Indications and versatility of the posterior tibial artery flap in head and neck reconstruction.

Importance Free tissue transfer for reconstruction of the head and neck requires complicated repair of complex anatomy. The posterior tibial flap is a free tissue flap that has viability and versatility to be used for complex reconstructions that is not offered by other free flaps. OBJECTIVE: The posterior tibial artery flap is a perforator flap which is found between the flexor digitorum longus and the soleus. It has been described as both a pedicled flap for lower extremity reconstruction as well as a free flap, including for head and neck reconstruction. Limited data exists on the subject in the English literature. The objective of this study is to present our experience with the flap in the head and neck. DESIGN: Retrospective review of cases from a single institution between October 2019 and May 2023. Primary indications included patients whose defects were felt to be larger than a conventional radial forearm free flap that were not well served by the anterolateral thigh flap, either because of body habitus or room for the associated muscle. SETTING: Tertiary academic hospital system performing free tissue transfer reconstruction of within the head and neck. RESULTS: Fifteen patients underwent posterior tibial artery free flap during the study period. Indications for flap reconstruction included oral cavity, tongue, oropharynx and skin of the scalp and forehead. Flap size ranged from 24cm2 to 143cm2. Only one flap failure was observed. Flap harvest time was universally under forty-six minutes, and as little as thirty-two. CONCLUSION: The posterior tibial artery flap is a useful option in head and neck reconstruction. It provides an intermediary in size and bulk between the radial forearm and the anterolateral thigh flap. Additionally, it provides a straightforward harvest with minimal donor site morbidity.

Naso-Orbital-Ethmoid Fracture Repair Techniques: A Systematic Review.

PURPOSE: Naso-orbital-ethmoid (NOE) complex fractures present a challenge to repair. The classification system used to categorize the fracture type was established in 1991 based off the medial canthal tendon attachment. The primary objective was to systematically review the literature outlining repair techniques for NOE fracture after the adoption of the Markowitz classification system. METHODS: A systematic search was performed in PubMed, Embase, and Web of Science to identify peer-reviewed research. Eligible studies were peer-reviewed articles reporting on operative techniques used to repair NOE fractures in adult patients after 1991. Two investigators independently reviewed all articles and extracted data. Level of evidence was assessed by Oxford Center for Evidence-based Medicine guidelines. RESULTS: This review identified 16 articles that met inclusion/exclusion criteria representing 517 patients. One article outlined a closed reduction technique with transnasal wiring. The remaining articles discussed open approaches with various exposure techniques, most common being the coronal incision. Miniplates and screws were most often implemented for rigid fixation as well as transnasal wiring to repair disrupted medial canthal tendon and canthal bearing bone in Type 2 and 3 NOE fractures. Ten of the studies included in this review had a level of evidence of 4. CONCLUSIONS: NOE fractures present a complex fracture pattern and challenge to repair. New exposure techniques and multidisciplinary approaches have been described. However, fixation techniques have remained relatively consistent through the years. Surgeon preference and comfort with performing the specific techniques leads to the best patient outcomes. With the low level of evidence referenced, more robust research is needed to evaluate these techniques.

Breast and thyroid cancer: A multicenter study with Accrual to Clinical Trials Network.

OBJECTIVE: To investigate a possible link between breast and thyroid cancer. METHODS: A multicenter retrospective review of patients in the electronic medical records of six Accrual to Clinical Trial (ACT) institutions with both breast cancer and thyroid carcinoma. Each center queried its data using a predefined data dictionary. Information on thyroid and breast cancer included dates of diagnosis, histology, and patient demographics. RESULTS: A random-effects model was used. There were 4.24 million women's records screened, 44 605 with breast cancer and 11 846 with thyroid cancer. The relative risks observed at each institution ranged from 0.49 to 13.47. The combined risk ratio (RR) estimate was 1.77 (95% confidence interval: 0.50-5.18). CONCLUSION: There was no association between the risk of developing thyroid cancer and being a breast cancer survivor compared to no history of breast cancer, but the range of relative risks among the participating institutions was wide. Our findings warrant further study of more institutions with larger sample size. Additionally, further analysis of the significance of regional RR differences may be enlightening.

