Recurrent Zenker's Traction Diverticulum After Cervical Spine Surgery: Lessons Learned.

This is a report of our institutional experience regarding pharyngoesophageal diverticula formation following anterior cervical spine surgery (ACSS). It is a retrospective chart review of institutional patients from January 2008 to May 2020. Patients at our institution were identified by our two senior authors. Inclusion criteria included patients > 18 years old, a history of prior ACSS, and a confirmed diagnosis of pharyngoesophageal diverticulum with radiographic imaging. Three patients were identified to have an ACSS-related diverticulum. The case presentations describe surgical management and the subsequent postoperative course. One patient had a particularly complicated course with recurrent diverticulum formation despite prior excision. The patient continued to have dense scar tissue adhering the posterior esophageal wall to the nearby cervical spine plates, despite prior excision and rotation of nearby tissue. This difficult case demonstrated the need for an open and aggressive approach. ACSS-related diverticula that form in patients with a history of prior anterior cervical spine surgery appear to be a form of traction diverticulum due to dense scar tissue that adheres the pharyngoesophageal mucosa to the adjacent cervical spinal plate. This type of diverticulum differs from Zenker's diverticulum. Surgical management is recommended to resolve patients' symptoms.

No-Show Rates in an Academic Otolaryngology Practice Before and During the COVID-19 Pandemic.

OBJECTIVE: Our objectives were to determine the no-show and nonattendance rate for an outpatient academic otolaryngology practice, to identify patient and systemic factors associated with nonattendance, and to evaluate the impact that the COVID-19 pandemic had on the rate of nonattendance. METHODS: This is a retrospective review of the Epic practice management and billing reports from all scheduled outpatient visits at a multi-physician, academic, general, and sub-specialty otolaryngology practice from January 2019 to December 2021. RESULTS: Over three years, 121,347 clinic visits were scheduled in the otolaryngology practice. The overall nonattendance rate was 18.3%. A statistically significant increase in nonattendance was noted during the COVID-19 pandemic (16.8% vs. 19.8%, p < 0.001). The rate of nonattendance in patients of younger age (under 18 years) (p <0.001), female gender (p=0.03), afternoon appointments (p=0.04), and extended time between the day of scheduling and the day of appointment (p <0.001) increased. Head and neck clinics were found to have the lowest nonattendance rates, while pediatric otolaryngology clinics had the highest (12.6% vs. 21.3%). On multivariate regression, younger age (p < 0.001), female gender (p=0.01), afternoon appointments (p< 0.001), and online self-scheduling (p< 0.001) were significantly associated with nonattendance. CONCLUSIONS: Both patient and appointment-related factors were found to impact rates of nonattendance in this academic otolaryngology practice. In this study, young age, female gender, afternoon appointments, and online self-scheduling were associated with increased nonattendance. In addition, the COVID-19 pandemic significantly impacted no-show rates across all otolaryngologic subspecialties.

Dysphagia After Prolonged Intubation in SARS-CoV-19 Patients: A Single Institution Retrospective Review.

OBJECTIVE: To determine the impact of various factors on swallowing in SARS-CoV-19 patients after prolonged intubation.  Methods: A retrospective chart review of SARS-CoV-19 patients intubated between February 2020 and March 2021 was performed. Independent variables, including duration and factors of intubation, and patient demographic characteristics were analyzed. Formal swallow studies were performed for patients who failed a screening swallow evaluation.  Results: Seventy-three individuals of 308 patients reviewed had a dysphagia score of ≤5. A total of 49% of patients' dysphagia resolved prior to discharge, with a median of eight days between extubation and the last evaluation. The median duration of intubation was 11 days. Increasing age, congestive heart failure, cerebrovascular disease, and hypertension were associated with dysphagia at the first and/or last evaluation. Hispanic ethnicity was associated with a decreased risk of dysphagia (all p<0.05).  Conclusions: Although various patient factors including age and congestive heart failure were associated with the development of dysphagia after prolonged intubation, the length of intubation was not.

Between a Rock and a Hard Place: Anticoagulating an Adolescent with Post-Tonsillectomy Massive PE: A Case Report.

