Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support.

Total nasal reconstruction is a complex challenge due to the need to establish new internal lining, internal structural support, and external skin covering that is both functional and esthetic. The medial femoral condyle corticoperiosteal free flap represents an innovative option for restoration internal structure and internal nasal lining. When used in conjunction with a paramedian forehead flap, acceptable results in both function and esthetics can be achieved.

Frontal Osteomyelitis and Sinusitis Complication After Type III Frontal Bone Cranioplasty for Facial Feminization.

Background: Forehead contouring can be a component of facial feminization surgery (FFS). Its complications have been rarely reported on and are often described as "hypothetical." Methods: A case report of complications from forehead contouring resulting in frontal osteomyelitis and sinusitis. Results: A female patient presented with frontal osteomyelitis, sinusitis, and forehead contour deformity after a type III forehead contouring surgery. She had failed prior treatment including oral antibiotics, IV antibiotics, revision sinus surgery, and revision nasal surgery. For definitive treatment, she underwent an anterior table resection, sinus obliteration with bony contouring, and pericranial flap. Conclusions: Forehead contouring represents a recent significant advancement in FFS and gender-affirming therapy. Descriptions of complications and their management are important when novel therapies such as FFS are introduced. This case demonstrates complications from type III forehead contouring including osteomyelitis, frontal sinusitis, and forehead deformity.

Actinomyces: An Under Appreciated Cause of Postoperative Infection in Rhinoplasty.

OBJECTIVE: To discuss a case series of Actinomyces infection post-rhinoplasty and review the literature for correct diagnosis and management. STUDY DESIGN: Case series with chart review. METHODS: Three cases are presented of patients with a history of recurrent infectious symptoms post revision rhinoplasty later being diagnosed as Actinomyces. RESULTS: Three patients were identified having undergone revision rhinoplasty and later being diagnosed with Actinomyces infection. They initially presented with underwhelming physical exams, mild erythema, slight swelling, yet extreme pain. They also had periods of recurrent infection once antibiotics were stopped. Aerobic, anaerobic, fungal, and Actinomyces cultures were sent to pathology and returned positive for Actinomyces. Treatment typically involved a combination of prolonged antibiotics, incision and drainage, and/or surgical debridement. CONCLUSIONS: Awareness of Actinomyces as a possible cause of infection post-rhinoplasty is significant as this pathogen can lead to extensive tissue destruction and fistula formation which could be detrimental for a rhinoplasty. Duration of treatment is beyond typical lengths for other infections and a specific culture for Actinomyces is required to be sent as it isn't captured in standard aerobic/anaerobic cultures. Therefore, a high index of suspicion is required by physicians to ensure that patients are evaluated thoroughly. Laryngoscope, 133:2948-2950, 2023.

Repair of Large Nasal Septal Perforations Using the Upper Lateral Cartilage Mucosal Flap.

OBJECTIVES/HYPOTHESIS: To describe the surgical technique and closure outcomes of larger septal perforation repair incorporating mucosa from the undersurface of the upper lateral cartilage into a superiorly positioned advancement flap. STUDY DESIGN: Retrospective case series. METHODS: A chart review was performed for patients who underwent perforation repair utilizing bilateral nasal mucosal flaps which incorporated mucosa from the undersurface of the upper lateral cartilage into the superior flap between January 2009 and December 2020. RESULTS: Sixty-six patients met study criteria. Prior septal surgery was the most common (28.8%) etiology. Mean perforation length and height were 18.9 and 14.4 mm, respectively. Complete perforation closure was noted in 91.2% of patients followed for a minimum of 6 months (mean follow-up time 32.1 months). Twelve patients underwent secondary surgery for persistent nasal obstruction. Postoperative loss of dorsal height was noted in seven patients. The NOSE-perf scores were available for the last 15 repairs and demonstrated significant symptom improvement from a mean score of 26.4 (95% confidence interval [CI], 5.2) to 14.5 (95% CI, 5.2) (P < .0001). CONCLUSION: The ventral surface of the upper lateral cartilage can provide additional mucosa for incorporation into a superior advancement flap to achieve successful closure for larger septal perforations. Optimization of surgical outcomes for this challenging condition may require secondary functional or aesthetic procedures. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:973-979, 2022.