Remote monitoring of head and neck free flaps using near infrared spectroscopic tissue oximetry.

PURPOSE: Near infrared spectroscopy (NIRS) measures tissue oximetry and perfusion of free tissue transfer with the advantage of remote wireless monitoring for free tissue transfer. It has been widely used in breast and extremity reconstruction but has had limited adoption in the head and neck. MATERIALS AND METHODS: A retrospective review of head and neck microvascular reconstruction by three different surgical services over 15 months at one tertiary care hospital was performed. Demographics, flap type, monitoring technique, complications, and flap outcomes were recorded. Monitoring techniques were (1) implantable/handheld Doppler or (2) NIRS. Flap monitoring outcomes were evaluated using multivariate analysis. RESULTS: 119 flaps were performed by four surgeons with a success rate of 92% (109/119). Flaps were monitored with Doppler (40%) or NIRS (60%). There was no difference in flap success based on monitoring technique. An ROC analysis identified that the optimal cutoff in immediate StO2 for classifying flap success at discharge was 68%. CONCLUSIONS: NIRS was successfully implemented in a high-volume head and neck reconstructive practice. NIRS remote monitoring allowed for flap surveillance without requiring in-hospital presence and was able to identify both arterial and venous compromise.

Clinical vs Microscopic Extranodal Extension and Survival in Oropharyngeal Carcinoma in the Human Papillomavirus Era.

OBJECTIVE: Extranodal extension (ENE) is known to be associated with poor outcomes in head and neck squamous cell carcinoma. The objective of this study is to examine the impact of extent of ENE on survival in oropharyngeal carcinoma in the human papillomavirus (HPV) era. STUDY DESIGN: Retrospective database review. SETTING: Review of the National Cancer Database. SUBJECTS AND METHODS: The National Cancer Database was used to examine surgically treated head and neck squamous cell carcinoma of the tonsil and base of tongue from 2010 to 2015. Nodes available for pathologic examination were classified as ENE negative (-), ENE clinically (+), or ENE (+) on pathology only. The primary outcome was overall survival. Cox regression modeling was used to examine the effect of ENE on survival while controlling for patient demographics, HPV status, stage, adjuvant radiation, and chemotherapy. RESULTS: Of the 66,106 patients identified, 16,845 were treated with surgery ± adjuvant therapy, 8780 of whom were known HPV+. Overall 5-year survival for this group was 86%. Documented ENE was associated with over a 60% decrease in survival for clinical (hazard ratio [HR], 1.63) and pathologic (HR, 1.62) ENE compared to negative ENE, after adjustment for stage, adjuvant radiation ± chemotherapy, HPV, and other variables. No significant differences were found between clinical and pathologic ENE (HR, 1.001). CONCLUSION: While both surgically resected clinical and pathologic ENE are associated with decreased survival, no significant differences are observed between the two. The impact of these observations on potential de-escalation therapeutic strategies requires further study.

Chronic Opioid Use after Laryngeal Cancer Treatment: A VA Study.

OBJECTIVE: To investigate opioid utilization in veterans undergoing laryngeal cancer treatment and describe the risk of chronic use after treatment cessation. STUDY DESIGN: A retrospective cohort study. SETTING: A single Veterans Health Administration site. SUBJECTS AND METHODS: Veterans with newly diagnosed and treated laryngeal cancer with attributable opioid use from 2005 to 2015. Milligram morphine equivalents (MMEs) were calculated from 90 days prior to diagnosis for up to 1 year. Adjuvant pain medications filled 30 days prior to and up to a year from the date of diagnosis were assessed. RESULTS: Of 74 veterans with biopsy-proven laryngeal carcinoma, 73 (98.6%) were male and 71 (96%) were white. Forty-three (58%) patients were stage 0/I/II; 31 (42%) were III/IV. Eleven (14.9%) were treated with surgery alone, 35 (47.3%) with radiation alone, and 28 (38%) with multimodal therapy. Twenty-four (32.4%) patients had preexisting opioid use prior to cancer diagnosis. Patients who used opioids more than 30 days prior to date of diagnosis were found to be 10 times more likely to have persistent opioid use at 90 days (P = .0024) and 8 times more likely to have chronic use at 360 days (P = .0041). Maximum MMEs within 1 year of diagnosis were significantly associated with chronic use at 90 days (P = .00045) and chronic use at 360 days (P = .0006). CONCLUSION: Preexisting opioid use and maximum MMEs are strongly associated with chronic opioid use among veterans treated for laryngeal carcinoma independent of stage and treatment type.

