Assessing the Prevalence of Burnout Among Female Microvascular Head and Neck Surgeons.

Background: Research has not explicitly explored differences between male and female microvascular head and neck (MHN) surgeon burnout, which should be identified and addressed to ensure career satisfaction and longevity. Objective: To measure and compare the prevalence of burnout among male versus female MHN surgeons. Methods: A prospective questionnaire based on the Maslach Burnout Inventory (MBI) was distributed through a web-based survey to the American Association of Facial Plastic and Reconstructive Surgeons and American Head and Neck Society in 2021 and 2022. Additional variables collected included demographics, relationship and parental status, academic rank, annual salary, and COVID-19-related questions. Results: One hundred thirteen surveys were collected. Twenty-nine (25.7%) were women and all completed MHN surgery fellowships. Women trended toward more emotional exhaustion than men (2.8 mean MBI vs. 2.3 mean MBI) but reported similar personal achievement (4.8 mean MBI vs. 4.9 mean MBI). Men experienced less workplace sexual harassment (p < 0.001). Women experienced more burnout (69% vs. 39%, p = 0.006) during the COVID-19 pandemic. Conclusion: Female MHN surgeons reported in this survey to experience more workplace sexual harassment and higher COVID-19-related burnout than their male counterparts.

Recent Developments in Vestibular Migraine: A Narrative Review.

PURPOSE: The aim of this study was to review current literature regarding the epidemiology of vestibular migraine (VM), patient presentation, pathogenesis, and treatment. RECENT FINDINGS: VM is becoming an increasingly recognized condition in the United States, currently affecting 2.7% of people. Patients may experience vestibular symptoms, such as vertigo and imbalance, with or without other migrainous symptoms. Recent evidence has also shown that patients with VM are at higher risk for cochlear dysfunction, such as sudden deafness, sensorineural hearing loss, and tinnitus. The heritability and genetics are not well understood, and the pathogenesis may involve calcitonin gene-related peptide, which is also implicated in migraine headaches. A disease-specific patient reported outcome measure, the Vestibular Migraine Patient Assessment Tool and Handicap Inventory, was recently developed and validated. A limited number of controlled trials have assessed various therapies for VM, including triptans and beta-blockers. More data are needed to understand whether or not currently available migraine treatments are effective for VM. SUMMARY: VM is a common etiology of vertigo and dizziness, presenting with a characteristic spectrum of symptoms. Early data suggest that migraine treatments may be helpful in some cases.

Anterolateral Thigh Free Flap Versus Thigh Split Thickness Skin Graft: Comparison of Morbidity in the First 30 Days.

Background: An anterior thigh split thickness skin graft (AT-STSG) is frequently needed to close the radial forearm free flap (RFFF) donor site, conferring morbidity to two extremities. The anterolateral thigh (ALT) free flap is virtually always closed primarily. Objective: To compare donor site pain, sensation, motor function, and cosmesis associated with the AT-STSG and the ALT. Methods: Patients undergoing an ALT or an RFFF with AT-STSG were enrolled in a prospective observational cohort study. Pain, tingling, numbness, lower extremity function, and subjective donor site cosmetic satisfaction were measured at 1 week and 1 month postoperation using validated instruments. Results: Forty-eight patients were included, with a mean age of 64.2 years (female 31.2%). There were no differences in age or medical comorbidities between the two groups. The average donor defect was 50 and 180 cm2 for the AT-STSG and ALT cohorts, respectively. At 1 week and 1 month postoperatively, we did not detect a difference in donor site pain, pruritus, numbness or tingling, lower extremity function, or subjective cosmetic satisfaction between the two cohorts. Conclusion: ALT primary donor site morbidity, including pain, sensory function, motor function, and cosmesis, is equivalent to RFFF secondary donor site morbidity at 1 week and 1 month postoperatively.

Anterior Inferior Cerebellar Artery Aneurysm Mimicking a Vestibular Schwannoma.

