Oncologic Safety of Close Margins in Patients With Low- to Intermediate-Grade Major Salivary Gland Carcinoma.

Importance: Postoperative radiation therapy for close surgical margins in low- to intermediate-grade salivary carcinomas lacks multi-institutional supportive evidence. Objective: To evaluate the oncologic outcomes for low- and intermediate-grade salivary carcinomas with close and positive margins. Design, Setting, and Participants: The American Head and Neck Society Salivary Gland Section conducted a retrospective cohort study from 2010 to 2019 at 41 centers. Margins were classified as R0 (negative), R1 (microscopically positive), or R2 (macroscopically positive). R0 margins were subclassified into clear (>1 mm) or close (≤1 mm). Data analysis was performed from June to October 2023. Main Outcomes and Measures: Main outcomes were risk factors for local recurrence. Results: A total of 865 patients (median [IQR] age at surgery, 56 [43-66] years; 553 female individuals [64%] and 312 male individuals [36%]) were included. Of these, 801 (93%) had parotid carcinoma and 64 (7%) had submandibular gland carcinoma, and 748 (86%) had low-grade tumors and 117 (14%) had intermediate-grade tumors, with the following surgical margins: R0 in 673 (78%), R1 in 168 (19%), and R2 in 24 (3%). Close margins were found in 395 of 499 patients with R0 margins (79%), for whom margin distances were measured. A total of 305 patients (35%) underwent postoperative radiation therapy. Of all 865 patients, 35 (4%) had local recurrence with a median (IQR) follow-up of 35.3 (13.9-59.1) months. In patients with close margins as the sole risk factor for recurrence, the local recurrence rates were similar between those who underwent postoperative radiation therapy (0 of 46) or observation (4 of 165 [2%]). Patients with clear margins (n = 104) had no recurrences. The local recurrence rate in patients with R1 or R2 margins was better in those irradiated (2 of 128 [2%]) compared to observed (13 of 64 [20%]) (hazard ratio [HR], 0.05; 95% CI, 0.01-0.24). Multivariable analysis for local recurrence found the following independent factors: age at diagnosis (HR for a 10-year increase in age, 1.33; 95% CI, 1.06-1.67), R1 vs R0 (HR, 5.21; 95% CI, 2.58-10.54), lymphovascular invasion (HR, 4.47; 95% CI, 1.43-13.99), and postoperative radiation therapy (HR, 0.10; 95% CI, 0.04-0.29). The 3-year local recurrence-free survivals for the study population were 96% vs 97% in the close margin group. Conclusions and Relevance: In this cohort study of patients with low- and intermediate-grade major salivary gland carcinoma, postoperative radiation therapy for positive margins was associated with decreased risk of local recurrence. In isolation from other risk factors for local recurrence, select patients with close surgical margins (≤1 mm) may safely be considered for observation.

A randomized study on the value of self-directed versus traditional mentor-led microsurgical training.

Objective: Analyze efficacy of self-directed resident microvascular training versus a mentor-led course. Study Design: Randomized, single-blinded cohort study. Setting: Academic tertiary care center. Methods: Sixteen resident and fellow participants were randomized into two groups stratified by training year. Group A completed a self-directed microvascular course with instructional videos and self-directed lab sessions. Group B completed a traditional mentor-led microvascular course. Both groups spent equal time in the lab. Video recorded pre and post-course microsurgical skill assessments were performed to assess the efficacy of the training. Two microsurgeons, blinded to participant identity, evaluated the recordings and inspected each microvascular anastomosis (MVA). Videos were scored using an objective-structured assessment of technical skills (OSATS), a global rating scale (GRS), and quality of anastomosis scoring (QoA). Results: The pre-course assessment identified that the groups were well matched with only "Economy of Motion" on the GRS favoring the mentor led group (p = .02). This difference remained significant on the post assessment (p = .02) Both groups significantly improved in OSATS and GRS scoring (p < .05). There was no significant difference in OSATS improvement between the two groups (p = .36) or improvement in MVA quality between groups (p > .99). Time to completion of MVA significantly improved overall by a mean of 8 min and 9 s (p = .005) with no significant difference between post training times to complete (p = .63). Conclusion: Different microsurgical training models have previously been validated as effective methods for improved MVA performance. Our findings indicate that a self-directed microsurgical training model is an effective alternative to a traditional mentor driven models. Level of Evidence: Level 2.

