Esophageal perforation after anterior cervical spine surgery.

Objective: To report our updated experience in the management of esophageal perforation resulting from anterior cervical spine surgery, and to compare two wound management approaches. Methods: This is a retrospective review of patients managed for esophageal perforations resulting from anterior cervical spine surgery (2007-2020). We examine outcomes based on 2 wound management approaches: closed (closed incision over a drain) versus open (left open to heal by secondary intention). We collected data on demographics, operative management, resolution (resumption of oral intake), time to resolution, number of procedures needed for resolution, microbiology, length of stay, and neck morbidity. Results: A total of 13 patients were included (10 men). Median age was 52 years (range, 24-74 years). All patients underwent surgical drainage, repair, or attempted repair of perforation, hardware removal, and establishment of enteral access. Wounds were managed closed versus open (6 closed, 7 open). There were 2 early postoperative deaths due to acute respiratory distress syndrome and aspiration (open group), and 1 patient was lost to follow-up (closed group). Among the remaining 10 patients: resolution rate was 80% versus 100%, resolution in 30 days was 20% versus 100%, median number of procedures needed for resolution was 3 versus 1, and median hospital stay was 23 versus 14 days, for the closed and open groups, respectively. Conclusions: Esophageal perforation following anterior cervical spine surgery should be managed in a multidisciplinary fashion with surgical neck drainage, primary repair when feasible, hardware removal, and establishment of enteral access. We advocate open neck wound management to decrease the time-to-resolution, number of procedures, and length of stay.

Reconstruction for Salvage Laryngectomy With Limited Pharyngectomy.

Importance: Closure technique for optimization of postoperative and functional outcomes following salvage laryngectomy remains an area of debate among head and neck surgeons. Objective: To investigate the association of salvage laryngectomy closure technique with early postoperative and functional outcomes. Design, Setting, and Participants: This retrospective cohort study included patients from 17 academic, tertiary care centers who underwent total laryngectomy with no or limited pharyngectomy after completing a course of definitive radiotherapy or chemoradiotherapy with curative intent between January 2011 and December 2016. Patients with defects not amenable to primary closure were excluded. Data were analyzed from February 14, 2021, to January 29, 2024. Exposures: Total laryngectomy with and without limited pharyngectomy, reconstructed by primary mucosal closure (PC), regional closure (RC), or free tissue transfer (FTT). Main Outcomes and Measures: Patients were stratified on the basis of the pharyngeal closure technique. Perioperative and long-term functional outcomes were evaluated with bivariate analyses. A multivariable regression model adjusted for historical risk factors for pharyngocutaneous fistula (PCF) was used to assess risk associated with closure technique. Relative risks (RRs) with 95% CIs were determined. Results: The study included 309 patients (256 [82.8%] male; mean age, 64.7 [range, 58.0-72.0] years). Defects were reconstructed as follows: FTT (161 patients [52.1%]), RC (64 [20.7%]), and PC (84 [27.2%]). A PCF was noted in 36 of 161 patients in the FTT group (22.4%), 25 of 64 in the RC group (39.1%), and 29 of 84 in the PC group (34.5%). On multivariable analysis, patients undergoing PC or RC had a higher risk of PCF compared with those undergoing FTT (PC: RR, 2.2 [95% CI, 1.1-4.4]; RC: RR, 2.5 [95% CI, 1.3-4.8]). Undergoing FTT was associated with a clinically meaningful reduction in risk of PCF (RR, 0.6; 95% CI, 0.4-0.9; number needed to treat, 7). Subgroup analysis comparing inset techniques for the RC group showed a higher risk of PCF associated with PC (RR, 1.8; 95% CI, 1.1-3.0) and predominately pectoralis myofascial flap with onlay technique (RR, 1.9; 95% CI, 1.2-3.2), but there was no association of pectoralis myocutaneous flap with cutaneous paddle interposition with PCF (RR, 1.2; 95% CI, 0.5-2.8) compared with FTT with cutaneous inset. There were no clinically significant differences in functional outcomes between the groups. Conclusion and Relevance: In this study of patients with limited pharyngeal defects, interpositional fasciocutaneous closure technique was associated with reduced risk of PCF in the salvage setting, which is most commonly achieved by FTT in academic practices. Closure technique was not associated with functional outcomes at 1 and 2 years postoperatively.