No-Show Rates in Employed Otolaryngology Practice.

OBJECTIVE: To report baseline no-show rates in the hospital-employed otolaryngology practice setting and to identify factors that may affect clinic show rates that are targets for potential improvement. STUDY DESIGN: Retrospective chart review. METHODS: Electronic medical records from October 2012 through July 2014 of a hospital-employed otolaryngology practice were reviewed. Patients were classified by insurance type: commercial, Medicare, Medicaid, and self-pay. Clinic visits were classified as new patient, follow-up, or postoperative. No-show rates were tabulated for each type of clinic visit and compared. Factors to improve no-show rates are discussed. RESULTS: There was an overall no-show rate of 8.3% for 5817 scheduled clinic visits. Among visit types, follow-up visits had the highest no-show rates. Among insurance types, Medicaid had the highest no-show rates. New patient Medicaid patients, follow-up Medicaid patients, and follow-up commercial insurance patients had the highest rate of no-shows among visit/insurance type combinations. Persistent reminders are a key factor in improving rate of clinic visit adherence. CONCLUSION: A previously unreported baseline no-show rate was established for hospital-employed otolaryngology clinics. The utilization of repeated, live-person reminders to mitigate the impact of clinic no-show rates needs to be further investigated.

Outcomes in surgically resectable oropharynx cancer treated with transoral robotic surgery versus definitive chemoradiation.

PURPOSE: Optimal treatment strategies for the management of oropharyngeal squamous cell carcinoma (OPSCC) remain unclear. The objective of this study is to examine the role of transoral robotic surgery (TORS) on functional and treatment outcomes. MATERIALS AND METHODS: A retrospective review of patients with OPSCC (tonsil/base of tongue) who underwent TORS with neck dissection± adjuvant therapy between January 2011 to December 2016 were compared to a stage matched cohort of patients treated with primary chemoradiation. Demographic, treatment, and outcome data were collected. RESULTS: 54 patients received primary chemoradiation and 65 patients (surgical group) received TORS ± adjuvant therapy for clinically staged disease meeting study criteria. 25% (N = 17) were treated with surgery alone. The remainder of the surgical group received postoperative radiation (N = 48), half of which received adjuvant chemotherapy (N = 24) in addition to radiation. 63% (N = 41) of the patients did not have risk factors for chemotherapy. No differences in overall or disease free survival were observed with TORS compared to chemoradiation (p = 0.9), although Charlson Comorbidity Index (CCI) was higher in the surgical group (p = 0.01). The strongest predictor of prolonged gastrostomy tube use was not treatment, but rather co-morbidity (p = 0.03), with no significant differences beyond 12 months. CONCLUSION: Although no significant survival differences were observed across treatment groups, this was maintained despite increased comorbidity index in the surgical patients. Given the ability to de-escalate and/or eliminate adjuvant therapy, particularly in a less healthy population, TORS would appear to be the viable treatment option it has become.

Factors associated with patient no-show rates in an academic otolaryngology practice.