OBJECTIVES: To report a case of a morbidly obese 17-year-old boy who presented 4 days post-tonsillectomy with acute deep venous thromboses and a massive pulmonary embolism. To describe a protocol and decision-making tree for providing anticoagulation in the immediate post-tonsillectomy period. METHODS: A chart review and review of the literature. RESULTS: The patient ultimately did well and had no bleeding from the tonsil beds or further thromboembolic complications. A review of the literature revealed no available data regarding the safety of anticoagulation in the immediate post-tonsillectomy period. CONCLUSIONS: We propose that if anticoagulation is needed within 14 days of tonsillectomy, submaximal anticoagulation with a reversible and titratable anticoagulant may be optimal. A multidisciplinary team approach is needed for these complex cases. Future reporting and investigation of anticoagulation post-tonsillectomy is needed.

Incidence of Vocal Cord Paralysis in Medullary Thyroid Cancer.

OBJECTIVE: Medullary thyroid cancer (MTC) is a neuroendocrine tumor that comprises 3-5% of all thyroid cancers in the United States. Vocal cord paralysis (VCP) may be due to involvement of the recurrent laryngeal nerve (RLN) preoperatively, or nerve sacrifice during surgery. The purpose of this study was to demonstrate the incidence of VCP in MTC and evaluate whether VCP has an impact on overall survival. METHODS: This was a retrospective chart review of patients with MTC treated at Loyola University Medical Center from 2007 to 2021. Information on demographics, cancer diagnosis and treatment, laboratory data, and survival were collected. RESULTS: A total of 79 patients were included in our study. 47 (59.5%) patients were female. The average age at the time of diagnosis was 51.3 years (SD 13.58). VCP was identified in 13 out of 79 (16.5%) patients. There were 71 patients with at least 1-year follow-up with median (Q1, Q3) years of 7.2 (3.9, 11.0). Those with VCP within 1 year had 7.2 (95% CI: 2.3, 22.7) times the risk of death compared to those without (p < 0.001). CONCLUSION: MTC is a rare thyroid cancer, however, its incidence is on the rise. Our study suggests that the incidence of VCP in these patients appears to be higher than seen in other thyroid malignancies, and VCP is associated with a statistically significant negative impact on survival. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:890-894, 2023.

Muscle-Nerve-Nerve Grafting Improves Facial Reanimation in Rats Following Facial Nerve Injury.

Nerve injury resulting in muscle paralysis from trauma or surgery is a major medical problem. Repair of such injuries with existing nerve grafting and reconstructive techniques often results in less than optimal outcomes. After previously demonstrating significant return of function using muscle-nerve-muscle (MNM) grafting in a rat facial nerve model, this study compares a variant of the technique, muscle-nerve-nerve (MNN) neurotization to MNM and interposition (IP) nerve grafting. Thirty male rats were randomized into four groups (1) control with no intervention, (2) repair with IP grafts, (3) MNM grafts and (4) MNN grafts. All groups had the buccal and marginal mandibular branches of the right facial nerve resected. Return of vibrissae movement, orientation, and snout symmetry was measured over 16 weeks. Functional recovery and muscle atrophy were assessed and quantified. All interventions resulted in significant improvement in vibrissae movement and orientation as compared to the control group (p < 0.05). The MNM and MNN groups had significantly less time to forward vibrissae movement as compared to controls (p < 0.05), and a large number of animals in the MNN group had coordinated vibrissae movement at 16 weeks. MNN and IP grafts retained significantly more muscle mass as compared to control (p < 0.05). Thus, MNN grafting is a promising adjuvant or alternative technique for reanimation for patients with unilateral peripheral nerve injury who are not candidates for primary neurorrhaphy.

The suction-assisted endoscopic suture technique: A simple method for endotracheal suturing.