Determination of posterolateral oropharyngeal wall thickness and the potential implications for transoral surgical margins in tonsil cancer.

BACKGROUND: Margins in transoral surgery for tonsil cancer can be limited by oropharyngeal wall thickness (OWT), but the normal range is not well established. METHODS: In 240 noncancer subjects, OWT was measured bilaterally in the vicinity of the tonsils with MRI. Statistical analysis was performed to assess for interaction of age, sex, location, and obesity. RESULTS: Mean(SD) OWT measured 3.4(0.6) mm posteriorly, 3.7(2.0) mm between the styloglossus and stylopharyngeus, and 5.3(0.8) mm laterally. OWT was greater in men, correlated with obesity, decreased posteriorly and laterally in the 60-80 versus 40-59 year age groups, and increased when styloglossus/stylopharyngeus were closer. OWT was <5 mm in 36.7%-97.9% of locations, with the largest percentage below this threshold located posteriorly. CONCLUSIONS: OWT is frequently <5 mm, particularly in the posterior and intermuscular areas, suggesting that a smaller surgical margin may need to be accepted in transoral tonsil cancer surgery for anatomic reasons.

Bipedicled submental musculofascial "hammock" flap for salvage laryngectomy closure reinforcement.

BACKGROUND: The aim of the study was to describe a novel technique for reinforcement of salvage laryngectomy closure using a bipedicled musculofascial submental flap. METHODS: A retrospective cohort study design identified patients who underwent salvage laryngectomy reinforcement with a bipedicled submental hammock flap between January 2008 and December 2016 were compared to salvage laryngectomy patients treated with primary closure of the neopharynx during the same time period. Pharyngocutaneous fistula rates were compared between groups. RESULTS: Pharyngocutaneous fistula rate in the submental hammock group (2/31, 6.5%) was significantly lower compared to the primary closure group (14/45, 31%, P < .05). CONCLUSION: The bipedicled musculofascial submental hammock flap is a viable method for reinforcement of salvage laryngectomy defects. It has a favorable pharyngocutaneous fistula rate compared to primary closure alone and has unique advantages over conventional methods of reinforcement.

Assessing the Breadth of Laryngology Training in Otolaryngology Residency Programs.

INTRODUCTION: Laryngology is an expanding field with incorporation in resident training nationwide. However, the breadth of training in laryngology reported by residents has not been previously evaluated. This project assesses the variability in laryngology training among otolaryngology residents. METHODS: A cross sectional, multi-institutional study was performed with an anonymous survey sent to residents and laryngology fellows nationally to assess different laryngology training practices. RESULTS: There were 151 responses to the survey with 9.6% response rate. 49 (32.9%) did not have a designated laryngology rotation. 134 (89.3%) had a fellowship-trained laryngologist as part of their institution. The greatest percentage of respondents intended to pursue general ENT (31; 20.7%). PGY5 responses were analyzed for total residency exposure showing, 66.7% of PGY5s received training to identify different types of dysphonic voices through auditory findings alone. 61.9% could interpret a videoflouroscopic swallow study.  Regarding surgical cases, 52.4% had been involved in open cricopharyngeal myotomies, 76.2% in endoscopic cricopharyngeal myotomies, and 100% in subglottic stenosis cases. Residents pursuing a career in laryngology and those with a designated laryngology rotation had more exposure to laryngeal surgeries and office-based procedures than their peers. CONCLUSION: Laryngology training and exposure varies across the country. Residents are more familiar with airway than voice and swallowing related pathology. Residents with a designated laryngology rotation and those pursing laryngology fellowships were more likely to have exposure to laryngeal surgery and office-based procedures. Programs with a laryngologist likely had higher response rates so the true laryngology exposure may be more limited than our data suggests.