OBJECTIVES/HYPOTHESIS: Factors affecting access to healthcare is an expanding area of research. This study seeks to identify factors associated with no-show rates in an academic otolaryngology practice to improve clinical efficiency and patient access to care. STUDY DESIGN: Retrospective review. METHODS: A retrospective review of scheduled clinical appointments from February 1, 2015 to January 30, 2016 at a single academic otolaryngology department was performed. Statistical analysis was completed to examine the association of no-show rates with the following: otolaryngology subspecialty, clinic location (e.g., main campus vs. satellite), patient demographic factors, attending seniority, temporal factors, insurance types, rurality, and visit type. RESULTS: There was an overall no-show rate of 20% for 22,759 scheduled clinic visits. Satellite clinics had the highest no-show rates at 25% (P < .001). New patient visits had the highest no-show rate at 24% (P < .001). Among subspecialties, facial plastic surgery had the lowest no-show rate (12.6%), whereas Pediatrics had the highest (23%) (P < .001). No significant association between gender and no-show rates was observed (P = .29), but patients over 60 years old had the lowest no-show rate (12.7%, P < .0001). Patients with Medicaid (28%), Medicare (15.3%), and commercial insurance (12.9%) had significantly different overall no-show rates (P < .0001). CONCLUSIONS: Increased clinic no-show rates are associated with satellite clinics, new patient visits, younger age, and insurance type. No-show rates varied among subspecialties. Further investigation is warranted to assess barriers to appointment compliance and to develop interventions to improve access to care. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:626-631, 2018.

Promotion of early pediatric hearing detection through patient navigation: A randomized controlled clinical trial.

OBJECTIVES/HYPOTHESIS: To assess the efficacy of a patient navigator intervention to decrease nonadherence to obtain audiological testing following failed screening, compared to those receiving the standard of care. METHODS: Using a randomized controlled design, guardian-infant dyads, in which the infants had abnormal newborn hearing screening, were recruited within the first week after birth. All participants were referred for definitive audiological diagnostic testing. Dyads were randomized into a patient navigator study arm or standard of care arm. The primary outcome was the percentage of patients with follow-up nonadherence to obtain diagnostic testing. Secondary outcomes were parental knowledge of infant hearing testing recommendations and barriers in obtaining follow-up testing. RESULTS: Sixty-one dyads were enrolled in the study (patient navigator arm = 27, standard of care arm = 34). The percentage of participants nonadherent to diagnostic follow-up during the first 6 months after birth was significantly lower in the patient navigator arm compared with the standard of care arm (7.4% vs. 38.2%) (P = .005). The timing of initial follow-up was significantly lower in the navigator arm compared with the standard of care arm (67.9 days after birth vs. 105.9 days, P = .010). Patient navigation increased baseline knowledge regarding infant hearing loss diagnosis recommendations compared with the standard of care (P = .004). CONCLUSIONS: Patient navigation decreases nonadherence rates following abnormal infant hearing screening and improves knowledge of follow-up recommendations. This intervention has the potential to improve the timeliness of delivery of infant hearing healthcare; future research is needed to assess the cost and feasibility of larger scale implementation. LEVEL OF EVIDENCE: 1b. Laryngoscope, 127:S1-S13, 2017.

Prognostic indicators and survival in salvage surgery for laryngeal cancer.

BACKGROUND: Perineural invasion (PNI) and lymphovascular invasion (LVI) are known to be poor prognostic indicators in primary surgery. The purpose of this study was to determine their impact on survival in the setting of salvage laryngectomy. METHODS: We conducted a retrospective review of patients who underwent salvage laryngectomy between 2006 and 2014. RESULTS: Seventy-eight patients were included in this study; PNI was diagnosed in 48 patients (61.54%) and LVI in 25 patients (32.05%). Median overall survival was 32 months; PNI was associated with decreased survival; and the unadjusted hazard ratio (HR) was 2.69 (P = .006). Cases of LVI trended toward a decreased survival; with an unadjusted HR of 1.74 (P = .076). On multivariate analysis, PNI, LVI, or both conferred decreased survival compared to having neither (P = .01). Extracapsular spread and nodal metastases significantly impacted survival, and positive margins trended toward significance. CONCLUSION: The presence of PNI, LVI, nodal disease, and extracapsular spread significantly affected survival in this cohort of patients with laryngeal cancer.

Patient compliance following isolated mandibular fracture repair.