Disseminated Blastomycosis Mimicking Metastatic Head and Neck Cancer in a 70-year-Old Man.

Blastomycosis is a fungal infection known to mimic many disease processes, including malignancy. A 70-year-old man presented with an enlarging neck mass and, incidentally found on preliminary imaging, a lung mass. The initial biopsy of the neck mass demonstrating cytologic atypia and mitotic figures was suggestive of malignancy. Whole body positron emission tomography (PET)/CT revealed hypermetabolic lesions in multiple sites, including the neck, lung, and soft tissue, raising concern for metastatic disease. Repeat sampling from multiple lesions, however, demonstrated granuloma. Microbiological studies were collected, and Blastomyces dermatitidis was isolated in culture. The diagnosis of disseminated blastomycosis was made, and the patient received antifungal therapy with good response. A high degree of suspicion for blastomycosis in endemic areas is required to ensure patients receive appropriate and timely treatment. Laryngoscope, 133:2237-2239, 2023.

Thyroglossal Duct Cyst Carcinoma in a Young Female: Case Report and Review of Literature.

Thyroglossal duct remnants form during embryologic development and can develop into a thyroglossal duct cyst (TGDC). In rare cases, carcinoma is present within these cysts, most commonly papillary thyroid carcinoma. Diagnosis is difficult, but imaging and fine-needle aspiration (FNA) biopsies can help with the diagnosis. Given the rarity of TGDC carcinoma, treatment is not well agreed upon and can include the Sistrunk procedure, thyroidectomy, nodal dissection, and postoperative radioactive iodine treatment. Here, we describe the presentation, workup, and treatment of a 20-year-old female with papillary thyroid carcinoma present within both a thyroglossal duct cyst and the thyroid gland.

Malignant paraganglioma presenting as a mandibular metastasis.

BACKGROUND: Metastatic paragangliomas are rare neuroendocrine tumors. Bony metastases most commonly occur in the ribs, vertebrae, and pelvis. Few cases of mandibular metastases have been reported. METHODS: A 75-year-old female presented with a 6-month history of an enlarging mandibular mass. A biopsy was consistent with a paraganglioma. RESULTS: Staging workup with 18 F-fluorodeoxyglucose positron emission tomography demonstrated 2 hypermetabolic intra-abdominal lesions adjacent to the inferior vena cava. These were confirmed as paraganglioma by biopsy and presumed as the primary lesions. The patient underwent left segmental mandibulectomy and neck dissection with osteocutaneous fibula free tissue reconstruction. CONCLUSION: A rare case of malignant paraganglioma presenting as a mandibular metastasis is described. Nuclear medicine studies for paraganglioma are reviewed.

Venous Complications in One Versus Two Vein Anastomoses in Head and Neck Free Flaps.

OBJECTIVE: The purpose of this study was to compare rates of reexploration and flap failure in patients with 1- and 2-vein anastomoses in free flap reconstructions. METHODS: Retrospective chart review of 300 patients undergoing free flap reconstruction to head and neck defects from 2010 to 2014. RESULTS: One venous anastomosis was performed in 229 patients, and 2 venous anastomoses were performed in 71 patients. The 1-vein group had significantly more reexplorations in the operating room (36/229, 15.7%) compared with the 2-vein group (4/71, 5.6%; P = .028), even when controlling for flap type ( P = .022). This finding remained true among radial forearm flaps (17/81, 21% vs 3/53, 5.7%; P = .024). The number of venous anastomoses was not significantly associated with flap failure, though patients with flap failure did have a significantly greater proportion of venous issues ( P < .001). CONCLUSIONS: Two-vein anastomoses do not appear to reduce rates of flap failure or postoperative venous thrombosis but are associated with a lower number of reexplorations in the operating room even after accounting for differences in flap types and surgeons.

A Fully Automated High-Throughput Zebrafish Behavioral Ototoxicity Assay.

