Operative technique: Pectoralis major flap with rib.

The osteomyocutaneous pectoralis major flap was first described in 1980 and provides a single stage reconstructive option for poor free flap or pectoralis major flap with reconstruction plate candidates requiring bony reconstruction. The flap provides good functional and cosmetic outcomes in appropriately selected patients. We describe the indications and operative techinique for harvesting this flap in written and video format.

Depression and anxiety in patients with head and neck cancer undergoing free flap reconstruction.

PURPOSE: To determine the prevalence and severity of depression and anxiety in patients with head and neck cancer (HNC) undergoing treatment with free-flap (FF) reconstruction. METHODS: Participants with HNC undergoing FF reconstruction were given the validated 9-item Patient Health Questionnaire (PHQ-9) and a 7-item Generalized Anxiety Disorder (GAD-7) questionnaire prior to surgery. Patient factors and responses were analyzed. RESULTS: Seventy-one patients were included. Mean (SD) pre-operative PHQ-9 was 7.6 (7.04) with 34 % (n = 24) having moderate to severe depression. Mean (SD) pre-operative GAD-7 was 6.5 (6.86) with 30 % (n = 21) having moderate to severe anxiety. CONCLUSION: Prevalence of depression and anxiety is high in this cohort and undiagnosed in 22 % and 18 % of patients, respectively. Due to the findings, it is prudent to screen HNC patients at initial diagnosis and offer mental health services.

Importance of PET/CT in Initial Workup of Head and Neck Squamous Cell Carcinoma.

Objective: Assess the impact of positron emission tomography/computed tomography (PET/CT) on disease staging at presentation in patients with head and neck squamous cell carcinoma. Study Design: Retrospective cross-sectional review. Setting: Academic multicenter single institution (Geisinger Health System). Methods: All patients who had PET/CT imaging during workup for head and neck squamous cell carcinoma were included in the study. Pre- and post-PET/CT clinical staging were recorded. Statistical analyses were performed for patients with a change in clinical staging or detection of second primary malignancies on PET/CT. Results: A total of 292 patients were included in the study, 238 of whom underwent PET/CT imaging as part of their initial workup. Twenty-eight (11.9%) patients were clinically upstaged on PET/CT with 7 patients having treatment alterations based on imaging. Eighteen (7.6%) patients were found to have second primary malignancies on PET/CT. Conclusion: The current study further illustrates the importance of PET/CT in the workup of head and neck squamous cell carcinoma. Without the inclusion of PET/CT imaging, 19.3% of patients would have either been staged inappropriately or had second primary malignancies missed, again confirming the necessity of comprehensive functional imaging during the initial pretreatment workup.

Thyroidectomy Outcomes in Patients Identified With RET Pathogenic Variants Through a Population Genomic Screening Program.

Importance: Population-based genomic screening can facilitate early detection of medullary thyroid carcinoma (MTC) in patients with pathogenic/likely pathogenic (P/LP) RET variants. Objective: To evaluate the clinical treatment and patient outcomes after identification of P/LP RET proto-oncogene variants associated with the risk of MTC via a population genomic screening program. Design, Setting, Participants: This retrospective cross-sectional study was completed between June 1, 2016, and May 31, 2022, for a mean follow-up period of 22.4 months (range, 2-76 months). The study included patients who were identified as having P/LP RET variants through a population genomic screening program at a rural tertiary care center and who underwent thyroidectomy after results disclosure. Main Outcomes and Measures: The outcomes of interest were preoperative evaluation and treatment-related outcomes. Measures included imaging and laboratory findings, extent of surgery, pathologic diagnosis, and staging. Results: Seventy-five patients were identified as having P/LP RET variants exclusively through genomic screening. Twenty of these patients (27%; 11 women [55%] and 9 men [45%]; median age, 48 years [range, 22-73 years]) underwent total thyroidectomy; 13 of these patients (65%) also had a central neck dissection. No patients had clinically apparent disease at the time of surgery. Pathologic findings indicated MTC for 12 patients and papillary thyroid carcinoma in 2. Of patients with MTC, 10 had stage I disease, 1 had stage II disease, 1 had stage III disease, and none had stage IV disease. Based on postoperative surveillance imaging and laboratory results, no patient had evidence of recalcitrant disease. Conclusions and Relevance: In this cross-sectional study, all malignant neoplasms identified on surgical pathology were clinically occult, with surgical intervention based solely on the identification of the P/LP RET variant via population genomic screening. This finding suggests that genomic screening may provide opportunities for early detection and treatment of MTC, with the potential for improved patient outcomes.