Diced Cartilage in Fibrin Glue for Dorsal Reconstruction as Part of Staged Paramedian Forehead Flap Reconstruction.

ABSTRACT: The use of diced cartilage grafting is a powerful tool during rhinoplasty for dorsal augmentation; however, its application to nasal structural reconstruction has rarely been reported. Here we present a unique technique for Mohs defect reconstruction combining diced cartilage graft for dorsal augmentation and a folded paramedian forehead flap for soft tissue. A 54-year-old female presented with recurrent basal cell carcinoma of the nose that had been previously resected 3 times in the past. This was treated with Mohs surgery resulting in a through and through nasal defect. This was reconstructed with a staged folded paramedian forehead flap with staged. Due to a loss of dorsal volume and definition creating an excess supratip break, a diced cartilage graft with fibrin glue and temporalis fascia was used for dorsal augmentation. The use of diced cartilage has regained popularity over the last 2 decades with multiple techniques utilizing diced cartilage alone, wrapped in fascia, covered in fascia, wrapped in oxidized methylcellulose, or solidified with fibrin glue. Literature describing the use of fibrin glue suggests that it improves wound healing by promoting cartilage growth, stabilization, and diffusion of nutrients to the graft. Its malleable nature allows for adjustments after the initial placement. This report demonstrates the viability of diced cartilage graft for dorsal augmentation with a paramedian forehead flap for nasal reconstruction. This technique can serve as a powerful tool for the nasal reconstructive surgeon needing scaffolding to rebuild and define the nasal dorsum.

Rhinologic Practice Special Considerations During COVID-19: Visit Planning, Personal Protective Equipment, Testing, and Environmental Controls.

As rhinologists return to practice amid SARS-CoV-2, special considerations are warranted given the unique features of their subspecialty. Rhinologist manipulation of nasal tissue, proximity, and frequent aerosol-generating procedures (AGPs) create high risk for infection transmission. There are 4 areas of special consideration to mitigate risk: (1) previsit planning for risk stratification/mitigation, (2) appropriate personal protective equipment, (3) preprocedural testing, and (4) environmental controls. During previsit planning, risk factors of the patient and procedures are considered. High-risk AGPs are identified by duration, proximity, manipulation of high-viral load tissue, and use of powered instrumentation. Appropriate personal protective equipment includes selection of respiratory and eye protection. COVID-19 testing can screen for asymptomatic carriers prior to high-risk procedures; however, alternative testing methods are required in rhinologic patients not eligible for nasopharyngeal testing due to nasal obstruction or skull base defects. Last, AGPs in rhinologic practices require considerations of room air handling and environmental controls.

High-Risk Aerosol-Generating Procedures in COVID-19: Respiratory Protective Equipment Considerations.

The correct selection and utilization of respiratory personal protective equipment is of the utmost importance in the current COVID-19 pandemic. This is especially true for health care workers exposed to high-risk aerosol-generating procedures, including otolaryngologists, ophthalmologists, neurosurgeons, maxillofacial surgeons, and laparoscopic surgeons. This communication provides a review of approved forms of respiratory protection and compares their characteristics, including surgical masks, N95 respirator, elastomeric respirators, powered air-purifying respirators, and controlled air-purifying respirators. For standard airborne precautions, N95 respirator are appropriate for respiratory protection. However, high-risk aerosol-generating procedures may create aerosolization of high viral loads that represent increased risk to health care workers. In these situations, enhanced respiratory protection with filters certified as 99, 100, or HEPA (high-efficiency particulate air) may be appropriate.

Outcomes Following Transoral Laser Microsurgery With Resection of Cartilage for Laryngeal Cancer.