Anterior inferior cerebellar artery (AICA) aneurysms are rare pathologies that may present with hearing loss, facial paralysis, vertigo, and tinnitus. Otologic symptoms at the time of presentation may prompt physicians to order an MRI, which can lead to the misdiagnosis of AICA aneurysms as vestibular schwannomas. We discuss the case of a 27-year-old female who presented with sudden-onset vertigo and right-sided hearing loss. She was found to have a right homogeneously enhancing internal auditory canal (IAC) mass abutting the vestibular nerve on post-gadolinium T1 MRI two hours after the presentation, which was initially diagnosed as a vestibular schwannoma. Serial T1 MRI highlighted the evolution of blood products within this mass by presenting as bright at two days and dark at two months after presentation. Profound ipsilateral sensorineural hearing loss and absent vestibulocochlear function were confirmed on audiometry and vestibular testing, respectively. The diagnostic cerebral angiogram was complicated by an iatrogenic right mid-cervical vertebral artery dissection, and the patient ultimately underwent successful embolization two months after presentation with the resolution of all presenting symptoms except right-sided hearing loss. Early recognition and treatment of an AICA aneurysm may help prevent associated vascular complications, and they should be considered as part of the differential diagnosis for IAC lesions despite their rarity.

Gender-Affirming Facial Surgery: Experiences and Outcomes at an Academic Center.

Background: Gender-affirming facial surgery (GFS) is becoming more widely available for transgender individuals, but data on surgical approaches and outcomes remain limited. Methods: Retrospective analysis of surgical outcomes among consecutive GFS cases performed at a tertiary care academic center between March 2016 and August 2020. Results: Seventy-seven patients underwent 109 surgeries, including 478 individual procedures. The median age was 42 years. Ninety-five percent of patients had public health insurance. Two-stage GFS was often used in older patients (p = 0.001), with the first stage involving bone and cartilaginous alterations, and the second stage involving soft tissue procedures. Mean hospital stay after first-stage GFS was 1.2 days, with 70% discharged on postoperative day 1. Mean follow-up was 11.3 months. Among 66 patients with at least 1 month of follow-up, all complications were minor and included surgical site infection (5%), dehiscence (3.0%), seroma (3%), and medical complications (6%). Thirty-day hospital readmission rate was 1.5%. Conclusions: There are unique surgical approaches for GFS, which demonstrate low complication and readmission rates. Understanding these approaches and outcomes may help guide preoperative patient consultations and clinical decision making.

Utility of Microporous Polysaccharide Hemosphere on Anterolateral Thigh Free Flap Donor Site Complications.

Background: Anterolateral thigh (ALT) microvascular free tissue transfer is an integral part of head and neck reconstructive surgery, but it can be complicated by postoperative donor site fluid collections. Objective: To measure the rate of hematoma and seroma formation in the ALT donor site in those treated with microporous polysaccharide hemosphere (MPH) and those without. Methods: This was a retrospective cohort study examining patients undergoing ALT free tissue transfer for head and neck reconstruction at a single academic center between 2014 and 2017. Primary outcomes were interventional hematomas and seromas and drain duration. Results: In total, 118 patients underwent ALT free flap reconstruction for head and neck defects. Of these, 57 patients received MPH at the donor site and 61 did not. Eleven patients had a clinically significant seroma in the non-MPH group compared with three in the MPH group (p = 0.045). Drain duration for the MPH group compared with that for the non-MPH group was 6.9 versus 8.2 days (p = 0.020), and drains were removed when output was <60 mL over 24 h. Conclusion: This study supports the use of MPH in ALT free flap donor sites for reduction of clinically significant postoperative seromas. Further investigation with larger prospective randomized clinical trials is warranted.

