Prophylactic antibiotics in head and neck free flap surgery: A novel protocol put to the test.

OBJECTIVE: Recent evidence supports the use of ampicillin-sulbactam as a favored choice for antibiotic prophylaxis following head and neck free flap reconstructive surgery. However, there is a paucity of evidence guiding the optimal duration of antibiotic prophylaxis. The aim of this study is to compare the infection rates of short courses of ampicillin-sulbactam versus extended courses of various antibiotics in head and neck free flap reconstructive surgery. METHODS: This is a retrospective cohort study conducted from 2012 to 2017 at a tertiary academic center on 266 consecutive patients undergoing head and neck surgery with free flap reconstruction. The primary outcome measure was the rate of any infection within 30 days of surgery. RESULTS: There were 149 patients who received antibiotic prophylaxis for an extended duration of at least seven days. 117 patients received a short course of antibiotics defined as 24 h for non-radiated patients and 72 h for radiated patients. Postoperative infections occurred in 45.9% of patients, of which 92.6% occurred at surgical sites. There was no significant difference in terms of postoperative infection rate between patients receiving an extended duration of antibiotics versus a short duration (p = 0.80). This held true for subgroups of surgical site infections (p = 0.38) and distant infections (p = 0.59 for pneumonia and p = 0.76 for UTI). Risk factors for infections were identified as hypothyroidism (p = 0.047) and clean contaminated wound classification (p = 0.0002). CONCLUSION: Shorter duration of ampicillin-sulbactam prophylaxis in free flap reconstruction of head and neck defects does not negatively affect postoperative infection rates. LEVEL OF EVIDENCE: Level 2b.

Rat Model of External Auditory Canal Stenosis.

HYPOTHESIS: Circumferential electrocautery injury of the rat external auditory canal (EAC) can induce a reproducible animal model of acquired stenosis. BACKGROUND: Acquired EAC stenosis may occur as a result of chronic inflammation or trauma to the EAC skin and is characterized by narrowing of the EAC, retention of debris, and hearing loss. Treatment is surgery but it is often complicated by restenosis. A reliable and inexpensive animal model of EAC stenosis has not been described. There have been no studies correlating the extent of EAC injury with the extent of stenosis. METHODS: Rats received a 25, 50, or 75% circumferential EAC injury with electrocautery. The extent of resulting stenosis was quantified 21 days following injury. The nature of the injury and healing response was assessed with histology. RESULTS: A 25% circumferential injury led to 4 to 34% stenosis (mean, 13%), 50% injury resulted in 43 to 100% stenosis (mean, 73%), and 75% injury resulted in 94 to 100% stenosis (mean=99%, p < 0.0001). The 50% circumferential injury produced 30 to 75% stenosis in five of eight ears, the remainder had >75% stenosis. Wounded ears showed evidence of intact cartilage and epithelium, with increased thickness of the subepithelial layer and localized fibrosis. CONCLUSIONS: Electrocautery injury in the ventral aspect of the rat EAC resulted in reproducible EAC stenosis. This rat model may be useful in studying therapy to prevent acquired EAC stenosis due to acute injury. The correlation of the extent of injury (circumference) with resulting stenosis may inform clinical management of EAC injuries.

Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days.

OBJECTIVE: Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated. METHODS: Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay. RESULTS: In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children ( P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday ( P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay. DISCUSSION: DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient's closest family. Understanding limitations of the patient's insurance may help plan DC destination. Optimizing hospital resources when available should be a focus. IMPLICATIONS FOR PRACTICE: Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team's overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.

Improving quality outcomes in head and neck free flap surgery with the use of a physician inpatient coordinator.

OBJECTIVES/HYPOTHESIS: Head and neck free flap patients require complex postoperative care. The quality of care for these patients often depends on their management from the time they leave the operating room. The purpose of this study was to investigate the impact of a postoperative inpatient coordinator (IC) for head and free flap patients on quality outcomes: length of stay (LOS), 30-day unplanned return to the emergency department (30dRED), 30-day unplanned readmissions (30dUR), and complication rates. STUDY DESIGN: Retrospective cohort study. METHODS: One hundred eighty-eight consecutive patients who underwent head and neck free flap surgery between January 2012 and January 2016 were reviewed using a prospective database. Patients had an IC for their entire hospitalization (group 1) or for less than their entire hospitalization (group 2). Logistic regression analysis was performed to identify risk factors for quality outcomes. RESULTS: Mean LOS was 13.8 days and 17.3 days in groups 1 and 2, respectively (P = .002). The 30dRED rate was 12% and 22%, respectively (P = .04). Group 2 had an increased LOS by 4.1 days (P = .001) and a 2.4 fold increased 30dRED (P = .03). 30dUR and complications were not influenced by the IC (P > .05). CONCLUSIONS: An IC may help decrease LOS and 30dRED in head and neck free flap patients. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:336-342, 2018.

Is Pacific race a retinopathy of prematurity risk factor?