Characterizing Pediatric Bilateral Vocal Fold Dysfunction: Analysis with the Pediatric Health Information System Database.

OBJECTIVES: The purpose of this study was to characterize pediatric bilateral vocal fold dysfunction and to examine the overall inpatient mortality. METHODS: Retrospective cohort analysis. Data from the Pediatric Health Information System was gathered for all pediatric patients with a diagnosis of bilateral vocal fold dysfunction between January 2008 and September 2020. Univariate and multivariate analyses were performed using Cox proportional hazard models. RESULTS: 2395 patients accounted for 4799 hospitalizations with bilateral vocal fold dysfunction. Inpatient mortality occurred in 2.9% of the study sample. Chiari 2 was found in 2.8% of patients. The most common associated diagnoses were related to comorbid respiratory conditions (61.1%). The median adjusted ratio of cost to charges was $76,569. Aspiration was noted in 28 patients (1.2%). Gastrostomy was performed in 607 patients (25.3%). Tracheostomy was performed in 27% of patients. The overall 90-day readmission rate was 61%. On multivariate analysis, prognostic factors associated with increased hospital survival include gastrointestinal comorbidities (hazard ratio [HR]: 0.29; 95% confidence interval [CI]: 0.18-0.49) and tracheostomy (HR: 0.21; 95% CI: 0.12-0.37). CONCLUSION: This database study represents the largest cohort analysis to date characterizing bilateral vocal fold dysfunction. Favorable prognostic indicators of overall hospital survival include gastrointestinal comorbidities and the presence of tracheostomy. Tracheostomy is associated with an increase in hospital costs, comorbidities, gastrostomy tube placement, and Chiari diagnosis. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1228-1233, 2023.

Assessing Patient Barriers to Cochlear Implantation.

OBJECTIVE: Evaluate barriers that deter adult patients from following through with cochlear implantation. STUDY DESIGN: Retrospective chart review and phone survey. SETTING: Single tertiary referral center. PATIENTS: Between January 2019 and August 2021, 113 patients, without a previous cochlear implant (CI), were determined to be candidates for cochlear implantation. Thirty-eight (33.6%) patients deferred cochlear implantation. Survey response rate was 61.1% (22/36). INTERVENTION: None. MAIN OUTCOME MEASURES: Demographic, socioeconomic, otologic history, and comorbidity factors associated with deferment of cochlear implantation. Patient survey assessment of factors that had the greatest impact, rated on a scale of 1 to 10 (10 being the most impactful), on their decision to defer a CI. RESULTS: Out of the 113 patients who met inclusion criteria, 75 (66.3%) underwent cochlear implantation and 38 (33.6%) patients deferred. Comparing implanted versus deferred groups, there was no statistical difference in age (67.1 y versus 68.5 y; p = 0.690) or male sex (53.3% versus 57.9%; p = 0.692). The deferred group had higher mean neighborhood disadvantage state decile (5.3 versus 4.3; p = 0.064) and national percentile (73.0 versus 66.2; p = 0.106) scores, although neither were statistically significant. A greater proportion of the deferred group were not living independently at time of CI evaluation (13.2 versus 2.7%; p = 0.017). Fear of losing residual hearing was rated the highest among the survey respondents (mean rating of 5.1), followed by general medical health (4.9) and cost and financial concerns (3.6). CONCLUSION: The greatest concern among the patients was the fear of losing residual hearing. Spending greater time educating patients about the success and failure rates of cochlear implantation may reduce patient hesitancy with implantation.

Infantile Hemangioma Treated with Propranolol Readmission Trends, Complications of Therapy, and Cost: A PHIS Database Study.

