Outcomes of Vascularized Versus Nonvascularized Adipofascial Grafts for Parotidectomy Reconstruction.

Objectives: Parotidectomy defects can leave patients with considerable functional and cosmetic deformities. We aim to compare the success rates and complications associated with vascularized versus nonvascularized adipofascial grafts for reconstruction, including flap failure, return to surgery, infection, and delay to adjuvant treatment. Methods: Retrospective case series of patients undergoing either adipofascial anterolateral thigh (AFALT) free tissue transfer or free fat transfer (FFT) after parotidectomy from January 2010 to January 2020. Group comparisons and logistic regression were used to determine predictors of outcome measures. Results: Seventy-six patients underwent AFALT reconstruction, and 73 patients underwent FFT reconstruction. Patients treated with AFALT reconstruction had more aggressive tumor characteristics and underwent more complex resections, most commonly radical parotidectomy (n = 55, 72.4%). Postoperative complications at both the donor and recipient sites were more common in the FFT group (N = 20, 27.4% in FFT vs. N = 11, 14.5% in AFALT, odds ratio = 0.45, 95% confidence interval = 0.20-1.02, p = 0.052). Conclusions: Although used in more advanced disease and in a more heavily treated wound bed, the AFALT free flap was safe and associated with fewer infectious complications than that offered by FFT.

Success of Implantable Doppler Probes for Monitoring Buried Free Flaps.

OBJECTIVE: The objective of this study is to describe the operative success of completely buried free flaps and to determine the safety/reliability of using implantable dopplers for postoperative monitoring in completely buried free flaps. STUDY DESIGN: A retrospective chart review was conducted from 2014 to 2020. Patients were included who had implantable dopplers placed for monitoring a completely buried free flap without a visible skin paddle. SETTING: Single academic cancer hospital. METHODS: Patient charts were reviewed to determine flap viability after surgery, need for reoperation, and ability of implanted doppler probes to detected change in free flap status. RESULTS: A total of 65 patients were included. Locations of flaps were as follows: pharynx, 76.9%; skull base, 7.7%; trachea, 6.2%; esophagus, 4.6%; and facial reanimation, 4.6%. Types of free flaps performed included radial forearm (50.8%), anterolateral thigh (44.6%), and gracilis (4.6%). One patient (1.5%) returned to the operating room for vascular compromise, which was accurately detected by the implantable doppler and salvaged. All free flaps were viable upon hospital discharge based on clinical examination and implantable doppler signals. There were no complications related to implantable doppler use. CONCLUSIONS: Implantable dopplers are an effective method for evaluating postoperative success of completely buried free flaps. In our series utilizing implantable dopplers, buried free flap survival was higher than traditionally thought. The use of implanted dopplers for monitoring buried free flaps allows for an effective, cosmetically appealing, and simplified reconstructive technique.

Risk of Pathologic Extranodal Extension and Other Adverse Features After Transoral Robotic Surgery in Patients With HPV-Positive Oropharynx Cancer.