INTRODUCTION: The ability to treat more advanced laryngeal cancers by transoral approaches has expanded significantly in the past several decades. Transoral management of laryngeal cancers that require removal of the laryngeal framework is controversial. Resecting cartilage through endoscopic means carries inherent technical challenges and the question of oncologic safety. METHODS: We describe a retrospective review of patients undergoing resection of the thyroid cartilage during transoral laser microsurgery (TLM) for laryngeal cancer over a 10-year period. Only patients with 5-year follow-up were included. RESULTS: Fourteen patients were identified that underwent attempted endoscopic resection of the thyroid cartilage. Preoperative staging ranged from T1 to T4 laryngeal cancers. Most patients underwent resection of the thyroid cartilage either for close proximity of the tumor to cartilage or microscopic involvement of the inner perichondrium, although 6 patients had gross invasion of the cartilage. Twelve patients underwent successful endoscopic clearance. Two patients were converted to total laryngectomy either at the time of surgery or shortly after due to extent of disease that was deemed not amenable to endoscopic resection. Overall 5-year survival was 71%. Disease-free survival was 62% at 5 years. The majority of patients avoided gastrostomy and tracheostomy tube dependence. One patient underwent total laryngectomy following initial TLM for chronic aspiration. CONCLUSION: We conclude that TLM for laryngeal cancer performed with removal of thyroid cartilage is feasible. Both oncologic and functional outcomes are reasonable in a select group of patients. This paper describes that cartilage can be resected endoscopically in the appropriate setting and not necessarily that cartilage invasion should routinely be treated with TLM.

American Joint Committee on Cancer eighth edition human papilloma virus positive oropharyngeal cancer staging system: Discordance between clinical and pathological staging systems.

BACKGROUND: The American Joint Committee on Cancer (AJCC) eighth edition introduces a staging system specific for human papilloma virus positive oropharyngeal cancer with separate clinical (AJCC 8c) and pathological (AJCC 8p) criteria. METHODS: In this retrospective cohort study, preoperative imaging and pathology reports were used to stage patients based on the AJCC 8c and AJCC 8p criteria, respectively. The primary endpoint was agreement between AJCC 8c and AJCC 8p. RESULTS: A total of 213 patients met inclusion criteria. Kappa statistics showed poor agreement (κ = 0.3275) between AJCC 8c and AJCC 8p. In total, 30.3% of patient's preoperative AJCC 8c stage changed based on the postoperative pathologic staging (AJCC 8p) with 73.4% of those being upstaged. CONCLUSION: These data suggest that disagreement exists between AJCC 8c and AJCC 8p, in part due to the separate clinical and pathological staging criteria. This discrepancy should be considered as the new system is implemented.

Evolution of the butterfly graft technique: 15-year review of 500 cases with expanding indications.

OBJECTIVES/HYPOTHESIS: To describe the evolution of the butterfly graft technique for the treatment of nasal valve compromise, with specific attention to technical developments allowing for expanded indications. To review the impact on patient-reported outcomes of nasal airway function and nasal aesthetics. STUDY DESIGN: Retrospective chart review. METHODS: A review of a single surgeon's patients at a private practice and tertiary care center undergoing surgical correction for nasal valve compromise using the butterfly graft technique between July 2002 and April 2017. Data collected included etiology of nasal valve compromise, additional procedures performed, complications, and functional and aesthetic patient-reported outcomes. RESULTS: Over the study period, 512 patients underwent surgery to correct nasal valve compromise utilizing the butterfly graft technique. The overall patient-reported relief of nasal obstructive symptoms was complete in 87%, improved but not completely relieved in 10%, and not improved in 4%. No patients reported a worsening in their nasal obstructive symptoms. The overall patient-reported change in nasal appearance was improved 53%, the same 32%, worse in 15%. The patients in the latter half of the study tended to report better aesthetic results. CONCLUSIONS: The results of this study suggest that the surgical technique for the butterfly graft evolved over time and allowed for improved aesthetic outcomes, without reduction in the efficacy in correction of nasal valve compromise. The evolution in technique allowed for expansion of the indications for the butterfly graft while maintaining the favorable patient-reported aesthetic and functional results. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:S1-S10, 2019.