OBJECTIVE: Compliance with postoperative care in the maxillofacial trauma population often is considered poor. This lack of follow-up does not seem to be a function of decreased access to care but rather its anticipated lack of utilization. The goal of this study is to identify what factors are associated with increased compliance in postoperative management of mandible fractures. STUDY DESIGN: Retrospective cohort study. METHODS: Using Current Procedural Terminology codes to identify maxillofacial injuries requiring operative repair, a subset of isolated mandibular fractures was identified. Age, gender, race, insurance type, travel distance, mandible fracture location, surgical approach, and complications were used as variables in univariate regression modeling to examine factors associated with compliance to postoperative care. RESULTS: Between 2010 and 2013, 344 isolated mandible fractures were identified. A total of 83.1% of patients made their first postoperative follow-up visit. Demographic data, fracture location, distance to medical center (odds ratio [OR] = 1, P = 0.75), type of repair, use of drains (OR = 1.27, P = 0.61), or nonabsorbable suture (OR = 1.44, P = 0.32) did not appear to be associated with compliance. No association between complications and postoperative compliance was observed (OR = 2.37, P = 0.17). Trends toward improved compliance were observed when evaluating insurance type and use of temporary fixation hardware. The presence of current tobacco use was found to be negatively associated with patient compliance (OR = 0.33, P < 0.01). CONCLUSION: Postoperative compliance after surgical repair is better than what is currently represented in the literature. It appears that postoperative compliance is dependent on patient-related factors more so than what can be modified by the surgeon. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2230-2235, 2017.

Barriers to Repair in Maxillofacial Trauma.

IMPORTANCE: Multiple factors can be associated with the delayed repair of maxillofacial injuries that may be associated with increased morbidity. OBJECTIVE: To assess factors affecting timing of repair and barriers which may exist in the management of maxillofacial trauma. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study at a tertiary care facility used the Current Procedural Terminology coding to identify adult patients undergoing operative repair of maxillofacial injuries between January 2010 and December 2013. Demographic information, presence and severity of concomitant injuries, as well as fracture-specific data including fracture type(s), mechanism of injury, and documented complications were recorded. Identifiable delays for medical, logistical, or other reasons were also documented. Multivariate regression modeling was used to determine factors associated with increased time to repair. A comparative analysis was used to identify association between complications and time to operative repair. MAIN OUTCOMES AND MEASURES: Time to operative repair from date of presentation; association of known operative delay and perioperative complications. RESULTS: Overall, 780 patients were included in the study. Of patients meeting inclusion criteria, mean (SD) age was 36.7 (14.2) years (range, 18-88 years), and 616 patients (79%) were male. Average time to repair was 6.5 days (range, 0-43 days), and 138 patients (17.7%) were observed to have a documented reason for delay for medical reasons (n = 62 [44.9%]), operating room logistical factors (n = 17 [12.3%]), or other reasons (n = 59 patients [42.8%]) either as a function of delayed patient presentation or failure of patients to make scheduled appointments or operations. Injury severity score (ρ = 0.45; P < .001), concurrent injuries (P < .001), decreased Glasgow Coma Scale (P < .001) and inpatient status at time of surgery (P < .001), were associated with increased time to repair. The observed complication rate was 13.6%. There was no statistically significant association between known operative delay and development of complications (χ21 = 2.92; P = .08). CONCLUSIONS AND RELEVANCE: Management of maxillofacial trauma appears to occur in a timely manner. Patient injury severity appears to have the greatest effect on timing of repair. While delays in operative repair may be unavoidable in certain circumstances, streamlining and managing causes of known delay may help improve and expedite patient care. LEVEL OF EVIDENCE: 3.

Noncontact diffuse optical assessment of blood flow changes in head and neck free tissue transfer flaps.

Knowledge of tissue blood flow (BF) changes after free tissue transfer may enable surgeons to predict the failure of flap thrombosis at an early stage. This study used our recently developed noncontact diffuse correlation spectroscopy to monitor dynamic BF changes in free flaps without getting in contact with the targeted tissue. Eight free flaps were elevated in patients with head and neck cancer; one of the flaps failed. Multiple BF measurements probing the transferred tissue were performed during and post the surgical operation. Postoperative BF values were normalized to the intraoperative baselines (assigning "1") for the calculation of relative BF change (rBF). The rBF changes over the seven successful flaps were 1.89 ± 0.15, 2.26 ± 0.13, and 2.43 ± 0.13 (mean ± standard error), respectively, on postoperative days 2, 4, and 7. These postoperative values were significantly higher than the intraoperative baseline values (p<0.001), indicating a gradual recovery of flap vascularity after the tissue transfer. By contrast, rBF changes observed from the unsuccessful flaps were 1.14 and 1.34, respectively, on postoperative days 2 and 4, indicating less flow recovery. Measurement of BF recovery after flap anastomosis holds the potential to act early to salvage ischemic flaps.

