Co-surgery in head and neck microvascular reconstruction.

PURPOSE: Co-surgery with two attending reconstructive surgeons is becoming increasingly common in breast microvascular reconstruction due to case complexity and the potential for improved outcomes and operative efficiency. The impact of co-surgery on outcomes in head and neck microvascular reconstruction has not been studied. METHODS: Our multidisciplinary head and neck reconstruction team (Otolaryngology, Plastic Surgery) at the University of Pittsburgh transitioned to a practice of co-surgery on head and neck free flaps. In this study, we compare outcomes of two surgeon head and neck reconstruction to single surgeon reconstruction in a prospectively maintained database. RESULTS: 384 patients met our inclusion criteria from 2020 to 2022. Cases were performed by a single surgeon in 77.8 % of cases (299/384) and two surgeons in 22.1 % (85/384). The mean age was 62.5 years. There was no difference between the single surgeon cohort and the co-surgery cohort in terms of flap survival, procedure time, ischemia time, hospital length of stay, recipient site complications, or rates of return to the operating room. Donor site complications were less common in the co-surgery cohort (0 % vs 4.7 %, p = 0.021). For our reconstructive team, the transition to co-surgery has increased total surgeon fee collection per free flap by 28 % and increased surgeon flap related RVU production by 35 %. CONCLUSION: Co-surgery is feasible and safe in head and neck microvascular reconstruction. Benefits may include reduced complications, increased reimbursement, and improved interdisciplinary collaboration.

Otologic opioid usage and pain control in the postoperative period: An observational prospective study.

PURPOSE: Evaluate opioid prescribing patterns, opioid consumption, and patient pain patterns following otologic surgery. MATERIALS AND METHODS: Patients were included if they were ≥18 years old and received otologic surgery between November 2019 and August 2020. Patients were provided a survey which included a visual analog scale for recording their pain postoperatively and the amount of opioid they had remaining. Patients who did not complete all portions of the survey were excluded. RESULTS: Ninety-one patients completed the post-operative questionnaire. Collectively, patients were prescribed 5797 morphine milligram equivalents and used 3092: approximately 47% went unused. Of patients receiving a transcanal incision (n = 28/91, 31%), 70% went unused, whereas patients receiving a postauricular incision (n = 57/91, 63%), 38% went unutilized. The utilization difference between transcanal and postauricular cohorts was significant (p = 0.002). On multivariate analysis, patients who received a postauricular incision had 60% more opioid usage (p < 0.001), whereas those with a transcanal incision had an average reduction of 40% in opioid usage (p < 0.001). CONCLUSIONS: A significant amount of opioid medication went unused in this study. Patients with postauricular incisions had significantly increased opioid utilization as compared to those with transcanal incisions. Otologists may be able to successfully manage pain in the postoperative period with a reduced opioid prescription multimodal analgesia and increased patient education. Further study is needed to support this suggestion.

Initiation of acid suppression therapy for laryngomalacia.

OBJECTIVE: Evidence supporting the use of acid suppression therapy (AST) for laryngomalacia (LM) is limited. The objective of this study was to determine if outpatient-initiated AST for LM was associated with symptom improvement, weight gain, and/or avoidance of surgery. METHODS: A retrospective cohort was reviewed at a tertiary-care children's hospital. Patients were included if they were diagnosed with LM at ≤6 months of age, seen in an outpatient otolaryngology clinic between 2012 and 2018, and started on AST. Primary outcomes were improvement of airway and dysphagia symptoms, weight gain, and need for surgery. Severity was assessed by symptom severity. RESULTS: Of 2693 patients reviewed, 199 met inclusion criteria. Median age of diagnosis was 4 weeks (range: 0-29 weeks). LM was classified as mild/moderate (71.4%) and severe (28.6%) based on symptom severity. Severity on flexible fiberoptic laryngoscopy (FFL) was not associated with clinical severity. Weight percentile, airway symptoms, and dysphagia symptoms improved within the cohort. In total, 26.1% underwent supraglottoplasty (SGP). In multivariate analysis, only severe LM on FFL was predictive of SGP (OR: 7.28, 95%CI: 1.91-27.67, p = .004). CONCLUSION: Clinical symptom severity did not predict response to AST raising the question of utility of AST in LM. Severity of LM based on FFL, not clinical severity, was associated with decision to pursue SGP. Prospective randomized trials are needed to better understand the role of AST in LM. LEVEL OF EVIDENCE: Level 3.

