Tracheostomy Avoidance in Flap Reconstruction of the Upper Aerodigestive Tract is Safe in Selected Patients.

OBJECTIVE: Assess the impact of tracheostomy on postoperative morbidity and mortality and examine factors that predicted tracheostomy in head and neck flap patients. STUDY DESIGN: Retrospective cohort January 2017 to December 2021. SETTING: Single tertiary center. METHODS: Adult patients undergoing head and neck flap reconstruction were included, excluding cutaneous reconstruction, laryngectomy, or with tracheostomy present at surgery. Patients were routinely extubated immediately following surgery. Univariate and multivariable analyses examined associations between tracheostomy and postoperative outcomes and identified predictors of tracheostomy. RESULTS: We included 193 patients, 69 (35.8%) with tracheostomy and 124 (64.2%) without. Tracheostomy avoidance was associated with no difference in 30-day mortality (P = .531) and with decreased likelihood of 30-day complications (0.019), unplanned return to the operating room (0.021), and discharge to a facility (<0.001) and with 2.2 decrease in length of stay on multivariable analysis (confidence interval [CI]: 0.62-3.82, P = .007). Four patients (2.1%) required reactive tracheostomy with no resulting mortalities. Significant associations with tracheostomy on multivariable analysis included bilateral neck dissections (odds ratio [OR]: 3.13, CI 1.12-9.06, P = .030), number of resected mandibular subsites (OR: 2.65, CI: 1.50-5.67, P = .0023), specimen volume (OR: 1.87, CI: 1.29-2.71, P = .001), body mass index < 20 (OR: 3.80, CI: 1.24-11.64, P = .019), mandibulectomy (OR: 0.04, CI: 0.01-0.22, P < .001), forearm flap (OR: 0.15, CI: 0.05-0.41, P < .001), oral cavity site (OR: 0.21, CI: 0.06-0.73, P = .014), and age > 70 (OR: 0.33, CI: 0.14-0.81, P = .016). CONCLUSION: Tracheostomy avoidance is safe in properly selected patients undergoing head and neck flap reconstruction. Multiple factors predicted tracheostomy, which may guide patient selection at other centers.

Predictors of multiple dilations and functional outcomes after total laryngectomy and laryngopharyngectomy.

BACKGROUND: Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown. METHODS: Single-institution retrospective review of patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022. RESULTS: A total of 49 patients underwent stricture dilation after TL/TLP. Thirty-five (71%) underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group. CONCLUSIONS: Shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.

Early Weight-Bearing After Fibula Free Flap Surgery.

Importance: Despite the widespread use of fibula free flap (FFF) surgery for head and neck reconstruction, there are no studies assessing if early weight-bearing (EWB) affects postoperative recovery, and the timing of weight-bearing initiation following FFF surgery varies considerably across institutions. Therefore, it is important to understand the effect of EWB in these patients and whether it could improve postoperative recovery. Objective: To assess the association of EWB after FFF surgery with donor-site complications, length of stay, and discharge to home status. Design, Setting, and Participants: This retrospective cohort study took place at Massachusetts Eye and Ear, a single tertiary care institution in Boston, Massachusetts. A total of 152 patients who received head and neck reconstruction with a fibula osteocutaneous free flap between January 11, 2010, and August 11, 2022, were included. Exposure: EWB on postoperative day 1 vs non-EWB on postoperative day 2 or later. Main Outcomes and Measures: Patient characteristics, including demographic characteristics and comorbidities, surgical characteristics, donor-site complications, length of stay, and discharge disposition, were recorded. Descriptive statistics and multivariate logistic regressions were used to compute effect sizes and 95% CIs to compare postoperative outcomes in EWB and non-EWB groups. Results: A total of 152 patients (median [IQR] age, 63 [55-70] years; 89 [58.6%] male) were included. The median (IQR) time to postoperative weight-bearing was 3 (1-5) days. Among all patients, 14 (9.2%) had donor-site complications. EWB on postoperative day 1 was associated with shorter length of stay (adjusted odds ratio [AOR], 0.10; 95% CI, 0.02-0.60), increased rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80), and decreased donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94). Conversely, weight-bearing 3 or more days postoperatively was associated with an increased risk of pneumonia (AOR, 6.82; 95% CI, 1.33-34.99). Conclusions and Relevance: In this cohort study, EWB after FFF surgery was associated with shorter length of stay, increased rate of discharge to home, and decreased donor-site complications. These findings support the role of early mobilization to optimize postoperative recovery after FFF surgery.

Depth of resection predicts loss of tongue tip sensation after partial glossectomy in oral tongue cancer: A pilot study.

OBJECTIVE(S): To characterize the change in sensory function following partial glossectomy for oral tongue cancer (OTC) and to identify predictors of loss of tongue-tip sensation (LoTTS). MATERIALS AND METHODS: Patients with at least three months follow-up after partial glossectomy for primary OTC were included. All patients underwent a qualitative tongue sensation assessment and an objective tongue sensory exam of the native tongue tip. Additional details regarding the oncologic resection, surgical reconstruction, and pathological stage were collected. Multiple linear and logistic regressions were used for statistical analysis. RESULTS: Sixty-four patients were enrolled, including 34 (53%) men with a median age of 65 at enrollment. Ten (15%) patients reported LoTTS. Increased depth of resection (DOR) was an independent predictor of LoTTS on multivariate analysis, with an increased risk at a threshold of 1.3 cm. LoTTS was also associated with worse subjective quality of life and perceptive speech performance in our qualitative tongue assessment. CONCLUSIONS: In this pilot study, we found that DOR is a critical prognostic factor in predicting post treatment function. Patients with an increased DOR, particularly above 1.3 cm, are at greatest risk of LoTTS and associated morbidity. These findings may be used to predict post-operative sensory deficits, manage patients' expectations, and optimize the reconstructive approach. Future studies are needed to validate and replicate our results.

