample sizes in the literature and the rarity of complications associated with skull base reconstruction, intraoperative ICG enhancement has not been predictive of flap necrosis or postoperative complications such as CSF leak or meningitis. Level of Evidence This study presents level 3 evidence as a systematic review of case studies, case reports, and retrospective and prospective trials with no blinding, controls, and inconsistently applied reference standards.

Factors Associated With a Prolonged Diagnosis-to-Treatment Interval in Laryngeal Squamous Cell Carcinoma.

OBJECTIVE: Evaluate factors associated with treatment delays and their effect on survival in laryngeal squamous cell carcinoma. STUDY DESIGN: Retrospective cohort study. SETTING: National Cancer Database. METHODS: Patients receiving primary radiation or surgery for laryngeal squamous cell carcinoma were included from 2004 to 2017. The primary outcomes were the diagnosis-to-treatment interval (DTI) and 5-year survival. Variables of prolonged DTI (>30 days) were assessed via logistic regression models. Survival was then assessed through Cox proportional hazards models. Candidate variables for both outcomes included age, sex, race, ethnicity, distance to treatment facility, insurance coverage, treatment facility type, TNM T stage, nodal status, and DTI (in models estimating survival). RESULTS: An overall 136,203 patients with laryngeal cancer were identified, from which 51,747 remained after exclusions were applied: 18,499 received primary surgery and 33,248 received primary radiation. Being a member of a racial or ethnic minority, advanced age, female sex, ≥30 miles from treatment facility, lack of insurance, treatment at an academic cancer center, and primary radiation were associated with a prolonged DTI. However, in spite of a faster DTI, treatment at a community cancer center was independently associated with higher mortality (hazard ratio, 1.2; P < .0001). CONCLUSIONS: Despite being associated with prolonged DTI, receiving treatment at a high-volume academic facility was associated with significantly improved survival. Our results indicate that improved referral pathways or outreach may help improve survival in laryngeal cancer, especially in high-risk populations.

Does length of time between cases affect resident operative time for tonsillectomy and adenoidectomy?

OBJECTIVE: To evaluate the effect of prolonged time intervals between tonsillectomy and adenoidectomy (TA) on resident operative time and complications. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary academic hospital. METHODS: This retrospective study covers a five-year period from 2015 to 2020. Time intervals between isolated pediatric TA cases performed by eight otolaryngology residents were reviewed to assess effect on operative time (defined as prolonged if ≥ 30 min and non-prolonged if < 30 min). Intervals including a procedure involving either a tonsillectomy or adenoidectomy that was a non-isolated TA were excluded. RESULTS: A total of 309 isolated TAs were identified with 67.3% of procedures performed under 30 min. The mean surgical time interval between procedures was 5.83 ± 10.02 days (range 0.02-69.82). Most TAs were performed on patients aged 7 years or younger. Surgical time interval between TA was not a significant factor in determining prolonged operative time on univariable logistic regression, OR 1.01 (CI: 0.98 to 1.03) (p = 0.63). Patient age at surgery, adenoid grade, tonsil size and total number of TAs performed to date were significant factors in determining prolonged operative time in both univariable and multivariable logistic regression models. Prolonged operative time did not have a significant effect on readmission, reoperation, or post-operative bleeding. CONCLUSION: Extended time interval (up to 3 months) between routine TA does not affect operative time. Expansion of our methodology to more complex cases would be beneficial in designing resident training curriculum.

Variables predictive of surgical outcomes after hyoid myotomy with suspension to thyroid cartilage.

OBJECTIVES: To evaluate variables predicting improvement in obstructive sleep apnea (OSA) with hyoid suspension to thyroid cartilage 4-suture technique. METHODS: Sixty adult patients (age range 23-78 years) with OSA underwent hyoid suspension to thyroid cartilage with or without concurrent multi-level surgery over an eight-year period from 2011 to 2019 at a tertiary academic center. All patients had a preoperative apnea hypopnea index (AHI) ≥ 5. Changes in mean AHI, Epworth Sleepiness Scale (ESS), and lowest oxygen saturation (LSAT) were measured with paired Student t-test. Linear and logistic regression models were used to predict change in AHI and surgical success respectively with respect to body mass index (BMI), age, sex, previous sleep surgery, concurrent retrolingual surgery, concurrent palatopharyngoplasty, and preoperative AHI. RESULTS: The mean AHI demonstrated a significant improvement from a preoperative AHI of 39.0 ± 25.5 to a postoperative AHI of 31.2 ± 23.4 (p = 0.005). The mean Epworth Sleepiness Score (ESS) significantly improved from 13.1 ± 6.0 to 9.2 ± 5.7 (p = 0.000012). Surgical success, defined as a 50% reduction in preoperative AHI to a postoperative AHI ≤ 20, was obtained in 18/60 (30.0%) patients. Preoperative BMI significantly correlates with variation of change in AHI in multivariable linear regression model (p = 0.003). Preoperative AHI was significant predictor of surgical success in multivariable logistic regression model. CONCLUSION: The magnitude of improvement in polysomnographic parameters after hyoid suspension to thyroid appears to be more significant in patients with lower BMI. Even patients with an obese BMI and severe OSA achieve significant improvement from this procedure.

Surgical versus medical treatment for ocular surface squamous neoplasia: A quality of life comparison.

PURPOSE: To characterize vision-related and psychosocial quality of life (QoL) parameters in medically and surgically treated patients with OSSN. METHODS: Forty-one patients with OSSN treated with medical therapy consisting of interferon alpha 2b drops 1 MIU/ml (n = 22) or who underwent surgical excision (n = 19) were contacted. All subjects answered a quality of life assessment with an original questionnaire in which they were asked about a range of parameters. Overall satisfaction and motivating factors for treatment were also reviewed. RESULTS: The mean age at the time of the survey was 64.6 and 51% were male with similar demographics between groups. Based on the previous cohort, rates of tumor resolution and recurrences were comparable in the two groups. Reasons for choosing a particular treatment varied between the groups. Forty percent of individuals in the medical group reported a fear of surgery (p = 0.03) and often made the decision after personal research (p = 0.008). Thirty-two percent of patients in the surgical group chose surgery due to fear of decreased vision due to lesion growth, therefore wanting immediate resolution (p = 0.09). Drops precipitated more ocular symptoms such as tearing and itchiness, on the other hand, patients who had surgery reported having more pain. CONCLUSION: Quality of life considerations before, during, and after OSSN treatment is an important yet understudied topic. Our study is the first to look at QoL parameters in OSSN treatment and we found that patients in both medically and surgically treated groups had similar QoL metric but were driven to choose chemotherapy due to fear of surgery and/or prior literature review.