Thyroid Abscess: A Case Series and Literature Review.

OBJECTIVE: In this retrospective case series, we chronicle six patients presenting with acute suppurative thyroiditis (AST) with progression to thyroid abscess in a single institution. METHODS: Patients ranged in age from 16 to 74 years of age. The most common presenting symptoms were progressive unilateral neck pain, swelling, and odynophagia. Other symptoms included hoarseness and systemic signs of infection. Diagnosis of thyroid abscess was made with a CT scan of the neck, fine needle aspiration, and/or incision and drainage (I&D). RESULTS: Management included antibiotic therapy, I&D, and thyroidectomy. All patients were successfully treated except for one who developed mediastinitis and died. CONCLUSION: A complete literature review was performed to determine etiologies, common findings, and management of similar cases.

Accurate Operative Time Prediction in Thyroid Surgery: A Rural Tertiary Care Facility Experience.

OBJECTIVE: To determine whether surgeons can estimate thyroid operative time more accurately than a system-generated average time estimate. METHODS: Four otolaryngologists at a single institution with extensive endocrine surgery experience were asked to predict their operative times for all eligible thyroid surgeries. These estimates were compared to system-generated operative time predications based on averaging the surgeon's previous 10 cases with the same Current Procedural Terminology code. The surgeon-generated estimations and system-generated estimations were then compared to each other and the actual operative time. RESULTS: A final sample of 73 cases was used for all analyses. Average age was 51 years old and the majority of patients were female. Surgeon-generated operative time estimates were significantly more accurate than system-generated estimates based on time averaging (P < .001). These findings were consistent across each surgeon individually and within each procedure type (hemithyroidectomy and total thyroidectomy). These findings had a power of over 99% based on mean differences. CONCLUSION: As the financial center of modern hospitals, an efficient operating room is integral to economic success. Improving the precision of operative time estimation reduces costly unplanned staff overtime, canceled cases, and underutilization. Our research at a rural tertiary care center shows that experienced thyroid surgeons can substantially reduce the error of estimating thyroid operative times by considering individual patient characteristics. Although no objective variables have so far been identified to correlate with thyroid operative time, surgeon-generated operative time estimation is significantly more accurate than a generic system approach of averaging previous operative times.

Impact of Liposomal Bupivacaine on Post-Operative Pain and Opioid Usage in Thyroidectomy.

OBJECTIVES: Opioid analgesia has been integral in post-operative pain control for decades. The over-prescription of opioids, commonly in the surgical patient, has contributed to the current opioid epidemic. Liposomal bupivacaine (LB), a long-acting analgesia formulation, has demonstrated decreased post-operative pain and opioid requirements in patients treated across multiple surgical subspecialties. The aims of this retrospective study are to assess post-operative pain and opioid use in patients who received LB at the time of thyroidectomy. METHODS: A cohort-matched retrospective review of patients who underwent thyroidectomy by 2 surgeons between January 2010 and December 2019 was performed. Patients were divided into those that received LB intraoperatively and those that did not. Statistical analyses were performed using the Chi-square or Fisher's exact test, and 2-sample T-test or Wilcoxon rank sum test. RESULTS: Of the 201 patients included in this study, 113 patients received LB and 88 did not. Patients who received LB had a lower median visual analog scale (VAS) pain score (2 vs 3, P = .2252), lower maximum VAS pain score (6 vs 7, P = .0898), were less likely to require opioid medications (73.5% vs 85.2%, P = .0434), and had a lower percentage of daily morphine milligram equivalent value ≥45 (89.8% vs 95.3%, P = .1581) during the post-operative period when compared to those that did not. CONCLUSION: This study suggests a role for incisional infiltration with LB for post-operative pain management in patients undergoing transcervical thyroidectomy. We report reduced post-operative pain scores and opioid analgesia requirements in patients who received LB.

Impact of Giving Patients Your Personal Phone Number in Otolaryngology-Head & Neck Surgery.