Importance: Understanding patient-specific risk of adverse histopathologic findings after primary surgery for human papillomavirus (HPV)-positive oropharynx squamous cell carcinoma (OPSCC) may help guide patient consultations. Objective: To determine the likelihood of adverse histopathologic features that may indicate adjuvant radiotherapy or chemoradiotherapy after primary surgery for HPV-positive OPSCC according to 2021 National Comprehensive Cancer Network guidelines. Design, Setting, and Participants: This retrospective cohort study was performed at a single academic tertiary care center. Of 258 patients who underwent transoral robotic surgery (TORS) from March 1, 2012, to March 1, 2021, 136 consecutive, treatment-naive patients with HPV-positive OPSCC without obvious clinical extranodal extension (ENE) who underwent definitive TORS and neck dissection were included in the analysis. Indications for surgical treatment included non-deeply infiltrative oropharynx tumors, minimal soft palate involvement, and low suspicion for pathologic ENE. Exposures: Primary site TORS with neck dissection. Main Outcomes and Measures: The primary outcomes were the adverse histopathologic features of pathologic ENE and positive surgical margins (PSM) that are indications for possible adjuvant chemoradiotherapy. Outcomes were compared among varying American Joint Committee on Cancer 7th edition (AJCC-7) T and N categories and patient clinical characteristics. Results: Of the 136 patients included in the analysis (113 men [83.1%]; median age, 63 [interquartile range, 55-70] years), 109 (80.1%) had at least 1 indication for possible adjuvant radiotherapy. Twenty-seven patients (19.9%) had pathologic ENE and 10 (7.3%) had PSM. Thirty-four patients (25.0%) had pathologic ENE and/or PSM, whereas 3 (2.2%) had both. Age, smoking history, history of alcohol consumption, and clinical T category were not associated with pathologic ENE, PSM, lymphovascular invasion, perineural invasion, or pN2 category or greater. The proportion of pathologic ENE varied by clinical N category: 0 of 16 for cN0, 8 of 48 (16.7%) for cN1, 3 of 23 (13.0%) for cN2a, and 16 of 45 (35.6%) for cN2b. Compared with patients with cN1-cN2a disease, patients with cN2b disease had higher odds of pathologic ENE (odds ratio, 3.01; 95% CI, 1.14-8.10). Clinical and pathologic N category were concordant in 77 patients (56.6%), whereas 42 (30.9%) were upstaged and 17 (12.5%) were downstaged. Conclusions and Relevance: In this cohort study, approximately one-quarter of carefully selected patients with HPV-positive OPSCC without obvious clinical ENE undergoing primary surgery had pathologic ENE and/or PSM. Patients with AJCC-7 cT0-cT2 cN0-cN2b disease, especially cN0-cN2a, without signs of clinical ENE may represent appropriate candidates for primary surgery when avoidance of adjuvant chemotherapy and/or reduction of adjuvant radiotherapy dose/extent are the goals.

Penetrating Trauma Rapid Estimated Disability Scale: Assessing Facial Self-Inflicted Gunshot Wounds.

Objectives: Self-inflicted facial gunshot wounds (GSWs) result in complex but consistent injuries that are often survivable. We suggest a novel method for rapid stratification into groups that may be associated with hospital course and cost after self-inflicted facial GSWs. Methods: This is retrospective review of self-inflicted facial GSWs between January 1, 2009, and December 31, 2018, at a tertiary academic center. Patients were given a penetrating trauma rapid estimated disablity (PRED) score (1-4) based solely on radiologic imaging injury patterns. Clinicopathologic factors were then compared between groups. Results: There were 2 PRED 1 patients (15.1%), 8 PRED 2 patients (29.6%), 5 PRED 3 patients (18.5%), and 12 PRED 4 patients (44.4%). An increased PRED score was statistically associated with increasing mean days in intensive care unit (2.5 PRED 1, 4.2 PRED 2, 6 PRED 3, 11.6 PRED 4, p = 0.001), mean length of hospitalization (5.5 PRED 1, 13.1 PRED 2, 25.6 PRED 3, 39.8 PRED 4, p = 0.007), and mean cost ($) of hospitalization (22,000 PRED 1, 29,000 PRED 2, 37,000 PRED 3, 63,000 PRED 4, p = 0.01). Conclusions and Relevance: The PRED score for self-inflicted GSWs to the face is strongly associated with length of hospital stay and cost of hospitalization.

Inter-rater reliability in diagnosis and treatment of type one laryngeal cleft: A blinded observational study.

