Predictors of plate extrusion in oromandibular free flap reconstruction.

OBJECTIVES: Plate extrusions after free tissue transfer for mandibular reconstruction can be problematic and generally require revision surgery. Our objective was to assess the predictors of plate extrusion and compare outcomes between fibular free flaps (FFF), lateral border scapular flaps (LBSF), and scapular tip free flaps (STFF). METHODS: Retrospective review of consecutive patients who underwent osseous free tissue reconstruction of the mandible (2008-2014) at Victoria Hospital, London, Ontario. Patient demographics and treatment-related information were collected. RESULTS: We identified 134 procedures and 27 (20.2%) plate extrusions (21/61 FFF, 3/49 STFF, and 3/24 LBSF). Freedom from extrusion after 2 years was significantly associated with the use of FFF (P = .003, HR 6.09 1.82-20.44), performing 1 osteotomy (P = .03, HR 2.61 1.08-6.31), and anterior mandibular defects (P = .01, HR 2.66 1.25-5.66) in the univariate model. FFF's were employed more frequently in younger patients, with 2.4 mm plates, more anterior defects, and with a greater number of osteotomies (P < .001). However, after controlling for these variables in multivariate analyses the use of a FFF was the only significant predictor of extrusion at 2 years (P = .006, HR 3.68 1.46-9.28). CONCLUSIONS: At our institution, use of the STFF predicts mandibular defects that are less prone to developing plate extrusion and FFF tended to be used more frequently in anterior defects with osteotomies. However, after controlling for these factors use of the FFF appeared to have higher rates of extrusion than scapular flaps. Further prospective studies controlling for defect variables are needed to elucidate the risk factors for plate extrusion.

Shouldering the load of mandible reconstruction: 81 cases of oromandibular reconstruction with the scapular tip free flap.

BACKGROUND: The scapular tip free flap (STFF) is becoming more popular for oromandibular reconstruction. This article reviewed the early and late outcomes in a larger series over 9 years. METHODS: We conducted a retrospective review of all consecutive patients who underwent oromandibular reconstruction using the STFF at London Health Sciences Centre. Demographic information, surgical data, and complications were collected and analyzed. RESULTS: From April 2008 to March 2017, 81 STFFs were performed in 80 patients. The average bony reconstruction measured 5.4 cm. Bone-only flaps were utilized in 24 cases (29.6%). Five cases (6.2%) required a single osteotomy. There were 3 (3.7%) flap failures. There were 7 plate extrusions and 11 cases of radiographic nonunion. CONCLUSION: The STFF is a reliable option with acceptable early and long-term results. The STFF may be considered as a first line option especially for shorter bone defects or in conjunction with complex soft tissue requirements.

Outcomes of Cutaneous Squamous Cell Carcinoma in the Head and Neck Region With Regional Lymph Node Metastasis: A Systematic Review and Meta-analysis.

IMPORTANCE: There is a need to summarize the available evidence and provide quantitative data of the most important prognostic factors for patients with metastatic cutaneous squamous cell carcinoma of the head and neck region with regional lymph node metastasis (McSCCHN). OBJECTIVE: To undertake a PRISMA-compliant systematic review and meta-analysis of all published studies on the risk factors for overall survival (OS), locoregional control (LRC), locoregional recurrence (LRR), and disease-specific survival (DSS) for patients with McSCCHN. DATA SOURCES: PubMed, CINAHL, and Embase were searched from 1946 to August 2018 for English-language articles. STUDY SELECTION: Inclusion criteria were randomized clinical trials or observational studies reporting on at least 10 patients with McSCCHN; studies analyzing 1 defined risk factor; reporting OS, LRC, LRR, or DSS; and clinical follow-up of 1 year of more. For the final analysis we included risk factors that were analyzed for the same outcome in at least 3 studies. Of the 2923 articles screened, 21 articles met the inclusion criteria. DATA EXTRACTION AND SYNTHESIS: PRISMA guidelines were used for abstracting the data. Two reviewers independently abstracted the data. Risk of bias was estimated with the Newcastle-Ottawa Scale. Meta-analysis was performed using the random-effects model. All analysis took place between January and October 2018. MAIN OUTCOMES AND MEASURES: The primary end point was OS. Secondary end points included LRC, LRR, and DSS. RESULTS: A total of 20 observational studies and 1 randomized clinical trial were identified, representing 3534 patients (some reviewed articles reported no demographic characteristics), and were included in the analysis. Significant risk factors associated with OS were immunosuppression (hazard ratio [HR] of death, 2.66; 95% CI, 2.26-3.13), extracapsular spread (HR, 1.90; 95% CI, 1.12-3.23), adjuvant radiotherapy (HR, 0.45; 95% CI, 0.27-0.78), lymph node ratio (HR, 1.91; 95% CI, 1.09-3.35), and advanced age (HR, 1.03; 95% CI, 1.00-1.07). Immunosuppression (HR, 3.82; 95% CI, 2.47-5.92) and adjuvant radiotherapy (HR, 0.52; 95% CI, 0.33-0.84) were also significant risk factors for DSS. CONCLUSIONS AND RELEVANCE: Immunosuppressed patients and those with extracapsular extension have poor prognosis. Adjuvant radiotherapy is associated with an improvement in OS. These risk factors will assist with better risk stratification and may also help to inform future clinical trials.