Objective: To examine admission trends, complications, and costs for inpatient infantile hemangioma (IH) associated with propranolol therapy utilizing the Pediatric Health Information System (PHIS) database. Study Design. A retrospective cohort study was completed using the PHIS database. The PHIS database was queried from 2008 to 2020 for children without cardiac disease and between the ages of three weeks and one year who were admitted with a diagnosis of IH and administered propranolol. Admissions were trended annually and by geographic region. Primary outcomes were length of stay (LOS), readmission, mortality, propranolol-related complications, and costs. Bivariate and multivariable analyses were employed to identify predictors of the primary outcomes. Results: A total of 2290 unique patient encounters were identified. Admissions steadily decreased after 2011, with variations by geographic region. There was no mortality and only 60 (2.6%) propranolol-related complications. African-American race (odds ratio (OR) 1.20 [95% CI: 1.02-1.41]), respiratory comorbidities (OR 2.04 [95% CI: 1.42-2.93]), neurologic conditions (OR 1.34 [95% CI: 1.09-1.59]), admission to an intensive care unit (OR 1.31 [95% CI: 1.09-1.59]), bronchospasm (OR 1.37 [95% CI: 1.22-1.55]), and hyperkalemia (OR 1.86 [95% CI: 1.08-3.20]) were associated with increased LOS. Neurologic conditions (OR 2.87 [95% CI: 1.76-4.67]) and respiratory comorbidities (OR 2.48 [CI: 1.43-4.30]) were associated with readmission. Average cost per admission was $5,158 ($3,259 to $8,560 range). Conclusion: There is an overall national decline in rate of admissions for IH propranolol therapy. Inpatient admission may be beneficial for patients with neurologic or respiratory conditions.

Transforaminal lumbar interbody fusion with a silicon nitride cage demonstrates early radiographic fusion.

Background: Degeneration of the lumbar spine is common in aging adults and reflects a significant morbidity burden in this population. In selected patients that prove unresponsive to non-surgical treatment, posterior lumbar fusion (PLF) surgery, with or without adjunctive transforaminal lumbar interbody fusion (TLIF) can relieve pain and improve function. We describe here the radiographic fusion rates for PLF versus TLIF, using an intervertebral spinal cage made of silicon nitride ceramic (chemical formula Si3N4). Methods: This retrospective cohort analysis enrolled 99 patients from August 2013 to January 2017; 17 had undergone PLF at 24 levels, while 82 had undergone TLIF at 104 levels. All operations were performed by a single surgeon at one institution. Radiographic and clinical outcomes were compared between PLF and TLIF at 2 and 6 weeks and then at 3, 6, 12, and 24 months. Results: TLIF patients fused at higher rates compared to PLF at the 3-month (38.5% vs. 8.3%, P=0.006), 6-month (78.7% vs. 35.0%, P<0.001) and 12-month time periods (97.9% vs. 81.3%, P=0.018), with no difference at 24 months (100% vs. 94.4%, P=0.102). Index level segmental motion was significantly less and intervertebral disc height was improved in TLIF over PLF at all follow up intervals. Foraminal height was only greater in early follow up periods (2 weeks, 6 weeks and 3 months). TLIF patients experienced lover rates of PI-LL mismatch which was maintained across long term follow-up. Pelvic tilt was lower following TLIF compared to PLF, with no differences in complication rates between study groups. Conclusions: Our retrospective series demonstrated that TLIF performed with silicon nitride interbody cages led to earlier radiographic fusion, greater restoration of disc and foraminal height, increased segmental rigidity and improved sagittal alignment when compared to PLF alone.

Postoperative and 1-Year Functional Outcomes After Free Flap Surgery Among Patients 80 Years or Older.