INTRODUCTION: Type one laryngeal cleft (T1LC) has been implicated as a major contributor to aspiration in non-syndromic pediatric dysphagia. Despite an increasing incidence, there remains controversy in diagnosis and treatment algorithms. OBJECTIVES: The primary objective of this study was to evaluate the inter-rater reliability (IRR) for the diagnosis and treatment of T1LC. METHODS: A retrospective analysis was conducted to identify children evaluated for a T1LC from 2016 to 2017 at a single tertiary care center. The microlaryngoscopy video recordings depicting palpation of the interarytenoid region with a right-angle probe were reviewed. These recordings were shown to blinded pediatric otolaryngologists and each surgeon's determination of the presence or absence of a T1LC as well as recommended treatment (observation, injection laryngoplasty, or endoscopic cleft repair) was recorded and compared against the other blinded surgeons. Fleiss's kappa was calculated to evaluate IRR in both diagnosis and treatment. RESULTS: Eight pediatric otolaryngologists were included in the study with a mean post-training experience of 15 years (range 1-35 years). The inter-rater percent agreement in diagnosis of our patient population was 28.6% (range 3.7-71%) with a kappa value of 0.31 (p < 0.0001). In regard to management, the inter-rater percent agreement in treatment was 11.4% (range 0-35%) with a kappa value of 0.14 (p = 0.01). CONCLUSION: This study highlights the challenges and variation that exists among surgeons in diagnosing and managing potential T1LC. Further standardizing the endoscopic examination and treatment algorithm may reduce diagnostic and treatment discordance.

Characterization of Malignant Head and Neck Paragangliomas at a Single Institution Across Multiple Decades.

Importance: Malignant head and neck paragangliomas (HNPGLs) are rare entities, and there are limited data regarding optimal treatment recommendations to improve clinical outcomes. Objective: To classify succinate dehydrogenase (SDH) germline mutations associated with malignant HNPGLs, evaluate time from diagnosis to identification of malignant tumor, describe locations of metastases and the functional status of malignant HNPGLs, and determine the role of selective neck dissection at the time of initial surgical resection. Design, Setting, and Participants: A retrospective cohort study was completed of patients diagnosed with paragangliomas on various sites on the body at an academic tertiary cancer hospital between the years 1963 and 2018. A subanalysis of HNPGLs was also completed. Data regarding diagnosis, gene and mutation, tumor characteristics and location, and treatments used were reviewed between February 2017 and March 2018. Main Outcomes and Measures: Mutations of SDH genes associated with benign and malignant HNPGLs, treatments used, time to the discovery of malignancy, and location of metastasis. Results: Of the 70 patients included in the study, 40 (57%) were male, and the mean (SD) age was 47 (21.1) years. Of patients with tumors isolated to the head and neck, 38 (54%) had benign HNPGLs, which were associated with mutations in the genes SDH subunit B (SDHB) (n = 18; 47%), SDH subunit C (n = 2; 5%), and SDH subunit D (n = 18; 47%). Among those with malignant HNPGLs, all but 1 patient had mutations in SDHB (n = 5; 83%); 1 patient had no mutation associated with their disease. The average age at diagnosis for malignant HNPGLs was 35 years, while benign tumors were diagnosed at an average age at 36 years. All patients with malignant disease underwent surgery. Four patients were found to have metastasis at the time of selective neck dissection. Among patients with malignant HNPGLs, 5 (83%) were treated with adjuvant radiation, and 1 (17%) was treated with adjuvant chemotherapy. Conclusions and Relevance: Malignant HNPGLs are rare entities that are difficult to diagnose and are typically identified by the presence of regional or distant metastasis. The results of this study found the prevalence of malignant HNPGLs to be 9%. These data suggest that it is beneficial to perform a selective neck dissection at the time of tumor excision. All patients with malignant HNPGLs but 1 had SDHB mutations.

Adjuvant radiation for positive margins in adult head and neck sarcomas is associated with improved survival: Analysis of the National Cancer Database.

BACKGROUND: Adult head and neck (H&N) sarcomas are a rare malignancy with limited data delineating the role of postoperative radiotherapy (PORT), particularly for a positive surgical margin. There are no randomized trials supporting the use of PORT, therefore treatment trends vary between institutions. A positive margin predicts recurrence and poor survival outcomes. This study uses the National Cancer Database (NCDB) to investigate whether PORT improves overall survival (OS) in adult H&N sarcomas with a positive margin and how utilization has changed. METHODS: Patients (n = 1142) in the NCDB from 2004-2013 with adult H&N sarcomas who underwent resection and had a positive margin. RESULTS: Factors significantly associated with increased utilization of PORT were: having insurance, salivary gland primary site, high-risk histology, poor differentiation, and a macroscopic positive margin. Treatment with PORT was associated with improved 5-year OS for all patients with a positive margin (57% vs 48%; P = .002), both microscopic (57% vs 49%; P = .010) and macroscopic (57% vs 41%; P = .036). Improved OS was significant after controlling for other known covariates on multivariate analysis (HR: 0.76; [0.64-0.90]; P = .002). Treatment at a community-based facility was an independent predictor for reduced OS (HR: 1.37; [1.15-1.64]; P < .001). The percentage utilization (53%) of PORT for these patients did not change significantly over time. CONCLUSION: PORT provides a significant survival benefit for adult H&N sarcoma patients with either a microscopic or macroscopic positive margin; however, PORT is underutilized. Treatment at academic/research cancer programs was associated with increased utilization of PORT and improved survival outcomes.