Impact of Smoking and Primary Tumor Subsite on Recurrence in HPV-Associated Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVE: To describe risk of recurrence and recurrence characteristics between ever- and never-smoking patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC) when stratified by primary tumor subsite. STUDY DESIGN: Retrospective observational study. SETTING: Tertiary care center. METHODS: Retrospective chart review of 171 patients with HPV+ OPSCC with primary treatment between 2008 and 2019. Five-year recurrence-free survival and risk of recurrence were evaluated through Kaplan-Meier curves with log-rank test and Cox proportional hazards models, respectively. RESULTS: Of 171 patients with HPV+ OPSCC, 81.9% were male, and the average age was 63.9 years. Eighty patients (46.8%) had a smoking history (average, 17.7 pack-years), including 4 current smokers. Recurrence occurred in 31 patients (18.1%), 19 of whom were ever smokers. The recurrence rate for ever smokers with primary base of tongue (BOT) cancer was 41.7%, while 5.1% of never smokers with BOT primaries had recurrence. For primary tonsillar disease, 9.1% of ever smokers had recurrence versus 19.2% of never smokers. Five-year recurrence-free survival for BOT primaries was lower in ever smokers than never smokers (P = .001) but did not differ between ever and never smokers for tonsillar primaries (P = .215). In multivariable analysis across this period, ever-smoking status was associated with higher risk of recurrence than never-smoking status in BOT primaries (adjusted hazard ratio, 7.36; 95% CI, 1.61-33.68; P = .010) but with lower risk of recurrence after tonsillar primaries (adjusted hazard ratio, 0.23; 95% CI, 0.06-0.89; P = .033). CONCLUSION: Smoking may uniquely interact with tumor subsites within the oropharynx to influence recurrence risk. Understanding the association between smoking and HPV+ OPSCC recurrence could lead to personalized, evidence-based treatments to improve oncologic outcomes.

Vestibular and auditory manifestations of migraine.

PURPOSE OF REVIEW: The purpose of this narrative review is to discuss current literature about vestibular migraine and other cochleovestibular symptoms related to migraine. RECENT FINDINGS: Vestibular migraine affects 2.7% of the US population. Misdiagnosis is common. The pathophysiology is currently unknown but new research shows that calcitonin gene-related peptide, which is implicated in migraine headaches, is expressed in the audiovestibular periphery. A recent large-scale placebo-controlled trial looking at metoprolol for vestibular migraine was terminated early due to poor recruitment; however, at study completion, no differences were seen between treatment arms. Many other audiovestibular symptoms have been shown to be associated with migraine, including tinnitus, hearing loss, aural fullness, otalgia, and sinus symptoms. Migraine is also associated with risk for developing numerous otologic conditions, including Meniere's disease, vestibular loss, Benign Paroxysmal Positional Vertigo, and sudden sensorineural hearing loss. There is now some evidence that patients may experience fluctuating hearing loss and aural fullness without vertigo in association with migraine, which is called cochlear migraine. SUMMARY: Migraine can cause a variety of audiologic and vestibular symptoms, and further research is required to understand how migraine affects the inner ear.

Airway Hemangiomas in PHACE Syndrome: A Multicenter Experience.

OBJECTIVE: To describe the prevalence and clinical characteristics of airway findings in a multi-institutional cohort of PHACE patients. STUDY DESIGN: Multicenter retrospective case series. SETTING: Multidisciplinary vascular anomalies clinics at 2 institutions. METHODS: Data were collected from the electronic medical record, including clinical presentation, airway findings, treatment, and outcomes. RESULTS: Of 55 PHACE patients, 22 (40%) had airway hemangiomas. Patients with airway involvement were more commonly female (P = .034, odds ratio [OR] 23, 95% confidence interval [CI] 1.3-410) and of Caucasian ethnicity (P = .020, OR 5.3, 95% CI 1.3-21). Anatomically, patients with bilateral S3 involvement had higher rates of airway disease (P = .0012, OR 15, 95% CI 2.9-77). Most patients with airway hemangiomas had stridor (68%). Of the patients managed in the propranolol era (2008 or later, n = 35), 14 had airway involvement. All 14 were treated with propranolol, whereas 13 (62%) of 21 nonairway patients were treated with propranolol. The average treatment duration was longer in the airway patients (22.1 vs 16.7 months). All patients who underwent tracheostomy (n = 4) did so before 2008. CONCLUSION: Risk factors for airway involvement in PHACE include female gender, Caucasian ethnicity, and stridor. Since the widespread use of propranolol, fewer patients have required surgical management of their airway disease. Given the high prevalence of airway involvement even in patients without stridor, assessment of the airway is a crucial component of a comprehensive PHACE workup.