Robotic Thyroidectomy via Posterior Neck Approach Using the Da Vinci Single Port System.

We describe a remote access thyroidectomy technique: robotic thyroidectomy via posterior neck approach using the Da Vinci single port (Sp) robotic system. This approach is feasible and safe in the Western population. Laryngoscope, 2023.

Online Searches Related to Total Laryngectomy.

OBJECTIVE: To identify the most frequently asked questions regarding "laryngectomy" through an assessment of online search data. METHODS: Google Search data based on the search term "laryngectomy" were analyzed using Google Trends and Search Response. The most common People Also Ask (PAA) questions were identified and classified by the concept. Each website linked to its respective PAA question was rated for understandability, ease of reading, and reading grade level. RESULTS: Search popularity for the term "laryngectomy" remained stable between 2017 and 2022. The most popular PAA themes were post-laryngectomy speech, laryngectomy comparison to tracheostomy, stoma and stoma care, survival/recurrence, and post-laryngectomy eating. Of the 32 websites linked to the top 50 PAA's, eleven (34%) were at or below an 8th grade reading level. CONCLUSION: Post-laryngectomy speech, eating, survival, the stoma, and the difference between laryngectomy and tracheostomy are the most common topics searched online in relation to "laryngectomy." These are important areas for both patient and healthcare provider education. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:2971-2976, 2023.

Burn Pit Exposure Is Associated With Increased Sinonasal Disease.

OBJECTIVE: The aim of this study was to determine whether self-reported burn pit exposure is associated with increased subjective and objective sinus disease. DESIGN: A cross-sectional study was performed evaluating consecutive adult patients presenting to a US Military rhinology clinic. Demographics, medical histories, sinonasal quality-of-life scores, and nasal endoscopy examinations were obtained. Participants were divided into three cohorts based on self-reported exposure histories and outcomes compared. RESULTS: One hundred eighty-six patients met the inclusion criteria, the majority of whom were male. Patients with burn pit exposure had worse Sinonasal Outcome Test-22 scores (49.9) compared with those deployed without burn pit exposure (31.8) or never deployed (31.5). Endoscopic findings demonstrated worse disease within those exposed (Lund-Kennedy score, 3.3) compared with the other cohorts (1.8 and 1.7, respectively). CONCLUSIONS: These novel findings suggest that deployment-related burn pit exposure is associated with increased subjective and objective sinus disease.

COVID-19 Preprocedural Testing: What About the False Positives?

In the COVID-19 era, preprocedural patients are almost uniformly screened for symptoms, asked to quarantine preoperatively, and then undergo a test of uncertain validity with very low pretest probability. A small percentage of these tests return positive. As a result, surgical procedures are delayed and patients are required to quarantine. Are these asymptomatic patients truly positive for COVID-19? What are the impacts of these test results on the patient and the health care system? In the following commentary, we review how the uncertain validity of reverse transcription polymerase chain reaction testing combined with a low-prevalence population predisposes for false-positive results. As a mitigation strategy, we ask that readers refocus on the fundamental principal of diagnostic testing: pretest probability.

Airway Management of COVID-19 Positive Patients Aboard USNS COMFORT Mission to New York City.

During the USNS Comfort mobilization to New York City in response to the pandemic, the ship's medical team cared for over 35 mechanically ventilated corona virus disease 2019 (COVID-19) infected patients. Due to the better than expected mortality rates of these patients, tracheotomy for prolonged intubation or other indicated interventional bronchoscopies were performed on 7 COVID positive patients, as well as 2 with negative screening tests. No member of the health care team subsequently became symptomatic or tested positive for COVID-19. This was in part due to the formation of a dedicated surgical airway team, use of standardized procedural techniques and personal protective equipment (PPE), and construction of a negative pressure operating room within the COVID-19 isolation ward on the ship. This experience shows that tracheotomies and other aerosolizing procedures can be performed with due concern for patient and provider safety, regardless of patient's COVID status.

Conservative Management of an Intraoperative Chyle Leak: A Case Report and Literature Review.

Chyle leaks are a rare but potentially fatal complication of head and neck surgery carrying an incidence as high as 8.3%. The development of a chyle leak carries significant morbidity ranging from delayed wound healing to oropharyngeal fistulas. Presented here is a case of a chyle leak that developed following a left posterolateral neck dissection that was successfully managed with a combination of drain suction, pressure dressing, and a fat-restricted diet. However, the patient's course was complicated by repeated chyle leak recurrences that may have been associated with the initiation of medium-chain triglyceride supplementation. Although further research is required to establish a causal relationship, these findings support the concerns of other investigators about the possible counterproductive role of medium-chain triglyceride supplementation in the management of chyle leaks.