Association of the Patient Protection and Affordable Care Act With Insurance Coverage for Head and Neck Cancer in the SEER Database.

Importance: Patients with head and neck squamous cell cancer (HNSCC) are often uninsured or underinsured at the time of their diagnosis. This access to care has been shown to influence treatment decisions and survival outcomes. Objective: To examine the association of the Patient Protection and Affordable Care Act (ACA) health care legislation with rates of insurance coverage and access to care among patients with HNSCC. Design, Setting, and Participants: Prospectively gathered data from the Surveillance, Epidemiology, and End Results (SEER) database were used to examine rates of insurance coverage and access to care among 89 038 patients with newly diagnosed HNSCC from January 2007 to December 2014. Rates of insurance were compared between states that elected to expand Medicaid coverage in 2014 and states that opted out of the expansion. Statistical analysis was performed from January 1, 2007, to December 31, 2014. Main Outcomes and Measures: Rates of insurance coverage and disease-specific and overall survival. Results: Among 89 038 patients newly diagnosed with HNSCC (29 384 women and 59 654 men; mean [SD] age, 59.8 [7.6] years), there was an increase after implementation of the ACA in the percentage of patients enrolled in Medicaid (16.2% after vs 14.8% before; difference, 1.4%; 95% CI, 1.1%-1.7%) and private insurance (80.7% after vs 78.9% before; difference, 1.8%; 95% CI, 1.2%-2.4%). In addition, there was a large decrease in the rate of uninsured patients after implementation of the ACA (3.0% after vs 6.2% before; difference, 3.2%; 95% CI, 2.9%-3.5%). This decrease in the rate of uninsured patients and the associated increases in Medicaid and private insurance coverage were only different in the states that adopted the Medicaid expansion in 2014. No survival data are available after implementation of the ACA, but prior to that point, from 2007 to 2013, uninsured patients had reduced 5-year overall survival (48.5% vs 62.5%; difference, 14.0%; 95% CI, 12.8%-15.2%) and 5-year disease-specific survival compared with insured patients (56.6% vs 72.2%; difference, 15.6%; 95% CI, 14.0%-17.2%). Conclusions and Relevance: Access to health care for patients with HNSCC was improved after implementation of the ACA, with an increase in rates of both Medicaid and private insurance and a 2-fold decrease in the rate of uninsured patients. These outcomes were demonstrated only in states that adopted the Medicaid expansion in 2014. Uninsured patients had poorer survival outcomes.

Association of Celecoxib Use With Decreased Opioid Requirements After Head and Neck Cancer Surgery With Free Tissue Reconstruction.