OBJECTIVE: To evaluate the postoperative and 1-year functional outcomes after free flap surgery among patients ≥80 years old. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care center. METHODS: We conducted a retrospective review of 596 patients who underwent head and neck ablation and reconstruction with free tissue over a 7-year period. Patients ≥80 years of age were included. RESULTS: Fifty patients were ≥80 years old, with an average age of 83.7 years. Ninety-day mortality was 12.0%, and those who died were of older age (87.5 vs 83.1 years, P = .036). Prior radiation therapy (odds ratio, 6.8 [95% CI, 1.1-42.7]) and a Charlson Comorbidity Index ≥3 (odds ratio, 10.0 [95% CI, 1.5-67.0]) were associated with an increased risk of 90-day mortality. Overall 21 (42.0%) patients experienced a 30-day complication; 7 (14.0%) were readmitted within 30 days; and 5 (10.0%) underwent additional flap-related operations. Flap failure occurred in 2 (4.0%) patients. Before surgery, 45 (90%) patients were living independently or within assisted living; among these, 19.5% declined to dependent functional status at 90-day follow-up. At 90 days, 2 (8.3%) of 24 patients remained tracheostomy dependent, and 20 (66.7%) of 30 patients required feeding tube supplementation. Among 42 patients, 36 (85.7%) had unrestricted or modified oral diets at 90 days. Charlson Comorbidity Index ≥2 was associated with an increased risk of 1-year mortality (odds ratio, 5.1 [95% CI, 1.4-18.6]). CONCLUSION: The potential for functional decline and risk of 90-day mortality should be discussed with patients aged ≥80 years.

Model of an Advanced Practice Provider-Led Head and Neck Cancer Survivorship Clinic: Evaluation of a 4-Year Experience.

OBJECTIVE: To report the efficacy and safety of an advanced practice provider-led head and neck cancer survivorship clinic. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic medical center. METHODS: Patients were enrolled into the survivorship clinic after undergoing 1-year follow-up with the primary head and neck surgeon. Those enrolled between December 2016 and October 2020 were retrospectively reviewed for diagnosis, staging, pattern of recurrence, visit frequency, and compliance. Surgical respectability of recurrent disease was used as a surrogate for timely diagnosis. RESULTS: An overall 570 patients were followed within the survivorship clinic. The mean length of follow-up was 13.6 months. Mucosal primaries represented 72.6% of patients. A majority of the primary malignancies were squamous cell carcinoma (77.7%). The most common primary subsites were the oropharynx (26.7%), oral cavity (25.1%), cutaneous (17.0%), and larynx (15.3%). Recurrence was detected in 50 patients (8.8%): 26 local, 12 regional, and 14 distant. Two patients had multiple synchronous recurrences. Twelve (2.1%) second primary cancers were detected. Of the 36 cases of locoregional recurrence, 32 (88.9%) were deemed amenable to salvage surgical intervention, with or without adjuvant therapy. Negative margins were obtained in 21 of the 23 (91.3%) local recurrences that underwent salvage resection. CONCLUSION: Advanced practice provider-based surveillance of head and neck cancer, without risk stratification, appears to be a sound model but needs further prospective evaluation. Consistent with literature, 88.9% of patients with locoregional recurrence were candidates for curative-intent salvage surgery, emphasizing that recurrences are identified in a timely fashion.

Bedside Neck Exploration for Venous Flow Coupler Signal Loss in Postoperative Free Tissue Transfer Monitoring.

OBJECTIVE: To describe the role and efficacy of bedside neck exploration following free tissue transfer. STUDY DESIGN: Retrospective case series. SETTING: Single tertiary care institution. METHODS: A retrospective chart review was conducted of 353 patients who underwent free tissue transfer between January 2017 and April 2021. Bedside exploration was performed under mild sedation in patients who had loss of venous Doppler signal with equivocal clinical signs of venous insufficiency. RESULTS: A total of 11 patients underwent bedside assessment of the microvascular pedicle. In 6 cases, a return to the operating room was avoided. Five of these patients had coupler malfunction, and in 1 patient a venous kink was discovered and remedied at the bedside. Five patients required return to the operating room. Venous thrombosis requiring thrombectomy and revision of the venous anastomosis was discovered in 3 patients. One patient had a developing hematoma necessitating evacuation in the operating room, and 1 returned to the operating room due to sternocleidomastoid muscular compression of the venous pedicle. There were no flap failures within the study group. In all cases, broad-spectrum intravenous antibiotic coverage was prophylactically used, and no instances of wound infection were observed. Avoidance of returning to the operating room prevented an estimated $9222 of hospital charges per event. CONCLUSION: Bedside neck exploration can be incorporated as a safe and cost-effective intermediary for definitive determination of need for return to the operating room.