Assessment of Appalachian region pediatric hearing healthcare disparities and delays.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to examine the timing of diagnostic and therapeutic services in cochlear implant recipients from a rural Appalachian region with healthcare disparity. STUDY DESIGN: Retrospective analysis. METHODS: Cochlear implant recipients from a tertiary referral center born with severe congenital sensorineural hearing loss were examined. Rural status and Appalachian status of their county of origin were recorded. A log-rank test was used to examine differences in the distributions of time to definitive diagnosis of hearing loss, initial amplification fitting, and cochlear implantation in these children. Correlation analysis of the rural status of each county and the timing of services was assessed. RESULTS: A total of 53 children born with congenital hearing loss were included in the study (36 from rural counties and 17 from urban/suburban counties). The distribution of weeks after birth to diagnosis (P=.006), amplification (P=.030), and cochlear implantation (P=.002) was delayed in rural children compared with urban children. An analysis factoring in the effect of implementation of mandatory infant hearing screening in 2000 demonstrated a similar delay in rural children for weeks to diagnosis (P=.028), amplification (P=.087), and cochlear implantation (P<.0001). CONCLUSIONS: Children with severe hearing loss in very rural areas, such as Appalachia, may have significant delays in diagnostic and rehabilitative services. Further investigation is warranted to assess causative factors in delays of cochlear implantation and to develop interventions to promote timely diagnosis and care. LEVEL OF EVIDENCE: 3b.

Delays in diagnosis of congenital hearing loss in rural children.

OBJECTIVE: To examine the incidence of pediatric congenital hearing loss and the timing of diagnosis in a rural region of hearing healthcare disparity. STUDY DESIGN: Data from the Kentucky newborn hearing-screening program was accessed to determine the incidence of congenital hearing loss in Kentucky, both in the extremely rural region of Appalachia and non-Appalachian region of Kentucky. We also performed a retrospective review of records of children with congenital hearing loss at our institution to determine the timing of diagnostic testing. RESULTS: In Kentucky, during 2009-2011, there were 6970 newborns who failed hearing screening; the incidence of newborn hearing loss was 1.71 per 1000 births (1.28/1000 in Appalachia and 1.87/1000 in non-Appalachia); 23.8% of Appalachian newborns compared with 17.3% of non-Appalachian children failed to obtain follow-up diagnostic testing. Children from Appalachia were significantly delayed in obtaining a final diagnosis of hearing loss compared with children from non-Appalachian regions (P = .04). CONCLUSION: Congenital hearing loss in children from rural regions with hearing healthcare disparities is a common problem, and these children are at risk for a delay in the timing of diagnosis, which has the potential to limit language and social development. It is important to further assess the causative factors and develop interventions that can address this hearing healthcare disparity issue.

Hot or cold? Is monothermal caloric testing useful and cost-effective?

OBJECTIVES: Videonystagmography (VNG) is used widely in the assessment of balance dysfunction. The full test battery can be time-consuming and can induce patient discomfort. The purpose of this study was to examine the value of monothermal caloric testing in predicting unilateral caloric weakness, as well as abnormal VNG vestibular and nonvestibular eye movement, while considering the time and reimbursement associated with these tests. METHODS: In a retrospective review of 645 patients who completed a comprehensive VNG test battery with bithermal caloric testing, we calculated the specificity, sensitivity, and predictive values of monothermal caloric testing in relation to bithermal caloric results and noncaloric VNG results. RESULTS: With unilateral vestibular weakness (UVW) defined as a 25% interear difference, warm-air monothermal caloric testing yielded a sensitivity of 87% and a negative predictive value of 90% for predicting UVW. With a 10% UVW definition, the warm-air caloric testing sensitivity increased to 95% and the negative predictive value to 92%. Warm-air monothermal caloric testing had a positive predictive value of 85% and a negative predictive value of 18% for predicting noncaloric VNG findings; cold-air monothermal and bithermal testing displayed similar results. CONCLUSIONS: Isolated monothermal testing is a sensitive screening tool for detecting UVW, but is not adequate for predicting noncaloric VNG results.