OBJECTIVE: Patient-provider communication is a major barrier to care, with some providers giving their personal phone number (PPN) to patients for increased accessibility. We investigated participant utilization of provider's PPN, its effect on participant satisfaction, provider's ability to predict abuse of this practice, and evolving provider perceptions. STUDY DESIGN: Prospective, randomized study. SETTING: Single institution, tertiary referral center. METHODS: During a 2-week period, otolaryngology patients were randomized to either receive their provider's PPN or not. Providers predicted the likelihood of abuse. All calls/texts were documented for 4 weeks. At the study's conclusion, participants were surveyed using Press Ganey metrics. Providers were surveyed before and after to assess their likelihood of providing patients with their PPN and its impact on work demands. RESULTS: Of the 507 participants enrolled, 266 were randomized to the phone number group (+PN). Of 44 calls/texts from 24 participants, 8 were considered inappropriate. Ten participants were predicted to abuse the PPN, but only one was accurately identified. Participants in the +PN group had a greater mean composite satisfaction score than the control group (4.8 vs 4.3; Welch's t-test, P < .0011). At the conclusion of the study, providers were more likely to share their PPN (Wilcoxon signed-rank test, P < .0313), and their perceived impact of this practice on workload was lower (Wilcoxon signed-rank test, P < .0469). CONCLUSION: This study demonstrates low patient utilization of provider PPNs, and poor provider predictive ability of patient abuse. Receipt of provider's PPN was associated with improved patient satisfaction.

Observational study of population genomic screening for variants associated with endocrine tumor syndromes in a large, healthcare-based cohort.

BACKGROUND: In current care, patients' personal and self-reported family histories are primarily used to determine whether genetic testing for hereditary endocrine tumor syndromes (ETS) is indicated. Population genomic screening for other conditions has increased ascertainment of individuals with pathogenic/likely pathogenic (P/LP) variants, leading to improved management and earlier diagnoses. It is unknown whether such benefits occur when screening broader populations for P/LP ETS variants. This manuscript assesses clinical utility outcomes of a large, unselected, healthcare-based genomic screening program by describing personal and family history of syndrome-related features, risk management behaviors after result disclosure, and rates of relevant post-disclosure diagnoses in patient-participants with P/LP ETS variants. METHODS: Observational study of individuals informed of a P/LP variant in MEN1, RET, SDHAF2, SDHB, SDHC, SDHD, or VHL through Geisinger's MyCode Community Health Initiative between June 2016 and October 2019. Electronic health records (EHRs) of participants were evaluated for a report of pre-disclosure personal and self-reported family histories and post-disclosure risk management and diagnoses. RESULTS: P/LP variants in genes of interest were identified in 199 of 130,490 (1 in 656) adult Geisinger MyCode patient-participants, 80 of which were disclosed during the study period. Eighty-one percent (n = 65) did not have prior evidence of the result in their EHR and, because they were identified via MyCode, were included in further analyses. Five participants identified via MyCode (8%) had a personal history of syndrome-related features; 16 (25%) had a positive self-reported family history. Time from result disclosure to EHR review was a median of 0.7 years. Post-disclosure, 36 (55.4%) completed a recommended risk management behavior; 11 (17%) were diagnosed with a syndrome-related neoplasm after completing a risk management intervention. CONCLUSIONS: Broader screening for pathogenic/likely pathogenic variants associated with endocrine tumor syndromes enables detection of at-risk individuals, leads to the uptake of risk management, and facilitates relevant diagnoses. Further research will be necessary to continue to determine the clinical utility of screening diverse, unselected populations for such variants.

Perioperative Topical Antisepsis and Surgical Site Infection in Patients Undergoing Upper Aerodigestive Tract Reconstruction.