Impact of Preoperative Multidisciplinary Conference on Head and Neck Reconstruction Outcomes.

INTRODUCTION: Head and neck oncologic resections with microvascular reconstruction are lengthy and complex procedures with inefficiencies in the operating room (OR) associated with increased complications and higher costs. Multidisciplinary care has become increasingly used to provide improved care for complex patients; however, the potential role of this has not yet been studied in head and neck microvascular free flap procedures. METHODS: Patients between 2016 and 2022 treated before and after implementation of the conference were included. Primary outcome was total procedure time (TPT). Demographics, operative details, and postoperative complications were also collected. RESULTS: 233 patients were included in the preconference group and 330 in the post-conference group. Preconference mean (SD) age was 61.6 (12) years versus 62.9 (12) years in the post-conference group. The post-conference group was associated with shorter mean (SD) TPT (629 [117] vs. 719 [134] minutes), less mean (SD) estimated blood loss (ESD) (230 [201] mL vs. 306 [211] mL), fewer prolonged lCU stays (>1 day), and fewer returns to the operating room (RTOR). The post-conference group was associated with TPT ≤9 h (p < 0.001) on multivariate analysis. Factors associated with TPT greater than 9 h include history of head and neck radiation (p = 0.003), bony reconstruction (p = 0.05), stage IVa (p = 0.009), and stage IVb cancer (p < 0.001). CONCLUSIONS: Implementation of the multidisciplinary conference in head and neck surgery was associated with reduced TPT and reduced OR return. Our study suggests preoperative planning conferences may improve surgical efficiency and outcomes in head and neck oncologic resections with microvascular free flap reconstruction. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Immunotherapy in the Management of Sinonasal Mucosal Melanoma: A Systematic Review.

OBJECTIVE: The aim of this work is to comprehensively review and synthesize the literature related to sinonasal mucosal melanoma (SNMM) treatment with immunotherapy, including potentially targetable genetic mutations, survival outcomes, and adverse events. DATA SOURCES: Embase, Cochrane, Scopus, and Web of Science. REVIEW METHODS: The study protocol was designed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Databases were searched from inception through May 23, 2023. RESULTS: A total of 42 studies met inclusion criteria. Twenty-four of the included studies reported genetic mutations for a combined 787 patients with SNMM. 8.1% (95% confidence interval, CI: 7.6-8.6), 18.9% (95% CI: 18.1-19.8), and 8.5% (95% CI: 8.1-9.0) of reported patients were positive for BRAF, NRAS, and KIT mutations, respectively. The presence of brisk tumor-infiltrating lymphocytes was associated with improved recurrence-free survival and overall survival (OS). Six studies reported a combined 5-year OS after adjuvant immunotherapy treatment of 42.6% (95% CI: 39.4-45.8). Thirteen studies encompassing 117 patients reported adjuvant or salvage immune checkpoint inhibitor (ICI) immunotherapy response rates: 40.2% (95% CI: 36.8-43.6) had a positive response (tumor volume reduction or resolution). Eleven studies reported direct comparisons between SNMM patients treated with or without immunotherapy; the majority (7/11) reported survival benefit for their entire cohort or select subgroups of SNMM patients. With the transition to modern ICIs, there is a stronger trend toward survival improvement with adjuvant ICI. Tumors with Ki67 <40% may respond better to ICI's. CONCLUSION: ICI therapy can be an effective in select SNMM patients, especially those with advanced/metastatic disease.