Quality of life impact of external beam radiotherapy for advanced thyroid carcinoma.

BACKGROUND: External beam radiotherapy (XRT) has an established role in the management of recurrent or advanced well-differentiated thyroid carcinoma (WDTC). The goal of this study was to investigate the impact of this additional intervention on the quality of life (QOL) compared with total thyroidectomy (TT), with or without adjuvant radioactive iodine (RAI). METHODS: A cross-sectional analysis using validated QOL instruments was performed. Patients receiving XRT between 1992 and 2008 for WDTC were identified and offered study participation. The Quality of Life Radiation Therapy Instrument and the Head and Neck Companion Module were administered retrospectively (N=13). For a comparison, patients previously treated with TT (N=11) alone as well as TT with postoperative RAI (N=11) for WDTC were also evaluated. RESULTS: Thirty-four patients were included in the analysis. The XRT group reported significant decreases in chewing, swallowing, and appetite, and significant increase in pain, compared with both the RAI group and the TT group. Significant differences were reported for questions with regard to peace of mind, feeling discouraged, saliva, taste, ability to eat regular food, and concerns for the appearance of the neck in both RAI and XRT groups compared with TT patients. Subscale analysis of head and neck specific questions demonstrated significant overall differences for both RAI and XRT groups compared with thyroidectomy alone, with no differences observed between RAI and XRT groups in a direct comparison. CONCLUSIONS: RAI therapy results in a measurable decrease in head and neck specific QOL measures compared with TT alone. The addition of XRT results in additional measurable morbidity secondary to pain and dysphagia.

Utility of stereolithographic models in osteocutaneous free flap reconstruction of the head and neck.

Background Stereolithographic (SLA) models have become a valuable resource in preoperative planning in maxillofacial reconstruction. The objective of this study was to perform a defect specific analysis of the utility of SLA models. The goal was to determine the manner in which the perceived benefit of preoperative modeling translates to measurable clinical advantages. Methods Patients who underwent reconstruction of defects of the mandible or midface using SLA modeling between 2006 and 2011 were identified through billing records. Based on the nature and extent of bony defect, cases requiring nearly identical reconstruction, but without modeling, were matched case by case for comparison. Given the presumed efficiency of SLA modeling, a comparison of total and reconstructive operative times was performed to see if this could offset the cost of the model. Results There were 10 patients each in the "model" and "nonmodel" group. No significant differences were observed for total operative time between groups. Surprisingly, the total reconstructive time was lower in the group not using SLA models (p = 0.05). Conclusions SLA models provide several operative planning advantages, but did not appear to decrease operative time enough to sufficiently offset the cost of the model in this group.

Recognition and management of the spectrum of acute laryngeal trauma.

BACKGROUND: Blunt laryngeal trauma frequently takes place in the setting of more significant injuries. In the setting of multiple injuries or, more importantly, as an isolated event, missed injuries to the laryngotracheal complex can have devastating results. More importantly, underestimation of the severity of injury can result in an airway that becomes quite difficult to manage. However, early recognition and management of laryngotracheal injuries can result in minimal morbidity and the need for minimal long-term intervention. OBJECTIVES: Our goal is to heighten awareness of the severity of blunt laryngotracheal trauma and reduce both acute and long-term sequelae. CASE REPORT: We present a series of cases representing a spectrum of seemingly benign neck injuries requiring a diversity of interventions. The cases represent worsening gradations of laryngeal trauma, and the differing presentation, work-up, and management scenarios are discussed. CONCLUSIONS: Expedient evaluation, treatment, and management of blunt laryngeal trauma results in favorable outcomes. Awareness of the potential for significant injury in the presence of benign examination based on the history of injury and confirmed by radiographic or endoscopic evaluation is paramount. Although minimal findings on examination and stable patients in the setting of blunt trauma to the neck may be as innocuous as it seems, the severity of injury may "lie beneath."