BACKGROUND: Silicone stents are commonly employed to treat subglottic stenosis. A frequent complication is the tendency of stents to migrate. As such, various techniques to secure stents have been developed over the years, none of which have gained large popularity. We present a novel, low-cost, and easy-to-perform technique herein. OBJECTIVES: To describe a novel surgical technique to secure silicone stents and prevent migration for management of subglottic stenosis. MATERIALS AND METHODS: After standard excision and dilation of stenotic portions in the subglottic or trachea. A silicone stent is introduced in a standard fashion. To secure the stent, an 18-G needle loaded with braided suture is inserted through skin, trachea, and stent. Endoscopic visualization then permits the surgeon to grasp the suture with forceps. A separate transcutaneous puncture site is performed with an 18-G needle attached to a 10-cc syringe (plunger removed) and blue tip suction within the empty syringe, creating an airtight suctioning tool. The grasped suture is gently introduced into the eye of the needle and quickly travels into the 10-cc syringe with suction assist, leaving both extracorporeal ends of the suture to tie. RESULTS: This stitch has been employed on seven occasions on four patients. There have been no episodes of stent migration. A laboratory model found the 18-G needle and braided 3-0 suture performed optimally. CONCLUSIONS: We present a novel surgical technique to secure silicone stents in management subglottic or tracheal stenosis. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 130:E346-E348, 2020.

Delayed Pharyngeal Migration of a Mandibular Fixation Screw 30 Years After Orthognathic Surgery.

There have been reports of migrated screws after cervical spine procedures; however, similar cases after orthognathic procedures are rare. A 48-year-old female patient presented with a 6-month history of left-sided neck pain and left-sided otalgia. Her medical history was relevant for orthognathic surgery 30 years earlier. Flexible fiberoptic endoscopy and a computed tomography scan showed the tip of a fixation screw in the lateral pharyngeal wall on the left side. The patient was taken to the operating room for direct microlaryngoscopy using a carbon dioxide laser, with successful removal of the screw. We report a safe method for removal of pharyngeal foreign bodies.

Effects of the Number of Muscle-Nerve-Muscle Grafts on Rat Facial Nerve Functional Recovery.

INTRODUCTION: Facial nerve denervation can be devastating for patients. Primary neurorrhaphy and interposition (IP) nerve grafting are common reinnervation techniques. Muscle-nerve-muscle (MNM) grafting is a lesser known alternative. After previously demonstrating significant return of function using MNM grafting in a rat facial nerve model, the authors compare the use of multiple MNM nerve grafts with that of single MNM and IP nerve grafts. METHODS: Thirty-six male rats were randomized into 4 groups: (1) repair with IP grafts, (2) 1 MNM graft, (3) 3 MNM grafts, and (4) control with no intervention. All groups had the lower zygomatic, buccal, and marginal mandibular branches of the right facial nerve removed. Return of movement and snout symmetry was measured over 16 weeks. Axonal regeneration and muscle atrophy were assessed and quantified. RESULTS: All intervention groups had significantly improved movement and snout symmetry compared with control. Rats in the IP group had significantly increased axon density compared with those in the MNM groups but with smaller axonal diameter than control rats. No difference in axon density or diameter was observed between MNM groups. Use of 3 MNM grafts and IP grafts resulted in preservation of similar muscle mass compared with the control and 1-MNM groups. CONCLUSION: MNM grafting may be an alternative when other reanimation techniques are not possible. LEVEL OF EVIDENCE: NA.

Hyalinizing Clear Cell Carcinoma of the Tonsil: A Case Report.

Hyalinzing clear cell carcinoma is a rare tumor of the oral cavity and is even more rarely located in the tonsil. Here, we present a case report of a pedunculated tonsillar mass in a nearly asymptomatic patient that was present for 2 years prior to removal. Complete surgical excision was achieved and no adjuvant therapy was recommended. We include a discussion of this rare pathology and its typical clinical presentation and course.

Muscle-Nerve-Muscle Grafting for Facial Reanimation in Rats.

OBJECTIVE: Facial paralysis is a devastating condition leaving patients with a myriad of aesthetic and functional consequences. Muscle-nerve-muscle (MNM) neurotization is a reinnervation technique that involves implanting an autogenous nerve graft as a conduit between an innervated "donor" muscle and a denervated "recipient" muscle. We investigated the use of MNM reinnervation, alone or in combination with electrical stimulation (ES) and testosterone propionate (TP) in comparison to nerve reanastomosis (RE), on functional recovery following rat facial nerve injury. METHODS: Thirty-one male, Sprague-Dawley rats were assigned to groups: no graft (control), MNM grafting alone (MNM), MNM grafting with ES and TP (MNM+ES+TP), or RE. Harvested right facial nerve branches were used as the MNM graft. Functional recovery was assessed by behavioral observations and electromyographic recordings. RESULTS: The MNM grafting improved muscle tone and vibrissae movement. The ES+TP treatment further enhanced muscle tone as well as reduced recovery time for coordinated movement in a manner that is comparable to those of RE. Electromyographic recordings demonstrated electrical conductance across all MNM grafts. CONCLUSION: These data have important implications for patients with unilateral paralysis from facial or laryngeal nerve injury, particularly those who are not candidates for nerve reanastomosis.