Vasodilation by Verapamil-Nitroglycerin Solution in Microvascular Surgery.

OBJECTIVE: Papaverine is a topical vasodilator commonly used during microvascular surgery to inhibit undesired vasoconstriction. A previous national shortage of papaverine prompted evaluation of an alternative, effective vasodilator. This study aims to assess the experience of a solution of verapamil and nitroglycerin (VG) as a potential alternative pharmacologic vasodilator. STUDY DESIGN: Retrospective case series. SETTING: Two tertiary academic medical centers. SUBJECTS AND METHODS: Among 298 patients, 306 consecutive free tissue transfers performed between 2014 and 2017 for head and neck defect reconstruction utilized a VG solution. Patient and flap characteristics, intraoperative patient and flap complications, and postoperative complications were reviewed. Diameter of the cervical recipient artery was measured intraoperatively before and after topical application of the VG solution in a subset of 43 patients (44 flaps). RESULTS: Flaps included fibula, radial forearm, subscapular system, and anterolateral thigh. In total, 3 (0.98%) flaps failed with varied etiology unrelated to the VG solution (venous thrombosis, arterial anastomosis thrombosis, physical damage to the perforator). Specific to topical application of the VG solution, the mean recipient artery diameter increased from 2.1 to 3.1 mm, a 48% increase (P < .01). There were no intraoperative cardiac events or complications attributable to the VG solution. CONCLUSION: We describe the use of a VG solution for pharmacologic vasodilation during microvascular free tissue transfer. Its use was associated with an acceptable incidence of adverse events, none of which were directly attributable to the VG solution. Apparent and sustained vasodilation was demonstrated. The VG solution represents a safe and efficacious alternative to papaverine in microvascular surgery.

Round Cell Sarcoma with EWSR1-PATZ1 Gene Fusion in the Neck: Case Report and Review of the Literature.

EWSR1-PATZ1 is a rare gene fusion recently recognized to occur in round and spindle cell sarcomas. To date, fewer than 20 cases have been described in the literature. However, no dedicated case reports have detailed its presentation in the head and neck region. We recently cared for a 52-year-old woman with an isolated, single right level 5A cervical mass. Excisional biopsy at an external hospital revealed pathology results consistent with EWSR1-PATZ1 polyphenotypic round and spindle cell sarcoma. The patient subsequently underwent surgical excision of the tumor and right neck lymph node dissection followed by adjuvant chemoradiation. Laryngoscope, 2020.

Allograft of Primary Cutaneous Mucormycosis in a Preterm Neonate: A Case Report.

INTRODUCTION: Primary cutaneous mucormycosis (PCM) is a fungal infection of the skin that can affect compromised hosts. Skin lesions evolve from an indurated area to a necrotic ulcer. Preterm neonates are at increased risk due to poorly developed skin, immature immune function, and invasive devices. Antifungals and debridement with grafting have been reported as primary treatments. CASE REPORT: The authors report allografting in addition to systemic antifungals as an option for critically ill preterm neonates to decrease blood loss and risk of donor site infection. A female triplet was born to a 35-year-old G1P0211 mother; the triplet developed PCM (Rhizopus genus) and was treated with systemic liposomal amphotericin B in addition to debridement and allografting. Surgery was delayed initially, given concerns over the depth of invasion into the chest. As the wound began to contract and separate over the next few weeks, the decision was made to excise the lesion and reconstruct the chest wall with an allograft. The graft had good take and remained in place for 11 weeks until the patient succumbed to a third recurrence of bacterial sepsis. CONCLUSIONS: While PCM can be fatal for many preterm infants, debridement with allografting may serve as a valuable treatment option with fewer associated complications for neonates as they are stabilizing clinically.