Postoperative opioid-prescribing practices in otolaryngology: Evidence-based guideline outcomes.

Objectives: We previously reported that >50% of postoperative opioids prescribed at our institution went unused for common otolaryngologic procedures. Based on these findings, we instituted multimodal, evidence-based guidelines for postoperative pain management. In the second part of our multiphasic study, we evaluated the effects of these guidelines on (1) quantity of unused opioids, (2) patient satisfaction, and (3) institutional perceptions toward the opioid epidemic and prescribing guidelines. Methods: Standardized, procedure-specific opioid prescription guidelines were created using prospective data from the first phase of our study and evidence from current literature. Again, we examined sialendoscopy, parotidectomy, parathyroidectomy/thyroidectomy, and transoral robotic surgery (TORS). Patients were surveyed at their first postoperative appointment. Groups from Phases I and II were compared. Attending physicians were surveyed before the start of the multiphasic project and after prescribing guidelines were implemented. Results: Prescribing guidelines led to an average reduction in prescribed morphine milligram equivalents (MME) per patient by: 48% (sialendoscopy), 63% (parotidectomy), 60% (para/thyroidectomy), and 42% (TORS). Average used MME per patient for parotidectomy was significantly reduced (64%). The proportion of unused MME per patient and patient satisfaction scores did not significantly change after guidelines were implemented. Conclusion: Implementation of opioid-prescribing guidelines and the use of multimodal analgesia substantially reduced the amount of opioids prescribed across all procedures without impacting patient satisfaction. Level of Evidence: 2.

Head and Neck Reconstruction in Patients with Polycythemia Vera: Case Series and Literature Review.

Background Polycythemia vera (PV) is a myeloproliferative disease with overproduction of erythrocytes, leukocytes, and platelets causing an increased risk of both thrombosis and hemorrhage. There are limited reports and no established guidelines for managing such patients undergoing reconstructive surgery. Methods We present four patients with PV and head and neck cancer who required reconstruction after resection and provide a review of the current literature. Results Preoperatively, patients on cytoreductive therapy continued with their treatment throughout their hospital course and had hematologic parameters normalized with phlebotomy or transfusions if needed. Two patients who underwent free flap surgery (cases 1 and 2) had postoperative courses complicated by hematoma formation and persistent anemia, requiring multiple transfusions. Cases 3 and 4 (JAK2+ PV and JAK2- PV, respectively) underwent locoregional flap without postoperative complications. Conclusion Concomitant presentation of PV and head and neck cancer is uncommon and presents unique challenges for the reconstructive surgeon. Overall, we recommend that patients should have hematologic parameters optimized prior to surgery, continue ruxolitinib or hydroxyurea, and hold antiplatelet/anticoagulation per established department protocols. It is essential to engage a multidisciplinary team involving hematology, head and neck and reconstructive surgery, anesthesia, and critical care to develop a standardized approach for managing this unique subset of patients.

Discharge Disposition After Head and Neck Reconstruction: Effect on Adjuvant Therapy and Outcomes.

OBJECTIVES: Head and neck cancer patients that require major reconstruction often have advanced-stage disease. Discharge disposition of patients can vary and impact time to adjuvant treatment. We sought to examine outcomes in patients discharged to skilled nursing facilities (SNF) compared to those discharged home, including the impact on adjuvant therapy initiation and treatment package time (TPT). METHODS: Patients with head and neck squamous cell carcinoma treated with surgical resection and microvascular free flap reconstruction from 2019 to 2022 were included. Retrospective review was conducted to evaluate the impact of disposition on time to radiation (RT) and TPT. RESULTS: 230 patients were included, with 165 (71.7%) discharged to home and 65 (28.3%) discharged to SNF. 79.1% of patients were recommended adjuvant therapy. Average time to RT was 59 days for patients discharged to home compared to 70.1 days for patients discharged to SNF. Disposition was an independent risk factor for delays to starting RT (p = 0.03). TPT was 101.7 days for patients discharged to home versus 112.3 days for those who discharged to SNF. Patients discharged to SNF had higher rates of readmission (p < 0.005) compared to patients discharged home in an adjusted multivariate logistic regression. CONCLUSIONS: Patients discharged to an SNF had significantly delayed time to initiation of adjuvant treatment and higher rates of readmission. Timeliness to adjuvant treatment has recently been established as a quality measure, thus identifying delays to adjuvant treatment initiation should be a priority. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2977-2983, 2023.