Vocal Fold Paralysis after Esophagectomy for Carcinoma.

OBJECTIVES: (1) To recognize factors that contribute to vocal fold paralysis (VFP) after esophagectomy. (2) To describe the morbidity associated with VFP after esophagectomy. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: The medical records of 91 patients undergoing esophagectomy for malignancy were reviewed (2008-2014). Twenty-two patients with postoperative VFP were compared with 69 patients without VFP with regard to preoperative variables, surgical approach (transcervical vs other), and postoperative outcomes. A subset analysis of cervical approaches was performed, including those where an otolaryngologist assisted. RESULTS: There were no significant differences in preoperative variables between patients with and without VFP. Cervical approaches were associated with increased VFP (P < .0001). Recurrent laryngeal nerve (RLN) identification was associated with increased VFP (P = .0001). RLN dissection by head and neck surgeons was associated with decreased VFP (P = .0223). Patients with VFP had longer lengths of stay (P = .0078), higher rates of tracheotomy (P = .0439), and required more outpatient swallow evaluations (P = .0017). Mean time to diagnosis of VFP was 45.6 days (median, 7.5 days). CONCLUSIONS: Cervical approaches are associated with increased VFP in patients undergoing esophagectomy for malignancy. When cervical approaches and mobilization are required, the inclusion of an experienced cervical surgeon to identify the RLN may improve the rate of postoperative VFP. Patients with VFP after esophagectomy experience significantly more morbidity. Due to the potential delay in diagnosis and treatment of postoperative VFP, routine assessment of inpatient vocal fold function may be beneficial.

Dystonias of the head and neck: An overview.

Dystonias are a group of disorders characterized by muscle contractions that can produce twisting and repetitive movements or abnormal postures. Dystonias of the head and neck region, except for spasmodic dysphonia, are rarely described in the otolaryngology literature. Ironically, it is the otolaryngologic surgeon's knowledge of anatomy and physiology of the head and neck that can be of greatest benefit for patients suffering from these disorders. Medical and surgical treatment options are available in treating this disorder. This article is intended to serve as an introduction and overview of dystonias for the otolaryngologist-head and neck surgeon.

Jaw-opening dystonia: Quality of life after botulinum toxin injections.

The objective of this study was to investigate quality-of-life outcomes in patients with jaw-opening oromandibular dystonia who had received treatment with botulinum neurotoxin injections. The Glasgow Benefit Inventory (GBI) was used as a post-intervention questionnaire to measure patient benefit. Twenty-five questionnaires were sent to patients. Of the 12 patients who returned the form (48% response rate), the mean scores for the general GBI subscore (p = 0.001), the social support GBI subscore (p = 0.031), and the physical health GBI subscore (p = 0.002) demonstrated statistically significant benefit from the injections. No scores demonstrated a negative impact. Botulinum neurotoxin injections were demonstrated to benefit the quality of life in patients suffering from jaw-opening oromandibular dystonia.

Use of the ON-Q pain pump management system in the head and neck: preliminary report.

Management of postoperative pain can be critical to the success of a patient's recovery following head and neck surgery. Various medications and delivery methods have been described. They attempt to maximize patients' comfort while minimizing many of the medications' potential side effects. Continuous wound perfusion pain management systems are being used in various surgical specialties. However, this is the first paper to describe the use of one such pain management system (On-Q) in thyroid and parotid surgeries. Statistically significant less levels of pain, use of opioids and nausea/vomiting were noted in patients who used the On-Q system. There were no complications. Use of continuous wound perfusion management systems should be further investigated and highly considered in patients undergoing various head and neck procedures.