Importance: Head and neck cancer (HNC) surgery with free tissue reconstruction is associated with considerable postoperative pain. Opioids are typically used but can have adverse effects, including respiratory depression and high rates of dependence and addiction. Safe alternative analgesics that minimize opioid requirements are beneficial in HNC surgery. Objective: To investigate the association of celecoxib use with opioid requirements in the postoperative setting after HNC surgery with free tissue reconstruction. Design, Setting, and Participants: A retrospective, matched-cohort study of 147 patients who had undergone HNC surgery with free tissue reconstruction between June 2015 and Sept 2017 in an academic cancer hospital. Patients were separated into groups based on whether celecoxib had been used perioperatively or not. These groups were then matched by stage and site resulting in 102 included participants (51 celecoxib, 51 control). Main Outcomes and Measures: Oral, intravenous (IV), and total morphine equivalents used in the postoperative setting per patient per day. Results: There were 51 patients in the celecoxib cohort (19 women and 32 men) and 51 patients in the control cohort (20 women and 31 men) who met inclusion criteria after clinicopathologic data were matched. The mean age of the celecoxib and control cohorts was 61.6 years and 66.1 years, respectively. Treatment with celecoxib in the postoperative setting was associated with decreased mean use of opioids in oral (mean difference, 9.9 mg/d; 95% CI, -1.2 to 21.1), IV (mean difference, 3.9 mg/d; 95% CI, 1.0-6.8), and total (mean difference, 14 mg/d; 95% CI, 2.6-25.4) amount of morphine equivalents per day. When patients were matched to surgical procedure, the effect was more significant. Patients who underwent composite oral resection and received celecoxib had decreased opioid use in oral (mean difference, 25 mg/d; 95% CI, 12.5-25.4), IV (mean difference, 3.4 mg/d; 95% CI, 1.5-5.5), and total (mean difference, 28.4 mg/d; 95% CI, 15.7-41.5) amounts compared with those in the control group. There was no significant difference in complication rates between the 2 cohorts. Conclusions and Relevance: Use of celecoxib after head and neck cancer surgery and reconstruction with free tissue transfer was associated with a decrease in oral, IV, and total opioid requirements without increasing surgical or flap-related complications.

Outcomes after cricotracheal resection for idiopathic subglottic stenosis.

OBJECTIVES: Idiopathic subglottic stenosis (iSGS) is a rare disease in which patients develop airway narrowing and dyspnea from relapsing subglottic and tracheal granulation and scar tissue that narrows the airway. Definitive management has involved surgical resection and reconstruction of the subglottis and trachea. However, treatment options remain highly variable at different institutions. Here, we present our outcomes and experience after cricotracheal resection (CTR) for iSGS at a high-volume tertiary care center. METHODS: A review of one surgeon's experience with a population of iSGS patients who underwent CTR between the years 1999 and 2017. The diagnosis of iSGS was one of exclusion and was based on history and microlaryngoscopy and bronchoscopy exams. Recurrence of subglottic stenosis was evaluated using Kaplan-Meier survival estimate analysis. RESULTS: Sixty-one patients met criteria for iSGS and underwent CTR. Our population was 97% female and had an average of 4.3 balloon dilations prior to CTR. Mean follow-up time after CTR was 7.14 years. Eight (13%) patients developed recurrence of subglottic stenosis after CTR. Mean and median time to recurrence after CTR was 12.5 years and 14.1 years, respectively. CONCLUSION: Cricotracheal resection is associated with a small, long-term recurrence rate of stenosis. It remains an important option for individuals with refractory iSGS. It may be reasonable to consider early CTR in the management of certain patients with iSGS. Further research should investigate risk factors that predispose patients to recurrence after CTR. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2268-2272, 2018.

Academic Facility Utilization and Survival Outcomes in Adult Head and Neck Sarcomas: An NCDB Analysis.

Objectives To investigate clinicopathologic and treatment factors associated with survival in adult head and neck sarcomas in the National Cancer Database (NCDB). To analyze whether treatment settings and therapies received influence survival outcomes and to compare trends in utilization via an aggregated national data set. Study Design Prospectively gathered data. Setting NCDB. Subjects and Methods The study comprised a total of 6944 adult patients treated for a head and neck sarcoma from January 2004 to December 2013. Overall survival (OS) was the primary outcome. Results Increased age and tumor size, nodal involvement, and poorly differentiated histology had significantly reduced OS ( P < .001). Angiosarcoma, malignant nerve sheath tumor, malignant fibrous histiocytoma, osteosarcoma, and rhabdomyosarcoma histologic subtypes had significantly reduced OS, while liposarcoma, chondrosarcoma, and chordoma had improved OS ( P < .001). Utilization of surgical therapy was associated with improved OS, while positive surgical margins were associated with treatment at a community-based cancer program and had reduced OS ( P < .001). On multivariate analysis, treatment with radiation and/or chemotherapy was not significantly associated with OS; however, primary treatment with definitive chemoradiotherapy had significantly reduced OS. Patients treated at academic/research cancer programs (n = 3874) had significantly improved 5- and 10-year OS (65% and 54%, respectively) when compared with patients treated at community-based cancer programs (n = 3027; 49% and 29%; P < .001). The percentage utilization of these programs (56% vs 44%) did not change over the study period. Conclusion For adult head and neck sarcomas, treatment at an academic/research cancer program was associated with improved survival; however, despite increasing medical specialization, the percentage utilization of these programs for this rare tumor remains constant.