Association Between Conventional Bicycle Helmet Use and Facial Injuries After Bicycle Crashes.

Importance: Bicycling is an increasingly common activity in the United States that is often associated with fall injuries to the head and face. Although helmets lessen head injury, their role in reducing facial injuries is less clear; therefore, it is important to understand the protective capacity for the face in current helmet design. Objective: To estimate the conventional bicycle helmet's association with the rate of facial injury after bicycle crashes. Design, Setting, and Participants: This retrospective cohort study accessed records from January 1, 2010, to December 31, 2014, from the National Trauma Databank, which collects data from emergency departments in US hospitals. Each record pertained to 1 emergency department admission for a bicycle crash. The National Trauma Databank registry data are collected and recorded by incident, which is equivalent to an injury-related hospital admission. All injuries involving patients aged 18 to 65 years for whom data on helmet use and injury were available were included. Statistical analysis was conducted from July 19 to October 17, 2016. Exposures: Helmeted and nonhelmeted bicycle crashes. Main Outcomes and Measures: Head and facial injuries among helmeted and nonhelmeted bicycle crashes. Results: A total of 85 187 facial injuries met inclusion criteria (patient age 18-65 years, availability of helmet use status, and type of injury). Demographic information on bicycle riders was frequently unavailable. Among all injuries, fractures to the head (11.6% [9854]) and face (11.3% [9589]) occurred at similar rates. Helmets reduced head fractures by 52% (from 14.0% [7623] to 7.3% [2231]) and head soft-tissue injuries by 30% (from 15.0% [8151] to 10.9% [3358]), but had lower rates in protecting against facial injuries. While reducing facial injuries overall, the amount of protection with helmet use varied with facial location of the injury. Reduction in facial fractures was 35% (95% CI, 31%-39%) for upper face, 28% (95% CI, 23%-32%) for mid face, and 21% (95% CI, 15%-26%) for the lower face. Helmets were less protective against facial soft-tissue injuries, with a reduction of 33% (95% CI, 30%-36%) in the upper face, 21% (95% CI, 16%-26%) in the mid face, and 2% (95% CI, 0%-6%) in the lower face. Conclusions and Relevance: Although bicycle helmets provide some protection against facial injuries after bicycle crashes, the level of protection depends on the proximity of the injury to the helmeted head. The lower face is particularly vulnerable to injury despite helmet use.

O-GlcNAc Transferase Recognizes Protein Substrates Using an Asparagine Ladder in the Tetratricopeptide Repeat (TPR) Superhelix.

The essential mammalian enzyme O-GlcNAc Transferase (OGT) is uniquely responsible for transferring N-acetylglucosamine to over a thousand nuclear and cytoplasmic proteins, yet there is no known consensus sequence and it remains unclear how OGT recognizes its substrates. To address this question, we developed a protein microarray assay that chemoenzymatically labels de novo sites of glycosylation with biotin, allowing us to simultaneously assess OGT activity across >6000 human proteins. With this assay we examined the contribution to substrate selection of a conserved asparagine ladder within the lumen of OGT's superhelical tetratricopeptide repeat (TPR) domain. When five asparagines were mutated, OGT retained significant activity against short peptides, but showed limited limited glycosylation of protein substrates on the microarray. O-GlcNAcylation of protein substrates in cell extracts was also greatly attenuated. We conclude that OGT recognizes the majority of its substrates by binding them to the asparagine ladder in the TPR lumen proximal to the catalytic domain.