Zebrafish animal models lend themselves to behavioral assays that can facilitate rapid screening of ototoxic, otoprotective, and otoregenerative drugs. Structurally similar to human inner ear hair cells, the mechanosensory hair cells on their lateral line allow the zebrafish to sense water flow and orient head-to-current in a behavior called rheotaxis. This rheotaxis behavior deteriorates in a dose-dependent manner with increased exposure to the ototoxin cisplatin, thereby establishing itself as an excellent biomarker for anatomic damage to lateral line hair cells. Building on work by our group and others, we have built a new, fully automated high-throughput behavioral assay system that uses automated image analysis techniques to quantify rheotaxis behavior. This novel system consists of a custom-designed swimming apparatus and imaging system consisting of network-controlled Raspberry Pi microcomputers capturing infrared video. Automated analysis techniques detect individual zebrafish, compute their orientation, and quantify the rheotaxis behavior of a zebrafish test population, producing a powerful, high-throughput behavioral assay. Using our fully automated biological assay to test a standardized ototoxic dose of cisplatin against varying doses of compounds that protect or regenerate hair cells may facilitate rapid translation of candidate drugs into preclinical mammalian models of hearing loss.

The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials.

OBJECTIVE: To determine the effects of patient navigation (PN) on healthcare utilization outcomes using meta-analysis and the quality of evidence. METHODS: Medical and social science databases were searched for randomized controlled trials published in English between 1989 and May 2015. The review process was guided by PRISMA. Included studies were assessed for quality using the Downs and Black tool. Data were extracted to assess the effect of navigation on: health screening rates, diagnostic resolution, cancer care follow-up treatment adherence, and attendance of care events. Random-effects models were used to compute risk ratios and I2 statistics determined the impact of heterogeneity. RESULTS: Of 3985 articles screened, 25 articles met inclusion criteria. Compared to usual care, patients who received PN were significantly more likely to access health screening (OR 2.48, 95% CI, 1.93-3.18, P<0.00001) and attend a recommended care event (OR 2.55, 95% CI, 1.27-5.10, P<0.01). PN was favoured to increase adherence to cancer care follow-up treatment and obtain diagnoses. Most studies involved trained lay navigators (n=12) compared to health professionals (n=9). CONCLUSION: PN is effective to increase screening rates and complete care events. PRACTICE IMPLICATIONS: PN is an effective intervention for use in healthcare.

Predictors of survival in parotid adenocarcinoma not otherwise specified: a National Cancer Database study of 3155 patients.

BACKGROUND: Parotid adenocarcinoma not otherwise specified (PANOS) is a common parotid cancer, but studies specifically on this subject are limited. METHODS: We conducted a retrospective review of the National Cancer Database. RESULTS: Ten percent of all parotid cancers were PANOS (n = 3155). Median age was 67 years. Most patients were men (62.8%) with high-grade histology (67.2%). Regional metastasis was common (35.9%), whereas occult nodal metastasis (20.2% overall) was less frequent in non-high-grade lesions (8.5% vs 31.6%; p < .001). Distant metastasis was rare (7.9%). Five-year overall survival (OS) was 47%. In multivariate analysis, age, regional metastasis, distant metastasis, high-grade, and T classification were predictors of lower survival. Patients with stage III to IV disease receiving surgery and radiotherapy had a better OS than those receiving surgery alone (51% vs 41%; p < .001). CONCLUSION: PANOS is an aggressive disease with frequent regional metastasis and low survival. Numerous variables are associated with worse survival. © 2016 Wiley Periodicals, Inc. Head Neck 38:1208-1212, 2016.

Benign Parotid Tumors.

This article reviews the epidemiology, embryology, risk factors, clinical presentation, diagnostic work-up, and basic management principles for the more common benign parotid neoplasms. The various histopathologies are also discussed and summarized.

Cardiac rehabilitation referral and enrolment across an academic health sciences centre with eReferral and peer navigation: a randomised controlled pilot trial.