MRSA chronic bacterial laryngitis: A growing problem.

OBJECTIVES: Chronic bacterial infection of the larynx is characterized by long-standing hoarseness and exudative laryngitis. Prolonged antibiotic therapy is required to clear the infection, and methicillin-resistant staphylococcus aureus (MRSA) may be the responsible pathogen. The objective of this study was to describe the presentation, comorbidities, treatment response, and underlying etiology- including the incidence of MRSA-in our patient population with chronic bacterial laryngitis. METHODS: A review of patients with a diagnosis of chronic bacterial laryngitis from 2012 to 2016 was performed. Diagnosis of chronic bacterial laryngitis was based on clinical history and findings on flexible laryngoscopy. In selected cases, the diagnosis of bacterial laryngitis was confirmed by operative biopsy. Information regarding clinical presentation and course was collected. RESULTS: Twenty-eight patients were included in the study. Twenty-three were treated empirically with Amoxicillin-clavulonic acid for a minimum of 21 days. Twelve of the 23 (52%) had recurrence or nonresolution of infection. Seven of the 12 nonresponders (58%) were found to have MRSA by laryngeal tissue culture. Five patients were treated initially with Sulfamethoxazole and trimethoprim, and all resolved the infection without the need for further treatment. There was a nonstatistically significant increase in smoking and reflux in the MRSA population compared to the non-MRSA group. CONCLUSION: MRSA infection was documented in 30% of patients overall with chronic bacterial laryngitis. Based on the results of the study, a treatment algorithm for management of this unusual patient population is suggested. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:921-925, 2018.

Postoperative care after tonsillectomy: what's the evidence?

PURPOSE OF REVIEW: The purpose of this review is to evaluate the current literature regarding postoperative management after tonsillectomy in children. RECENT FINDINGS: Controversy remains regarding the ideal medication regimen to manage pain after tonsillectomy. Acetaminophen and ibuprofen are routinely used, although concerns of more severe postoperative hemorrhage with ibuprofen remain. Narcotics are prescribed commonly, but with extreme caution in children with severe obstructive sleep apnea. Although not always utilized by the authors, additional adjunctive medications such as perioperative dexamethasone, ketamine, and local infiltration of lidocaine into tonsillar pillars may decrease postoperative pain. Systematic reviews have shown that dexamethasone does not increase risk of posttonsillectomy bleeding. SUMMARY: Adenotonsillectomy is one of the most common procedures performed on children and may have significant morbidity from postoperative pain and bleeding. Managing pain remains challenging and the optimal treatment regimen has not been definitively identified. Many medications and alternative therapies have been studied and suggest possible benefit.

Auricular complications in parotid, temporal bone, infratemporal fossa, and lateral skull base surgery.

Neoplasms located in the parotid region, temporal bone, infratemporal fossa, and lateral skull base represent a challenge due to their difficult anatomic location and surrounding neurovascular structures. A variety of surgical approaches are appropriate to access this area, although several of them can place the auricular blood supply in danger. If the auricular blood supply is compromised, ischemia and, eventually, avascular necrosis of the auricle can occur. Auricular necrosis often can cause patients a delay in adjuvant radiation therapy and result in the need for additional reconstructive procedures. Therefore, it is imperative to identify risk factors associated with the development of this disabling complication. We conducted a retrospective review of 32 individuals undergoing treatment of benign and malignant lesions in the parotid gland, infratemporal fossa, and lateral skull base. To identify potential risk factors for auricular necrosis, the patients were analyzed based on the type of neoplasm (malignant or benign), risk factors affecting blood flow (diabetes mellitus, smoking history, prior radiation, prior surgery), body mass index, and the length of surgery. In our population examined, 3 instances of auricular necrosis occurred. None of the potential risk factors proved to be statistically significant (although malignant pathology approached significance at p = 0.07). Two of the patients required an auriculectomy with reconstruction. The third had multiple postoperative clinic visits for surgical debridement. Although no potential risk factors were statistically significant, surgeons should remain cognizant of the auricular blood supply while performing surgery via preauricular and postauricular approaches to this area.