Opioid Usage and Pain Control in Benign Oropharyngeal Surgery: An Observational Prospective Study.

OBJECTIVES: Little data is available on opioid usage in the adult population for benign oropharyngeal surgery. The objective here is to evaluate opioid prescribing patterns, opioid consumption, and patient pain patterns following benign oropharyngeal surgery, specifically tonsillectomy and adenoidectomy, tonsillectomy alone, and expansion sphincter pharyngoplasty. METHODS: Patients aged ≥18 years old and received a tonsillectomy, tonsillectomy and adenoidectomy, or expansion sphincter pharyngoplasty between November 2019 and August 2020 were included. Patients were provided a survey which included a visual analog scale for recording their pain postoperatively and the amount of opioid they had remaining. RESULTS: About 103 patients completed the post-operative questionnaire. Patients were prescribed 38 837 morphine milligram equivalents and used 28 644: approximately 26% went unused, which is the equivalent of 1346 5 mg oxycodone pills. Opioid consumption correlated with the initial dosage: patients consumed 12% more narcotic on average as the initial prescription went upwards by 50 morphine milligram equivalents. Obstructive sleep apnea, history of smoking, and being female predicted increased opioid usage in this cohort. Pain was reported the highest on postoperative day 1. A prescription of approximately 225 morphine milligram equivalents (150 mg oxycodone) was associated with decreased opioid use in this cohort. Larger initial prescriptions did not result in fewer requests for refills. CONCLUSION: A significant amount of opioid medication went unused in this study. A prescription of 225 morphine milligram equivalents (or 150 mg oxycodone) provided appropriate analgesia for the majority of patients. Larger prescriptions may result in increased opioid consumption and may not reduce the amount of refills. More study is needed to confirm these findings.

Postoperative opioid-prescribing practices in otolaryngology: A multiphasic study.

OBJECTIVES: In otolaryngology, postoperative pain management lacks evidence-based guidelines. We designed a prospective, multiphasic study aimed to develop evidence-based guidelines for postoperative pain management within our institution. In this first phase of our project, we investigated opioid prescription and consumption as well as pain trends for common otolaryngologic procedures. METHODS: Patients (n = 161) who underwent procedures between July 2018 and February 2019 were surveyed on their postoperative opioid usage and pain from day of discharge to first clinic visit. Opioid prescriptions were converted to standardized units of morphine milligram equivalents (MME). The procedures selected for analysis were parathyroidectomy/thyroidectomy, parotidectomy, sialendoscopy, and transoral robotic surgery resection (TORS). RESULTS: In total, 19,748 MME were prescribed: 8,588 MME (43.5%) were used, leaving 11,159 MME (56.5%) unused. TORS average MME used: 221 ± 227; total MME unused: 38%. Sialendoscopy average MME used: 31 ± 46; total MME unused: 67%. Parathyroidectomy/thyroidectomy average MME used: 30 ± 37; total MME unused: 66%. Parotidectomy average MME used: 43 ± 53; total MME unused: 65%. Male gender, smoking (current and former), and psychiatric medication use were positive predictors of opioid consumption in postoperative patients (P < 0.001). CONCLUSION: At our institution, over 50% of prescribed postoperative opioids went unused. This was most pronounced for nonmucosal surgeries. Postoperative pain management should account for this to minimize unnecessary opioid prescriptions. Based on our findings and review of current literature, we are in the process of developing prescribing recommendations to be implemented within our institution. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:659-665, 2020.