Boot Camps: Preparing for Residency.

Simulation-based boot camps are growing in popularity and are effective in onboarding novice residents with new knowledge, skills, and behaviors. These intensive and immersive courses may be used to train residents and allied health professionals in specific procedures, teamwork, and management of rare clinical scenarios. A needs assessment of learners determines the course curriculum. Boot camps are designed to encourage active and hands-on participation with deliberate practice and immediate feedback. As surgical education shifts toward competency-based medical education, there may be an even greater role for simulation-based boot camps as a training and assessment tool.

Reconstruction after salvage laryngectomy.

Both early and advanced stage laryngeal cancers are treated with organ-preserving strategies including radiation alone or concurrent chemoradiotherapy. While organ-preserving modalities have proven effective in eradicating cancer while also preserving laryngeal function, there remains a proportion of cases where residual or recurrent cancer prevails, or conversely, where radiotherapy renders a larynx dysfunctional. In these circumstances, salvage total laryngectomy is often the surgical treatment. The effects of radiotherapy to the neck, amplified by chemotherapy, can create an inhospitable surgical environment, making the salvage laryngectomy an operation fraught with the potential for major complications such as the dreaded pharyngocutaneous fistula. The introduction of vascularized tissue from outside the irradiated field decreases the risk of major wound complications. Free tissue transfer, with a variety of donor sites available, is commonly employed to reconstruct either a patch or a circumferential segment of the pharynx. When there is enough pharyngeal mucosa for primary closure, a vascularized onlay graft or a pharyngeal interposition graft can be used to reinforce the closure. This has been demonstrated to both reduce the severity of pharyngocutaneous fistula and decrease the risk of developing a pharyngocutaneous fistula compared to primary closure alone. Beyond mitigating the risk for perioperative complications, flap selection may have implications on the long-term outcomes after salvage total laryngectomy and these must be considered preoperatively. The purpose of this review is to examine the various options for reconstruction after salvage total laryngectomy and to examine some of their advantages and disadvantages in the short and long-term.

Metastatic mammary carcinoma to the orbit masquerading as maxillary sinusitis.

INTRODUCTION: We report on a case of isolated metastatic breast cancer to the medial rectus muscle. This entity is exceedingly rare. CASE: A 44-year-old female with a history of breast cancer presented with unilateral maxillary symptoms and was treated for sinusitis. Over time, she developed ocular pain, diplopia, blurred vision and eventually complete adduction deficit. RESULTS: T1-weighted magnetic resonance imaging revealed a medial rectus lesion. Biopsy via transnasal transorbital endoscopic approach revealed metastatic mammary carcinoma. DISCUSSION: Metastatic disease to the orbit should be considered in the differential diagnosis of refractory maxillary sinus pain in patients with a known underlying malignancy.

The usefulness of routine histopathology of bilateral nasal polyps - a systematic review, meta-analysis, and cost evaluation.