OBJECTIVES: To describe (1) cardiac rehabilitation (CR) referral across cardiac units in a tertiary centre with eReferral; (2) characteristics associated with CR referral and enrolment and (3) the effects of peer navigation (PN) on referral and enrolment. This pilot was a 2 parallel-arm, randomised, single-blind trial with allocation concealment. SETTING: 3 cardiac units (ie, interventional, general cardiology, and cardiac surgery) in 1 of 2 hospitals of a tertiary centre. PARTICIPANTS: CR-eligible adult cardiac inpatients were randomised to PN or usual care. 94 (54.7%) patients consented, of which 46 (48.9%) were randomised to PN. Outcomes were ascertained in 76 (80.9%) participants. INTERVENTION: The PN (1) visited participant at the bedside, (2) mailed a card to participant's home reminding about CR and (3) called participant 2 weeks postdischarge to discuss CR barriers. OUTCOME MEASURES: The primary outcome of enrolment was defined as participant attendance at a scheduled CR intake appointment (yes/no). The secondary outcome was referral. Blinded outcome assessment was conducted 12 weeks postdischarge, via CR chart extraction. RESULTS: Those who received care on the cardiac surgery unit (77.9%) were more likely to be referred than those treated on the general cardiology (61.1%) or interventional unit (33.3%; p=0.04). Patients who had cardiac surgery, hypertension and hyperlipidaemia were significantly more likely, and those with congenital heart disease, cancer and a previous cardiac diagnosis were less likely to be referred. Participants referred to a site closer to home (76.2% of those referred) were more likely to enrol than those not (23.7%, p<0.05). PN had no effect on referral (77.6%, p=0.45) or enrolment (46.0%, p=0.24). CONCLUSIONS: There is wide variability in CR referral, even within academic centres, and despite eReferral. Referral was quite high, and thus, PN did not improve CR utilisation. Results support triaging patients to the CR programme closest to their home. TRIAL REGISTRATION NUMBER: NCT02204449; Results.

Lymphoepithelial carcinoma of the major salivary glands: Predictors of survival in a non-endemic region.

INTRODUCTION: Lymphoepithelial carcinoma (LEC) of the salivary glands is extremely rare worldwide, with studies limited to small case reports and case series from endemic areas (Southern China, Arctic Inuits) and strong association to Epstein Barr Virus (EBV). Studies on non-endemic regions are even more limited given the reality of only sporadic cases in these areas. Using the National Cancer Database (NCDB), we present the largest study on salivary LEC from a non-endemic region, the United States. METHODS: A retrospective review of the NCDB from 1998-2012 for LEC of the major salivary glands was performed. Demographic and clinical variables were extracted for analysis. Multivariate COX regression was used to assess predictors of survival. RESULTS: Two hundred and thirty-eight cases were identified (0.66% of all salivary cancers). Median age at diagnosis was 62 with peak incidence in ages 50-70. Most patients were Caucasian (81.2%), without gender preference. Regional metastasis was common (45.1%) and did not significantly impact survival. Distant metastasis was rare (2%). Overall survival (OS) at 5- and 10 years was 77% and 56%. Surgery and radiotherapy significantly showed better survival outcomes than surgery alone (p<0.001). Age >62, advanced stage, and dual modality therapy were significant predictors of survival in multivariate analysis. CONCLUSION: Lymphoepithelial carcinoma in the US mostly affects an older, Caucasian demographic. Regional metastasis is common and survival is fair at 5- and 10 years. Surgery and radiation are recommended for early and advanced disease stages. Age, stage, and therapy are significant predictors of survival outcomes.

Treatment and Survival Trends in Glottic Carcinoma in Situ and Stage I Cancer From 1988 to 2012.

OBJECTIVE: To identify trends in treatment and survival for patients with stage I glottic cancer and glottic carcinoma in situ (CIS). METHODS: The 18-registry SEER data were analyzed for CIS and stage I glottic cancer. Treatment variables and observed and relative survival were assessed separately for stage I and glottic CIS. RESULTS: Among 14 025 cases of stage I glottic cancer identified from 1988 to 2012, radiation was the most common treatment for all eras. An increase in surgical treatment occurred with a decline in combination therapy. There were 3169 cases of glottic CIS, with surgery the most common initial treatment but with radiotherapy increasing across the years. Relative survival was similar for treatment type and era of diagnosis. Among the 3738 patients with glottic CIS, 5.4% went on to develop invasive glottic carcinoma of any stage, with invasive cancer more common in patients treated by surgery alone compared to radiation or surgery with radiation. CONCLUSIONS: Despite changes in treatment modalities for CIS and stage I glottic cancer, there have not been significant changes in survival for CIS, with slightly improved survival for treatment with surgery alone. Patients treated with surgery alone had an increased rate of subsequent invasive cancer.

Airway algorithm for the management of patients with a King LT.

