Efficacy of tympanostomy tube placement with adjuvant adenoidectomy in children less than 4 years of age.

OBJECTIVE: About 8.6 % of children in the United States undergo tympanostomy tube (TT) placement every year. Of these, 24.1 % require a second set of tubes. Adjuvant adenoidectomy in children over 4 years is thought to improve the efficacy of TT. The goal of this study is to characterize the efficacy of adjuvant adenoidectomy at the time of TT placement in children under 4 years, to further improve middle ear function. METHODS: All patients undergoing TT placement alone or TT placement with adenoidectomy from 2014 to 2016 were reviewed. The primary outcome was need for subsequent tube placement. RESULTS: A total of 409 patients were included in the study (60.6 % male, 39.4 % female). Median age at initial TT placement was 18 months (range 5-48 months); extreme outliers for age were removed from further analysis. Patients were followed for 1-8 years. 250 patients received TT alone while 159 received TT with adenoidectomy. 120 required a second set of tubes. There was a statistically significant benefit to those undergoing adjuvant adenoidectomy with TT placement: 33.6 % of those receiving TT alone required subsequent tubes, whereas only 22.6 % of patients who underwent TT with adjuvant adenoidectomy required reinsertion (X2 = 5.630, p = 0.018). Adjuvant adenoidectomy in patients 0-48 months was associated with decreased likelihood of requiring subsequent tube placement (OR = 0.578, p = 0.018). There was an increased likelihood of experiencing otorrhea in those receiving TT alone compared to the TT with adenoidectomy group (X2 = 4.353, df = 1, p = 0.0369). CONCLUSION: Adjuvant adenoidectomy at the time of initial TT placement may have a role in the management of chronic middle ear disease in patients younger than 4 years. However, further studies and prospective randomized studies are needed to explore if this benefit can also be seen in children without chronic rhinosinusitis or nasal obstruction. The benefit-risk ratio from adenoidectomy and modifications in anesthesia technique in the case of adjuvant adenoidectomy should also be further explored.

Implantable arterial doppler efficacy in free flap reconstruction: A systematic review and meta-analysis.

The implantable arterial doppler (IAD) is frequently used to postoperatively monitor free flaps with high accuracy, but there are no guidelines for its use. Bedside exam is used adjunctively to determine necessary intervention. This systematic review seeks to discover why the doppler is used adjunctively despite its established record of accuracy. Criteria for inclusion and exclusion were established. In total, 280 articles were found on PubMed and Web of Science, then screened accordingly. Data from 22 articles were analyzed using a bivariate hierarchical random effects model. Twenty-two studies yielded 2996 total patients undergoing 3127 free flap procedures. The meta-analysis found a high sensitivity of 0.809 (95% CI = 0.709, 0.880) and specificity of 0.966 (95% CI = 0.947, 0.979). False-positive rate was found to be 0.034 (95% CI = 0.021, 0.053). Positive and negative predictive values were 0.711 (95% CI = 0.581, 0.817) and 0.979 (95% CI = 0.966, 0.988). Positive and negative likelihood ratios were 24.7 (95% CI = 14.5, 39.5) and 0.20 (95% CI = 0.12, 0.30). The established efficacy of the IAD is supported by this study. Clinical exams may remain as the final adjunct due to the risks of inaccurate IAD signals. Further studies are warranted to optimize its use for future practice guidelines.

Examining Trends in Implantable Arterial Doppler Usage Among North American Head and Neck Microsurgeons: A Survey Study.

BACKGROUND: There are variations in implantable arterial Doppler usage for microvascular free tissue monitoring among North American surgeons. Identifying utilization trends among the microvascular community may elucidate practice patterns that may be useful in determining protocols. Furthermore, study of this information may yield novel and unique applications in other disciplines such as vascular surgery. METHODS: Electronically disseminated survey study shared with a large database of North American head and neck microsurgeons. RESULTS: Seventy four percent of respondents use the implantable arterial Doppler; 69% report use in all cases. Ninety five percent remove the Doppler by the seventh postoperative day. All respondents felt that the Doppler did not impede care progression. Any implication of flap compromise was followed with a clinical assessment in 100% of respondents. If viable, 89% would continue monitoring after clinical examination, while 11% would take the patient for exploration regardless of clinical examination. CONCLUSIONS: The efficacy of the implantable arterial Doppler has been established in the literature and is supported by the results of this study. Further investigation is required to establish a consensus on use guidelines. The implantable Doppler is more often used in conjunction with rather than substitution for clinical examination.

Analysis of vein grafting versus arteriovenous loop in microvascular head and neck reconstruction: Multicenter series of 36 patients.

BACKGROUND: The utilization of an arteriovenous loop is an underreported technique that affords the creation of reliable vascular options. Understanding the efficacy and impacting variables of microvascular reconstruction with an arteriovenous loop can be critical to its use. METHODS: Multi-institutional study of 36 patients who underwent vein grafting or AV loop with free tissue transfer. RESULTS: 58.3% of patients received prior radiation and 38.9% prior flap reconstruction. Flap success for vein grafting was 76% and AV loop was 100% (p = 0.16). Success for the radiated cohort was 90.5% and non-radiated 80% (p = 0.63). Flap success for the radiated, vein grafted patient was 83.3% and 100% flap success rate for radiated, AV loop patient (p = 0.49). Overall flap survival was 83.3% versus 97% overall success rate in the United States. CONCLUSION: The AV loop is a viable modality for vessel-depleted free tissue reconstruction. Radiation and previous surgery do not significantly impact flap success rates.

Impact of smoking on donor site following rectus flap harvest for head and neck reconstruction.

OBJECTIVES: The rectus abdominis myocutaneous free flap has been widely used as a reconstructive option in head and neck reconstruction with great success. Challenging the popular assumption, this study sought to examine the effects of smoking on donor site complications in this population. METHODS: Multi-institution retrospective study of 103 patients (50 active smokers, 28 former and 25 never smoked). RESULTS: Overall complication rate was 14.5 %. Hernia rate 4.8 %, evisceration 0 %, dehiscence 2.9 %, infection 6.7 %. Smoking history did not significantlly influence complication rates (chi square test, p = 0.33). Abdominal wall closure technique also did not influence the complication rate (chi square test, p = 0.58). CONCLUSIONS: The rectus abdomonis myocutaneous free flap has an acceptable complication rate that does not appear to be influenced by smoking history. While patients should be counseled regarding smoking cessation, smoking habits should not delay treatment nor obviate consideration of rectus flap utilization.