Outcome Comparison of Functional Laryngectomy for the Dysfunctional Larynx to Salvage Laryngectomy.

OBJECTIVE: To compare functional outcomes of total laryngectomy (TL) with microvascular free tissue transfer (MVFTT) reconstruction in the treatment of dysfunctional larynx (DL) versus salvage therapy for locally recurrent disease in patients with a history of laryngeal squamous cell carcinoma (SCC). METHODS: Retrospective review from a tertiary medical center between August 2015 and August 2022. RESULTS: Sixty-nine patients underwent TL with MVFTT following primary laryngeal radiation or chemoradiation; 15 (22%) patients underwent functional laryngectomy (FL) and 54 (78%) underwent a salvage laryngectomy (SL). There were no total flap failures. Four (6%) patients developed a pharyngocutaneous fistula; one (7%) FL patient and 3 (6%) in the SL cohort. There was no significant difference in average hospital length of stay (LOS) between the cohorts (8.6 ± 3.0 days vs. 12.8 ± 10.1 days, p = 0.12). All patients (100%) in the FL cohort achieved a total oral diet compared to 41 (76%) in the SL cohort (p = 0.03). Two (13%) and 10 (19%) patients developed pharyngoesophageal stenosis in the FL and SL cohorts, respectively (p = 1.0). Nine (60%) and 23 (43%) patients in the FL and SL cohorts underwent tracheoesophageal puncture (TEP) placement, with 89% and 91% achieving fluency, respectively (p = 0.23). CONCLUSION: Although the role of TL for the definitive treatment of laryngeal SCC has decreased over the past 30 years, organ-preservation protocols can impact speech, swallowing, and airway protection with life-threatening consequences. The use of elective FL with MVFTT for the treatment of DL results in similar or better functional outcomes compared to SL for recurrent disease. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:222-227, 2024.

Considerations for Functional Nasal Surgery in the Obstructive Sleep Apnea Population.

Obstructive sleep apnea (OSA) and nasal obstruction are common in the general population and frequently treated by otolaryngologists and facial plastic surgeons. Understanding the appropriate pre-, peri-, and postoperative management of OSA patients undergoing functional nasal surgery is important. OSA patients should be appropriately counseled in the preoperative period on their increased anesthetic risk. In OSA patients who are continuous positive airway pressure (CPAP) intolerant, the role of drug-induced sleep endoscopy should be discussed with the patient, and depending on the surgeon's practice may prompt referral to a sleep specialist. Should multilevel airway surgery be indicated, it can safely be performed in most OSA patients. Surgeons should communicate with the anesthesiologist regarding an airway plan given this patient population's higher propensity for having a difficult airway. Given their increased risk of postoperative respiratory depression, extended recovery time should be given to these patients and the use of opioids as well as sedatives should be minimized. During surgery, one can consider using local nerve blocks to reduce postoperative pain and analgesic use. After surgery, clinicians can consider opioid alternatives such as nonsteroidal anti-inflammatory agents. Neuropathic agents, such as gabapentin, require further research in their indications for managing postoperative pain. CPAP is typically held for a period of time after functional rhinoplasty. The decision on when to restart CPAP should be individualized to the patient based on their comorbidities, OSA severity, and surgical maneuvers performed. More research would provide further guidance in this patient population to shape more specific recommendations regarding their perioperative and intraoperative course.

Pediatric orbital fractures.

PURPOSE OF REVIEW: The aim of this study was to summarize current evidence on the clinical presentation, evaluation, and management of pediatric orbital fractures. Recent trends in management strategies as well as emerging surgical techniques for pediatric orbital fracture repair are presented. RECENT FINDINGS: Although somewhat limited, growing bodies of evidence support a conservative approach with close follow up in pediatric orbital fractures. For those patients necessitating surgical repair, resorbable implants are increasingly preferred given their lack of donor site morbidity and a minimal impact on the developing craniofacial skeleton. There are emerging data reporting the use of three-dimensional (3D) printing-assisted approaches and intraoperative navigation; however, more research is needed to assess their applicability in the pediatric population. SUMMARY: There are few studies with large patient cohorts and long-term follow up given the rare incidence of pediatric orbital fractures, which restricts the generalizability of research on the topic. The studies available increasingly suggest that fractures without clinical evidence of entrapment can be managed conservatively with close follow up. A variety of reconstructive implants are available for those fractures necessitating repair. Donor site morbidity, availability, and need for additional procedures should all be factored into the reconstructive decision-making process.

P16 and human papillomavirus in sinonasal squamous cell carcinoma.

Human papillomavirus (HPV) in oropharyngeal squamous cell carcinoma (SCC) is a well-known cause and prognostic indicator, and the utility of p16 as a surrogate marker for HPV status has been established. P16 and its relationship with HPV have not been defined in sinonasal malignancy nor has a link with outcomes been established. Patients with sinonasal SCC from 2011 to 2017 were identified from our pathology database. P16 immunohistochemistry and HPV RNA in situ hybridization were performed on tissue specimens. Forty-seven patients were included. Disease-free survival for p16+ patients was significantly higher than p16- patients (P = .043). Fewer HPV+ patients died (P = .052) or experienced recurrence (P = .0437). Odds ratio between p16 and HPV status was 14.19 (95% CI: 1.72, 442.03). Our findings demonstrate improved survival in both the p16+ and HPV+ groups and a positive association between p16 and HPV. There may be similar potential for modifying classification for HPV+ sinonasal SCC.