Intraorbital Dermoid Cyst With Zygomaticofrontal Suture Erosion in an Adult.

BACKGROUND: Dermoid cysts are squamous epithelium-lined sacs that result from abnormal migration of ectodermal cells. They are typically superficial and present in children. This study reviews a rare patient with a congenital dermoid cyst occurring as a superolateral intraorbital and extraconal mas. METHOD: Clinical report and review of the literature. RESULTS: A 27-year-old male presented with progressive left hypoglobus, proptosis, and diplopia. On computed tomography, a 2.0 × 2.1 × 1.1 cm well circumscribed mass centered on, and extended into, the frontozygomatic suture with smooth remodeling of the frontal bone. Magnetic resonance imaging showed heterogeneous T1 and T2 hyperintensity with hypointensity on fat suppression. A dermoid cyst originating from the frontozygomatic suture was suspected. Excision was performed through a left orbitocranial approach with a lateral orbitotomy through an upper eyelid crease incision. The mass occurred in the superior-lateral portion of the left orbit and originated from the intraorbital surface of the zygomaticofrontal suture line with significant bony remodeling without osseous transgression. The mass was removed completely including the lateral portion of the zygomaticofrontal suture. Pathologic examination was consistent with a dermoid cyst. Postoperative examination revealed resolution of his presenting headaches and diplopia. CONCLUSION: Congenital dermoid cysts occurring within the craniofacial region occur most commonly in the lateral orbit involving the superficial surface of the frontozygomatic suture. This patient represents the rare occurrence of a dermoid cyst originating from the deep surface of the frontozygomatic suture, resulting in delayed presentation and orbital symptoms of hypoglobus and diplopia. Definitive treatment remains complete surgical excision.

Submental flap for reconstruction of anterior skull base, orbital, and high facial defects.

PURPOSE: Large anterior skull base, orbital, and high facial defects can present a challenging reconstructive problem. Limited data exists in the literature on the use of a submental flap for reconstructing such defects. We aimed to describe the feasibility, success, and advantages of using variations of the submental flap for reconstruction of anterior skull base, orbital, and high facial defects. MATERIALS & METHODS: Outcomes measured included flap method, flap survival, flap size, reconstructive site complications, donor site complications, and length of hospital stay. RESULTS: Nine patients were identified that underwent submental flap reconstruction of anterior skull base, orbital, or high facial soft tissue defects. There were 5 pedicled, 2 hybridized, and 2 free submental flap reconstructions. Flap survival was 100%. One flap required leech therapy for early post-operative venous congestion. Average flap skin paddle size was 63.7 cm2. Average length of hospital stay was 7.3 days. No complications from the donor site were reported. CONCLUSIONS: Different variations on the submental flap are viable options for reconstruction of high defects in the head and neck. Such flaps have a number of unique qualities that are suitable for reconstruction of anterior skull base, orbital, and high facial defects.

Measurement of cochlear length using the 'A' value for cochlea basal diameter: A feasibility study.

OBJECTIVES: To determine whether the cochlea basal diameter (A value) measurement can be consistently and precisely obtained from high-resolution temporal bone imaging for use in cochlear length estimation. METHODS: A feasibility study at a tertiary referral center was performed using the temporal bone CTs of 40 consecutive patients. The distance from the round window to the lateral wall was measured for each cochlea by two independent reviewers, a neuroradiologist and an otolaryngologist. The interrater reliability was calculated using the intraclass correlation coefficient (ICC) and the Bland-Altman plot. RESULTS: Forty patients (19 males, 21 females) for a total of 80 cochleae were included. Interrater reliability on the same ear had a high level of agreement by both the ICC and the Bland-Altman plot. ICCs were 0.90 (95% CI: 0.82, 0.94) for the left ear and 0.96 (95% CI: 0.92, 0.98) for the right ear. Bland-Altman plot confirmed interrater reliability with all 96% of measurements falling within the 95% limits of agreement. CONCLUSIONS: Measurement between the round window and lateral cochlear wall can be consistently and reliably obtained from high-resolution temporal bone CT scans. Thus, it is feasible to utilize this method to estimate the cochlear length of patients undergoing cochlear implantation.