Correlation between pre-admission blood pressure and outcome in a large telestroke cohort.

BACKGROUND: Telemedicine rapidly connects patients, with acute ischemic stroke symptoms, with neurovascular specialists for assessment to reduce chemical thrombolysis delivery times. Management of AIS includes maintaining target systolic blood pressures (SBP). In this retrospective study, we assess the efficacy of the telestroke (TS) system at a primary stroke center and the prognostic value of SBP throughout the transportation process. METHODS: Patients presenting with acute-onset neurological symptoms to the TS hospitals network, over a 5-year period, were assessed. Those with a confirmed diagnosis of AIS were included. We examined demographics, presenting-NIHSS, last SBP before transfer from the network hospital and continuous BP during transport, stroke risk factors, hospital-course, door-to-needle (DTN) time, treatments, and modified Rankin Scale(mRS). Multivariate analysis was conducted to evaluate the prognostic value of SBP on stroke outcome. RESULTS: Of 2,928 patients identified, 1,353 were diagnosed with AIS. Mean age was 66.6 years (SD = 15.4), 47.6% female. Most cases affected the MCA(44.5%). Mean presenting-NIHSS was 8.67(SD = 8.38) and mean SBP was 148 mmHg(SD = 25.39). 73.2% treated using a standard protocol, 23.7% given IVrt-PA, and 6.8% received mechanical thrombectomy(MT). Mean DTN was 96 min(SD = 46; 27.3% <60 min). Age, presenting-NIHSS and pre-existing hypertension were associated with higher mortality and/or higher mRS. SBP was not associated with higher mortality and morbidity. CONCLUSIONS: This study displays better clinical outcomes at latest follow-up when compared to current international TS studies. SBP during transportation to the hub hospital did not prove to be a useful prognostic metric. However, future studies should address the limitations of this study to confirm these findings.

Rare case of diffuse spinal arachnoiditis following a complicated vertebral artery dissection.

Spinal arachnoiditis (SA) is an extremely rare and delayed complication of subarachnoid hemorrhage (SAH). Little is known about its underlying pathogenesis and subsequent clinical course. A middle-aged patient presented with the worst headache of her life and a grade 3 SAH of the basal-cisterns and posterior fossa was identified on Computed Tomography scans (CT). Angiography revealed a ruptured dissecting aneurysm of the left vertebral artery (VA-V4), as well as an unruptured left Anterior Cerebral Artery (ACA-A1) aneurysm. The VA aneurysm was treated with flow diversion. The patient re-ruptured the stented aneurysm, another telescoping pipeline was placed. The patient developed polymicrobial ventriculitis, and returned several months later complaining of paraparesis and left sided weakness. Magnetic Resonance Imaging (MRI) revealed diffuse thecal dural thickening from the cervicomedullary junction to the sacrum. Loculations, diffuse edema and cord compression were noticed along the inferior surface of the cerebellum, and the cervico-thoracic spine with a T4-T6 syrinx. The patient underwent a posterior (T4-T8) spinal fusion and (T5-T7) decompression with arachnoid-cyst fenestration and placement of a subarachnoid-pleural shunt. On latest follow-up, the patient is weaning off the thoraco-lumbosacral orthosis and ambulating with a cane. SA is often a complicated two-staged disease in which a "free interval phase" separates the initial inflammatory reaction (IIR) from the late adhesive phase. Posterior fossa bleeding, warranting prolonged surveillance, additional bleeding and ventriculitis might augment the risk and the severity of arachnoiditis.

A comparison of two stroke cohorts cared for by two different specialties in a practice-based tele-stroke population.