Immediate postoperative imaging after uncomplicated endoscopic approach to the anterior skull base: is it necessary?

BACKGROUND: Postoperative imaging is frequently performed to assess for intracranial complications following anterior skull base (ASB) surgery. However, there is little data to suggest that radiologic studies change the management of complications. In this study, the utility of postoperative imaging within 72 hours after uncomplicated ASB surgery was examined. METHODS: A retrospective review was conducted of 143 patients who underwent endoscopic ASB surgery between 2007 and 2013 at Loyola University Medical Center. The main outcomes measures included the ability of head computed tomography (CT) scan to identify postoperative complications and hallmark symptoms associated with complications. RESULTS: Seventy-nine patients underwent postoperative imaging within 72 hours of the initial surgery. The most common finding was pneumocephalus (35/79; 44%). Expanding pneumocephalus requiring surgical intervention developed in 3 cases. Cerebrospinal fluid (CSF) leak was the most common complication, occurring in 22 of 143 (15%) of the patients. Of the 24 patients who developed a postoperative complication, all had clinical signs or symptoms indicative of the need for surgical or medical intervention. The positive predictive value for a head CT scan to detect a complication was 12%, negative predictive value was 92%, and sensitivity and specificity were 63% and 48%, respectively. CONCLUSION: Routine postoperative imaging may be unnecessary after uncomplicated endoscopic ASB surgery because (1) it may not alter patient management; (2) it may not detect the most common complication (CSF leak); and (3) when imaging is positive, the patient has clinical symptoms suggesting a need for intervention.

Cannabinoid concentrations in hair from documented cannabis users.

Fifty-three head hair specimens were collected from 38 males with a history of cannabis use documented by questionnaire, urinalysis and controlled, double blind administration of delta9-tetrahydrocannabinol (THC) in an institutional review board approved protocol. The subjects completed a questionnaire indicating daily cannabis use (N=18) or non-daily use, i.e. one to five cannabis cigarettes per week (N=20). Drug use was also documented by a positive cannabinoid urinalysis, a hair specimen was collected from each subject and they were admitted to a closed research unit. Additional hair specimens were collected following smoking of two 2.7% THC cigarettes (N=13) or multiple oral doses totaling 116 mg THC (N=2). Cannabinoid concentrations in all hair specimens were determined by ELISA and GCMSMS. Pre- and post-dose detection rates did not differ statistically, therefore, all 53 specimens were considered as one group for further comparisons. Nineteen specimens (36%) had no detectable THC or 11-nor-9-carboxy-THC (THCCOOH) at the GCMSMS limits of quantification (LOQ) of 1.0 and 0.1 pg/mg hair, respectively. Two specimens (3.8%) had measurable THC only, 14 (26%) THCCOOH only, and 18 (34%) both cannabinoids. Detection rates were significantly different (p<0.05, Fishers' exact test) between daily cannabis users (85%) and non-daily users (52%). There was no difference in detection rates between African-American and Caucasian subjects (p>0.3, Fisher's exact test). For specimens with detectable cannabinoids, concentrations ranged from 3.4 to >100 pg THC/mg and 0.10 to 7.3 pg THCCOOH/mg hair. THC and THCCOOH concentrations were positively correlated (r=0.38, p<0.01, Pearson's product moment correlation). Using an immunoassay cutoff concentration of 5 pg THC equiv./mg hair, 83% of specimens that screened positive were confirmed by GCMSMS at a cutoff concentration of 0.1 pg THCCOOH/mg hair.