OBJECTIVES/HYPOTHESIS: To discuss an algorithm for managing the airway in patients presenting with a King LT in place. STUDY DESIGN: Case series at a single institution with planned chart review. METHODS: This study reviewed the management of three patients who presented to a tertiary academic medical facility emergency department following placement of a King LT at an outside hospital or in the field. Clinical history at admission as well as each patient's hospital course was evaluated. We discuss the management of the airway in each of these cases and use these to help design an algorithm for improving outcomes in patients with a King LT in place. RESULTS: In each of the three cases presented, the Otolaryngology Department was consulted for definitive airway management. In two of these patients, the airway was successfully secured using endotracheal intubation. Only one patient required tracheostomy. We discuss an algorithm for managing these patients to obtain a safe airway, which includes assessing the airway with flexible endoscopy and then proceeding with intubation by the Seldinger technique or intubation using a video laryngoscope. In some cases, tracheostomy will be required to definitively secure the airway. CONCLUSIONS: The King LT is a valuable tool available in the field to help to temporarily secure the airway. Otolaryngologists should have an appropriate airway algorithm for managing patients with a King LT in place to minimize the need for a tracheostomy.

Local repair of persistent tracheocutaneous fistulas.

Tracheocutaneous fistulas may persist after tracheostomy. Suture closure of the fistula may result in complications, including infection, wound dehiscence, and pneumomediastinum. We present a simplified and relatively safe technique to close persistent fistulas that may be performed under local anesthesia. A retrospective chart review was performed on 13 patients who were successfully treated, including 1 with incomplete closure that was successfully addressed by additional procedures. Our review included analysis of reported risk factors for persistence of tracheocutaneous fistulas: previous irradiation of the neck, an extended duration of cannulation, previous tracheostomies, obesity, and use of a Bjork flap or 4-flap epithelial-lined tracheostomy. All 13 patients in the study were found to have at least 1 of these risk factors.

Use of the King LT for emergency airway management.

OBJECTIVE: To discuss the role of the King LT reusable supraglottic airway in emergency airway management. DESIGN: Retrospective case series review. SETTING: Tertiary academic medical facility. PATIENTS: We studied patients who presented to the emergency trauma center having undergone intubation at an outside facility or at the scene of the incident. The otolaryngology service was consulted for definitive management of the airway. MAIN OUTCOME MEASURE: Airway evaluation and management once the King LT has been placed. RESULTS: Six patients with known prehospitalization use of the King LT presented to the emergency trauma center and subsequently required emergency tracheostomy for establishment of a secure airway. Fiberoptic and/or direct laryngoscopic evaluation performed with the tube in place failed to reveal whether safe oral endotracheal intubation could be performed because of visualization problems. Examination after tracheostomy and removal of the King LT revealed that in 2 patients, orotracheal intubation would have been difficult or impossible, whereas another 4 patients could have been intubated. One patient had prehospitalization placement of a King LT, which resulted in subcutaneous emphysema because of placement within the mediastinum. The patient was able to be successfully intubated and did not require tracheostomy. CONCLUSIONS: The King LT offers benefits in emergency situations, but evaluation of the airway is challenging and often necessitates tracheostomy for establishment of a safe and secure airway. Even if tracheostomy is not required, serious complications may occur.

Beta-lactams and beta-lactamase-inhibitors in current- or potential-clinical practice: a comprehensive update.

The use of successive generations of beta-lactams has selected successive generations of beta-lactamases including CTX-M ESBLs, AmpC beta-lactamases, and KPC carbapenamases in Enterobacteriaceae. Moreover, this cephalosporin resistance, along with rising resistance to fluoroquinolones, is now driving the use of carbapenems and unfortunately the carbapenem resistance has emerged markedly, especially in Acinetobacter spp. due to OXA- and metallo-carbapenemases. The industry responded to the challenge of rising resistance and recently developed some novel beta-lactams such as ceftobiprole, ceftaroline etc. and many beta-lactam compounds, including beta-lactamase-inhibitors, such as BMS-247243, S-3578, RWJ-54428, CS-023, SMP-601, NXL 104, BAL 30376, LK 157, and so on are under trials. This review provides the comprehensive accounts of the developments in penicillins, cephalosporins, carbapenems, and beta-lactamase-inhibitors, and the insight about medicinal chemistry, mechanism(s) of action and resistance, potential strategies to overcome resistance due to beta-lactamases, and also the recent advancements in the development of newer beta-lactam compounds; some of which are still under trials and yet to be classified. This review will fill the gap since previously published reviews and will serve as a comprehensive update on the current topic.