OBJECTIVES: Neurologists have continually led the assessment and management of Acute Ischemic Stroke(AIS) by use of IV-rtPA, anti-platelet therapy, antihypertensives, and other pharmacologic agents. Since the advent of mechanical thrombectomy(MT) and its proven efficacy, neurovascular surgeons(NS) are playing an increasingly important role in the management and overall care of AIS. We assessed outcomes of AIS patients managed by NS, who have been traditionally managed by neurologists. PATIENTS AND METHODS: Outcomes of AIS patients who presented to the telestroke system, over a 5-year period, were assessed. NIHSS and mRS stroke scales were used as outcome metrics. Multivariate analysis was conducted to compare outcomes of patients treated by neurovascular surgeons and those treated by neurologists. RESULTS: 1353 AIS patients were identified. 21.6% received care from neurosurgeons and 78.4% received care from neurologists. Of the neurologist-managed group: 7.8% received MT and were followed by NS, 34% received IVrt-PA, average discharge NIHSS = 9.0 (SD = 8.42), latest follow-up mRS < 2 = 57.5% and mortality rate = 9.4%. Of the neurovascular surgeon-managed group: 7.4% patients received MT, 20% received IVrt-PA, average discharge NIHSS = 0.14(SD = 0.72), latest follow-up mRS ≤2 = 98.6% and mortality rate = 8.3%. There were no significant differences between groups in MT use (OR 1.22; CI95%, 0.971-2.09; p = 0.464), IVrt-PA administration (OR 0.98; CI95%, 0.70-1.38; p = 0.924), mortality rate (OR 1.21; 0.71-2.03; p = 0.483) and patients' latest mRS, p = 0.873. CONCLUSIONS: AIS requires multidisciplinary management. Care provided by neurosurgeons has similar efficacy and patient outcomes as the care provided by neurologists. These findings support the role and ability of neurosurgeons to manage and care for these patients.

Proposed Iraq/Afghanistan War-Lung Injury (IAW-LI) Clinical Practice Recommendations: National Academy of Sciences' Institute of Medicine Burn Pits Workshop.

High rates of respiratory symptoms (14%) and new-onset asthma in previously healthy soldiers (6.6%) have been reported among military personnel post-deployment to Iraq and Afghanistan. The term Iraq/Afghanistan War-Lung Injury (IAW-LI) is used to describe the constellation of respiratory diseases related to hazards of war, such as exposure to burning trash in burn pits, improvised explosive devices, and sandstorms. Burnpits360.org is a nonprofit civilian website which voluntarily tracks medical symptoms among soldiers post-deployment to the Middle East. Subsequent to initiation of the Burnpits360.org website, the Department of Veterans Affairs started the Airborne Hazards and Open Burn Pit registry. This paper: (a) analyzes the latest 38 patients in the Burnpits360.org registry, validated by DD214 Forms; (b) compares strengths and weaknesses of both registries as outlined at the National Academy of Sciences Institute of Medicine Burn Pits Workshop;

Emerging Novel Therapies for Heart Failure.

Heart function fails when the organ is unable to pump blood at a rate proportional to the body's need for oxygen or when this function leads to elevated cardiac chamber filling pressures (cardiogenic pulmonary edema). Despite our sophisticated knowledge of heart failure, even so-called ejection fraction-preserved heart failure has high rates of mortality and morbidity. So, novel therapies are sorely needed. This review discusses current standard therapies for heart failure and launches an exploration into emerging novel treatments on the heels of recently-approved sacubitril and ivbradine. For example, Vasoactive Intestinal Peptide (VIP) is protective of the heart, so in the absence of VIP, VIP knockout mice have dysregulation in key heart failure genes: 1) Force Generation and Propagation; 2) Energy Production and Regulation; 3) Ca(+2) Cycling; 4) Transcriptional Regulators. VIP administration leads to coronary dilation in human subjects. In heart failure patients, VIP levels are elevated as a plausible endogenous protective effect. With the development of elastin polymers to stabilize VIP and prevent its degradation, VIP may therefore have a chance to satisfy the unmet need as a potential treatment for acute heart failure.