BACKGROUND: Controversy regarding the usefulness of routine histopathological examination of bilateral nasal polyps removed during endoscopic sinus surgery to identify occult diagnoses still exists. There is a paucity of high-level evidence in the literature. METHODS: A systematic review and meta-analysis was conducted. Two independent reviewers were used. Pooled proportions and numbers needed to screen were calculated. A cost per life year model was generated based on varying survival benefits and compared to other Canadian screening programs to provide financial context. RESULTS: Six studies (n = 3772 patients) were included. Of the 3772 patients, 3751 had a pre-operative clinical and post-operative pathological diagnosis of inflammatory nasal polyps. Agreement proportion was 99.44 %. There were 18 unexpected benign and three unexpected malignant diagnoses identified. This translated to a proportion of 0.48 and 0.08 % respectively. Number needed to screen was 210 and 1258 respectively. Pooled proportion for expected findings using a random effect model was 0.99 (95 % CI = 0.99-1). Pooled proportion for unexpected benign findings using a random effect model was 0.00522 (95 % CI = 0.00133-0.01). Pooled proportion for unexpected malignant findings using a random effect model was 0.00107 (95 % CI = 0.000147-0.00283). The cost to pick up one unexpected benign diagnosis was $14557.2. The cost to pick up 1 unexpected malignant diagnosis was $87204.56. Cost per quality life year calculated ranged from 3211.83 to $64677.58 based on varying assumptions on the survival benefits of identifying an unexpected malignancy. CONCLUSIONS: Routine pathological examination in screening for neoplasia may be low yield, however, no compelling evidence was found to cease such practice. Surgeons should exercise individual judgment in requesting routine examination.

Surgeon-estimated costs of common consumables in otolaryngology.

OBJECTIVES/HYPOTHESIS: The current fiscal climate demands increasing emphasis on curbing hospital expenses incurred from surgical procedures. Disposable instruments and consumables play a major role, but the end user (the surgeon) is often unaware of the cost of these materials. The objectives of our study were: 1) to assess knowledge of costs of disposable instruments and consumable products, and 2) to gauge interest in greater access to cost information and its potential to change practice. STUDY DESIGN: We used a cross-sectional survey study to meet our study's objectives. METHODS: A paper-based anonymous questionnaire was administered in the Department of Otolaryngology at McGill University and at Western University asking for estimations of costs of 23 commonly used products in the operating room. Our primary outcome measure was accuracy of cost estimations, which were considered accurate if within ± 50% of the true cost at the respective institution. RESULTS: The average accuracy was 29.9% (standard deviation = 16.7%). There was no significant difference between residents (32.5%, 95% confidence interval [CI]: 10.2%-54.7%) and staff (28.3%, 95% CI: 11.0%-45.6%). Less than 10% of participants were able to accurately estimate the costs of at least half of the disposable products. The majority of participants (82%) felt that greater information would change their use of consumables. CONCLUSIONS: Surgical residents and staff have a generally poor knowledge of the cost of common consumable products used in the operating room. There is potential for increased awareness of costs to change behavior. LEVEL OF EVIDENCE: NA.

The utility of routine polyp histopathology after endoscopic sinus surgery.

BACKGROUND: Routine histopathological assessment is standard practice for nasal polyp specimens obtained during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Retrospective studies suggest that routine histopathology of nasal polyps shows few unexpected diagnoses that alter patient management. Our objective was to study the use of routine pathological analysis, and its cost to the healthcare system, in a prospective manner. METHODS: A multicenter prospective assessment was performed from data collected between 2007 and 2013. Only cases of patients undergoing ESS for bilateral CRS were included. We excluded unilateral disease cases, and cases in which diagnoses other than polyps were suspected either preoperatively or intraoperatively. We then compared the preoperative diagnosis with the final histopathology and identified the rate of unexpected pathologies. A cost analysis was performed. RESULTS: Only 4 of 866 pathological specimens were identified as having a clinically significant unexpected diagnosis. All unexpected pathologies in this series were benign. These 4 cases account for 0.46% of all specimens reviewed. This translates to a number needed to screen of 217 cases of bilateral CRS to discover 1 unexpected pathology. The associated cost for making an unexpected diagnosis was $19,192.73. CONCLUSION: Routine histopathology of nasal polyps in ESS for bilateral CRS with polyps yields few unexpected and management-altering diagnoses. It carries a significant cost to the healthcare system. In cases of bilateral CRS with no other concerning clinical features, clinicians should exercise judgment in submitting polyp specimens for pathology rather than routinely sending polyps for histopathologic analysis.