Positive and Negative Predictive Value of PET-CT in Skull Base Lesions: Case Series and Systematic Literature Review.

Objectives To study positive (PPV) and negative predictive value (NPV) of positron emission tomography with computed tomography (PET-CT) scans in determining malignancy in skull base lesions and perform a systematic literature review for optimal PET-CT interpretation. Design Retrospective case series and systematic literature review of the current English literature. Setting Tertiary referral academic medical center. Participants All patients with skull base lesions that underwent PET-CT and tissue biopsy from 2010 to 2013. Main Outcome Measures PPV and NPV of radiologist's report and standardized uptake value (SUV) cutoff of 2.5 and 3, biopsy with pathologic interpretation, clinical follow-up. Results A total of 31 PET-CT scans of 16 patients were studied; 10 PET-CT were performed upfront for diagnostic purposes and 21 were post-treatment surveillance scans. The PPV of radiologist's interpretation, SUV cutoff of 2.5, and SUV cutoff of 3.0 was 80%, 60%, and 68.4%, with a NPV of 100%, 83.3%, and 75%, respectively. Literature search yielded 500 abstracts; 7 studies met inclusion criteria for detailed review. No consensus or guidelines for optimal SUV cutoff value was found. Conclusions PET-CT based on SUV cutoff criteria alone has high NPV but low PPV in determining malignancy in skull base lesions. Interpretation by a radiologist experienced in nuclear medicine and neuroradiology, synthesizing clinical, SUV, and radiologic data are of superior value.

Reconstruction of Lateral Skull Base Defects: A Comparison of the Submental Flap to Free and Regional Flaps.

OBJECTIVES: To compare reconstructive techniques, operative times, duration of hospitalization, and need for subsequent flap revisions between reconstructive approaches to lateral skull base defects. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic referral center. SUBJECTS: Patients (n = 31) undergoing reconstruction of composite lateral skull base defects from 2002 to 2014. METHODS: Data were analyzed for demographics, tumor characteristics, reconstructive technique, operative time, duration of hospitalization, complications, and outcomes. RESULTS: Thirty-one patients were identified for inclusion. Lateral temporal bone defects resulted from resection of malignant lesions, including squamous cell carcinoma (n = 25), basal cell carcinoma (n = 2), and other carcinoma (n = 4). Defects were reconstructed with submental flaps (n = 16), pedicled latissimus dorsi flaps (n = 6), and free anterolateral thigh flaps (n = 9). All cases involved neurosurgery, neurotology, and head and neck surgery services. Although time of surgical resection was similar, time saving was noticed with submental reconstruction. Compared with free flaps, submental flap reconstruction was associated with significantly reduced total operative time (mean, 544 vs 683 min; P = .00817) and duration of hospitalization (4.9 vs 9.8 days; P = .02067). Submental flaps were significantly less likely to require revision debulking procedures (mean = 0.6) compared with latissimus dorsi flaps (mean, 1.3; P < .00001) and free flaps (mean, 1.6; P < .00001). There was 100% flap survival. CONCLUSION: The musculocutaneous submental flap provides an excellent option for reconstruction of lateral skull base defects given its proximity, reliability, ease of harvest, and exceptional color match. Submental flap reconstruction was associated with reduced operative time, hospitalization duration, and flap revisions.