Importance: Surgical site infections (SSIs) after vascularized reconstruction of the upper aerodigestive tract (UADT) are associated with considerable morbidity. The association between perioperative prophylaxis practices, particularly topical antisepsis, and SSIs remains uncertain. Objective: To assess the association between perioperative topical antisepsis and SSIs in patients undergoing vascularized reconstruction of the UADT. Design, Setting, and Participants: This cohort study included patients from 12 academic tertiary care centers over an 11-month period, from July 1, 2020, to June 1, 2021. Patients undergoing open surgical procedures requiring a communication between the UADT and cervical skin with a planned regional pedicled flap, free flap, or both were included. Patients with an active infection at the time of surgical procedure were excluded. Main Outcomes and Measures: The primary outcome measure was an SSI within 30 days of surgery. The association of demographic characteristics, perioperative antibiotic prophylaxis, surgical technique, and postoperative care with SSIs was assessed using univariable and multivariable analyses. The relative risk ratio and 95% CIs for developing SSI were calculated for each of the variables based on predetermined categories. Variables for which the relative risk 95% CI did not include the value of zero effect (relative risk = 1.00) were included in the multivariable model. Results: A total of 554 patients (median age, 64 years; range, 21-95 years; 367 men [66.2%]) were included. Cancer ablation was the most frequent reason for surgery (n = 480 [86.6%]). Overall, the SSI rate was 20.9% (n = 116), with most infections involving the head and neck surgical site only (91 [78.4%]). The median time to SSI diagnosis was 11 days (range, 1-28 days). Topical antisepsis mucosal preparation was performed preoperatively in 35.2% (195) and postoperatively in 52.2% (289) of cases. Ampicillin and sulbactam was the most common systemic antibiotic prophylaxis agent used (n = 367 [66.2%]), with 24 hours being the most common duration (n = 363 [65.5%]). On multivariable analysis, preoperative topical antisepsis mucosal preparation (odds ratio [OR], 0.49; 95% CI, 0.30-0.77) and systemic prophylaxis with piperacillin and tazobactam (OR, 0.42; 95% CI, 0.21-0.84) were associated with a decreased risk of a postoperative SSI. The use of an osseous vascularized flap was associated with an increased risk of postoperative SSI (OR, 1.76; 95% CI, 1.13-2.75). Conclusions and Relevance: Findings of this study suggest that preoperative topical antisepsis mucosal preparation was independently associated with a decreased risk of SSIs in a 12-center multi-institutional cohort. Further investigation of the association between individual perioperative practices and the incidence of postoperative SSIs is necessary to develop evidence-based protocols to reduce SSIs after UADT reconstruction.

Implantation of Squamous Cell Carcinoma in a Free Flap Donor Site.

INTRODUCTION: It is well known that malignant cells can be implanted at distant donor sites due to iatrogenic surgical contamination. Only a small number of reports, however, have been published describing this. CASE PRESENTATION: We present a case of oral cavity Squamous Cell Carcinoma (SCC) reconstructed with a radial forearm free flap in which SCC developed in the subcutaneous tissues beneath the donor incision site 6 months after surgery. MANAGEMENT: The implanted tumor was excised and the field was subsequently treated with radiation. The patient remains disease-free on follow-up. DISCUSSION: We present the second report of tumor implanted in a free flap donor site. Additionally, we discuss the risks of tumor implantation, review the literature, and make recommendations to avoid this complication.

Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy.

IMPORTANCE: The optimal reconstruction of total glossectomy defects with or without total laryngectomy is controversial. Various pedicled and free tissue flaps have been advocated, but long-term data on functional outcomes are not available to date. OBJECTIVES: To compare various total glossectomy defect reconstructive techniques used by multiple institutions and to identify factors that may lead to improved long-term speech and swallowing function. DESIGN, SETTING, AND PARTICIPANTS: A multi-institutional, retrospective review of electronic medical records of patients undergoing total glossectomy at 8 participating institutions between June 1, 2001, and June 30, 2011, who had a minimal survival of 2 years. INTERVENTION: Total glossectomy with or without total laryngectomy. MAIN OUTCOMES AND MEASURES: Demographic and surgical factors were compiled and correlated with speech and swallowing outcomes. RESULTS: At the time of the last follow-up, 45% (25 of 55) of patients did not have a gastrostomy tube, and 76% (42 of 55) retained the ability to verbally communicate. Overall, 75% (41 of 55) of patients were tolerating at least minimal nutritional oral intake. Feeding tube dependence was not associated with laryngeal preservation or the reconstructive techniques used, including flap suspension, flap innervation, or type of flap used. Laryngeal preservation was associated with favorable speech outcomes, such as the retained ability to verbally communicate in 97% of those not undergoing total laryngectomy (35 of 36 patients) vs 44% (7 of 16) in those undergoing total laryngectomy (P < .001), as well as those not undergoing total laryngectomy achieving some or all intelligible speech in 85% (29 of 34 patients) compared with 31% (4 of 13) undergoing total laryngectomy achieving the same intelligibility (P < .001). CONCLUSIONS AND RELEVANCE: In patients with total glossectomy, feeding tube dependence was not associated with laryngeal preservation or the reconstructive technique, including flap innervation and type of flap used. Laryngeal preservation was associated with favorable speech outcomes such as the retained ability to verbally communicate and higher levels of speech intelligibility.