BACKGROUND: Black race affords some protection from retinopathy of prematurity (ROP), but more ROP was previously found in another darkly pigmented race, the Alaskan natives. DESIGN: From fall 1989 through summer 2003, all Alaskan infants with a birth weight of 1500 g or less were examined, documenting mother's stated race, prenatal care, and neonatal intensive care unit course. RESULTS: Retinopathy of prematurity was classified as to predefined threshold for peripheral ablative treatment (region of avascular retina and fibrovascular ridge and vessel tortuosity) in 873 infants. Threshold ROP was more prevalent in Alaskan natives (24.9%) and Asians (15.9%) (10% overall), with no significant difference between Alaskan natives and Asians (P = .24). Alaskan native males had more threshold ROP (69%) compared with non-Alaskan native males (51%). Compared with threshold nonnatives, Alaskan native threshold infants had greater birth weights (829 +/- 222 vs 704 +/- 186 g), required less time on ventilation (46 +/- 22 vs 70 +/- 75 days), and progressed to treatment at a younger age (35.5 +/- 2.2 vs 36.2 +/- 2.6 weeks' gestational age) (data are given as mean +/- SD). CONCLUSIONS: In this limited study, we find increased risk of threshold ROP in 2 northern Pacific races. Threshold Alaskan natives had similar or better prenatal and neonatal intensive care unit variables than did threshold nonnatives; however, Alaskan native males were still at a greater risk.

The positive prognostic implications of crying during exam on threshold ROP.

INTRODUCTION: Most infants cry with lid speculum, scleral depression and indirect ophthalmoscopy. This simple observation, "did the infant cry?" during the initial 31-week ROP screening exam was prospectively studied. METHODS: From Fall 1989 through Summer 2003, all Alaskan infants with birthweight < or = 1500 grams were examined by RWA. After 1992, at the 31-week initial ROP screening, we recorded whether the infant was able to cry (cry), did not cry (quiet), or was intubated (vent) during indirect ophthalmoscopy with lid speculum and scleral depression. RESULTS: ROP was classified as to threshold in 873 infants. Infants who were able to cry during their 31-week GA screening exam were less likely to progress to threshold (Chi square 600, 2 = 36, p < .001). Using a logistic fit of Threshold, the increased risk of ROP in infants unable to cry persisted independent of gestational age or birthweight. CONCLUSIONS: Respiratory and neurologic co-morbidity may render those infants unable to cry during the first screening examination at increased risk to progress to threshold ROP.

Mechanisms of programmed cell death signaling in hair cells and support cells post-electrode insertion trauma.

CONCLUSION: Programmed cell death (PCD) initially starts in the support cells (SCs) after electrode insertion trauma (EIT), followed by PCD in hair cells (HCs). Activation of caspase-3 was observed only in SCs. Protecting both SCs and HCs with selective otoprotective drugs at an early stage post implantation may help to preserve residual hearing. OBJECTIVES: Cochlear implant EIT can initiate sensory cell losses via necrosis and PCD within the organ of Corti, which can lead to a loss of residual hearing. PCD appears to be a major factor in HC loss post-EIT. The current study aimed to: (1) determine the onset of PCD in both SCs and HCs within the traumatized organ of Corti; and (2) identify the molecular mechanisms active within the HCs and SCs that are undergoing PCD. METHODS: Adult guinea pigs were assigned to one of two groups: (1) EIT and (2) unoperated contralateral ears as controls. Immunostaining of dissected organ of Corti surface preparations for phosphorylated-Jun, cleaved caspase-3, and 4-hydroxy-2,3-nonenal (HNE) were performed at 6, 12, and 24 h post-EIT and for contralateral control ears. RESULTS: At 6 h post-EIT the SCs immunolabeled for the presence of phosphorylated-Jun and activated caspase-3. Phosphorylated p-Jun labeling was observed at 12 h in both the HCs and SCs of middle and basal cochlear turns. Cleaved caspase-3 was not observed in HCs of any cochlear turn at up to 24 h post-EIT. Lipid peroxidation (HNE immunostaining) was first observed at 12 h post-EIT in both the HCs and SCs of the basal turn, and reached the apical turn by 24 h post-EIT.

Safety and efficacy of carbomethylcellulose foam in guinea pig middle ear surgery.

OBJECTIVE: Carbomethylcellulose (CMC) foam has been widely adopted to promote hemostasis and healing in sinus surgery. There has been interest in the use of CMC in middle ear surgery. The purpose of this study was to evaluate the safety and efficacy of CMC foam for use in middle ear surgery. STUDY DESIGN: Prospective, controlled. SETTING: Academic research laboratory. SUBJECTS AND METHODS: Adult guinea pigs underwent experimental tympanoplasty followed by packing of the middle ear (n = 19 per group) with CMC, hyaluronic acid (HA), or gelatin sponge (GS). Auditory evoked brainstem response testing and otomicroscopy were performed before and serially for eight weeks after surgery. Tympanic membrane healing, hemostasis, and retention of packing material were assessed. RESULTS: All tympanic membranes treated with CMC healed by week eight. Less postoperative bleeding was observed with CMC than with HA or GS. Surgery elevated auditory thresholds, at least temporarily, in all groups. However, CMC was associated with greater auditory threshold elevation (15-25 dB) at eight weeks across all test frequencies relative to HA or GS (P < 0.01). Residual CMC and scarring were not found in the middle ear, indicating that the hearing loss was sensorineural. No head tilt posturing suggestive of vestibulopathy was seen. CONCLUSION: CMC was associated with hearing loss and may be ototoxic. Therefore, CMC should not be used in human middle ears given the presence of several nontoxic alternative materials.