Cutaneous hyperpigmentation following bleomycin sclerotherapy for vascular malformations.

Systemic bleomycin therapy is associated with pulmonary fibrosis and cutaneous side effects. While it is believed that there is little to no systemic distribution of bleomycin when utilized to treat vascular malformations (VMs), we present a case series in which cutaneous, adhesive-related hyperpigmentation suggests that there is systemic egress of bleomycin following direct puncture sclerotherapy (DPS). This risk of hyperpigmentation after intralesional bleomycin should be discussed with patients, and steps to minimize the chances of it occurring should be implemented.

Pedicled Cervical Lymphoadipose Tissue for Volume Reconstruction after Superficial Parotidectomy.

Volume restoration is often required after parotidectomy due to the resultant facial contour deformity. Common procedures include local pedicled flaps, such as the sternocleidomastoid muscle flap, fat grafting, and even autologous free flaps, for more extensive defects. Local pedicled flaps have the advantage of a single surgical site, which spares the patient the added morbidity of a separate fat graft donor site, while simultaneously reducing the operative time. We report two cases of a novel reconstructive option using pedicled level I and II cervical lymphoadipose tissue for volume restoration after superficial parotidectomy. This reconstruction would be useful for patients with benign parotid lesions and inferior parotid defects. In addition, with maintained blood supply to this tissue, it would likely provide sustained bulk over time.

Cyanoacrylate glues for wilderness and remote travel medical care.

Cyanoacrylate (CA) glues are commonly used in medical and household repairs. Their chemical compositions have been refined over half a century, making some more suitable than others for creative applications. In remote settings where advanced medical care is not accessible, readily available CAs of differing chemical composition may possess an important therapeutic function. Within this paper we critically examine the published therapeutic risks and benefits of both pharmaceutical and hardware grade CAs when applied in acute care situations. Topics discussed include wound closure as well as the treatment of burns, abrasions, and blisters. Also considered are their chemical properties, toxicities, and potential off-label uses.

Lightning safety awareness of visitors in three California national parks.

OBJECTIVE: To assess the level of lightning safety awareness among visitors at 3 national parks in the Sierra Nevada Mountains of California. METHODS: A 12-question, short answer convenience sample survey was administered to participants 18 years of age and over concerning popular trails and points of interest with known lightning activity. There were 6 identifying questions and 5 knowledge-based questions pertaining to lightning that were scored on a binary value of 0 or 1 for a total of 10 points for the survey instrument. Volunteers in Fresno, California, were used as a control group. Participants were categorized as Sequoia and Kings Canyon National Park (SEKI), frontcountry (FC), or backcountry (BC); Yosemite National Park (YNP) FC or BC; and Fresno. Analysis of variance (ANOVA) was used to test for differences between groups. RESULTS: 467 surveys were included for analysis: 77 in Fresno, 192 in SEKI, and 198 in YNP. National park participants demonstrated greater familiarity with lightning safety than individuals from the metropolitan community (YNP 5.84 and SEKI 5.65 vs Fresno 5.14, P = .0032). There were also differences noted between the BC and FC subgroups (YNP FC 6.07 vs YNP BC 5.62, P = .02; YNP FC 6.07 vs SEKI FC 5.58, P = .02). Overall results showed that participants had certain basic lightning knowledge but lacked familiarity with other key lightning safety recommendations. CONCLUSIONS: While there are statistically significant differences in lightning safety awareness between national parks and metropolitan participants, the clinical impact of these findings are debatable. This study provides a starting point for providing educational outreach to visitors in these national parks.