Validation of a 3D-Printed Silicone-Based Laryngeal Model for Resident Education.

OBJECTIVE: We sought to validate a laryngeal simulation model and subsequently demonstrate its efficacy in improving surgical technique. STUDY DESIGN: Pre-post interventional study. SETTING: Otolaryngology Program at a Tertiary Care Center. METHODS: A low-cost, high-fidelity laryngeal model was created using a 3-dimensional-printed cast and multilayered silicone to mimic vocal fold lesions. Participants (attendings and trainees) were first given a series of tasks including mucosal vocal fold lesion resection and microflap excision of a submucosal lesion. Trainees were then provided with an instructional video from a laryngologist and asked to repeat the same tasks on the model. Performance data was then assessed using validated surveys and blinded expert reviewers. RESULTS: Eighteen participants completed the simulation. All subjects agreed that the "simulation experience was useful" and 93% agreed "the simulator helped improve my ability to do microsurgical tasks." In the postinstruction self-evaluation, trainees reported a significant decrease in mental demand (95% confidence interval [CI]: 0.37-0.91; P = .038) and significant increase in subjective performance (95% CI: 1.51-51.89; P = .016) compared to the preinstruction self-evaluation. On the postinstruction attempt, there was a significant improvement in all domains of the adapted objective structured assessment of technical skills as measured by 3 blinded, expert reviewers. DISCUSSION: This study demonstrates the usefulness of a silicone larynx model and the value of instructional video in developing laryngeal microsurgical skills. Participants positively reviewed the laryngeal model and trainees saw both a subjective and objective improvement indicating tangible operative benefits from the use of this laryngeal simulation.

Closing the Loop on Concentric Tube Robot Design: A Case Study on Micro-Laryngeal Surgery.

Concentric tube robots (CTRs) are well-suited to address the unique challenges of minimally invasive surgical procedures due to their small size and ability to navigate highly constrained environments. However, uncertainties in the manufacturing process can lead to challenges in the transition from simulated designs to physical robots. In this work, we propose an end-to-end design workflow for CTRs that considers the oftenoverlooked impact of manufacturing uncertainty, focusing on two primary sources - tube curvature and diameter. This comprehensive approach incorporates a two-step design optimization and an uncertainty-based selection of manufacturing tolerances. Simulation results highlight the substantial influence of manufacturing uncertainties, particularly tube curvature, on the physical robot's performance. By integrating these uncertainties into the design process, we can effectively bridge the gap between simulation and real-world performance. Two hardware experiments validate the proposed CTR design workflow. The first experiment confirms that the performance of the physical robot lies within the simulated probability distribution from the optimization, while the second experiment demonstrates the feasibility of the overall system for use in micro-laryngeal surgical tasks. This work not only contributes to a more comprehensive understanding of CTR design by addressing manufacturing uncertainties, but also creates a new framework for robust design, as illustrated in the context of microlaryngeal surgery.

The current state of autonomous suturing: a systematic review.

BACKGROUND: Robotic technology is an important tool in surgical innovation, with robots increasingly being used in the clinical setting. Robots can be used to enhance accuracy, perform remote actions, or to automate tasks. One such surgical task is suturing, a repetitive, fundamental component of surgery that can be tedious and time consuming. Suturing is a promising automation target because of its ubiquity, repetitive nature, and defined constraints. This systematic review examines research to date on autonomous suturing. METHODS: A systematic review of the literature focused on autonomous suturing was conducted in accordance with PRISMA guidelines. RESULTS: 6850 articles were identified by searching PubMed, Embase, Compendex, and Inspec. Duplicates and non-English articles were removed. 4389 articles were screened and 4305 were excluded. Of the 84 remaining, 43 articles did not meet criteria, leaving 41 articles for final review. Among these, 34 (81%) were published after 2014. 31 (76%) were published in an engineering journal9 in a robotics journal, and 1 in a medical journal. The great majority of articles (33, 80%) did not have a specific clinical specialty focus, whereas 6 (15%) were focused on applications in MIS/laparoscopic surgery and 2 (5%) on applications in ophthalmology. Several suturing subtasks were identified, including knot tying, suture passing/needle insertion, needle passing, needle and suture grasping, needle tracking/kinesthesia, suture thread detection, suture needle shape production, instrument assignment, and suture accuracy. 14 articles were considered multi-component because they referred to several previously mentioned subtasks. CONCLUSION: In this systematic review exploring research to date on autonomous suturing, 41 articles demonstrated significant progress in robotic suturing. This summary revealed significant heterogeneity of work, with authors focused on different aspects of suturing and a multitude of engineering problems. The review demonstrates increasing academic and commercial interest in surgical automation, with significant technological advances toward feasibility.

Free flap jaw reconstruction with dental implantation: A single-institution experience.

BACKGROUND: We sought to review our institution's experience with dental implant placement in free flap jaw reconstruction to determine factors impacting restoration of dental occlusion. METHODS: Exactly 48 patients underwent free flap jaw reconstruction with or without dental restoration from 2017 to 2022. Primary outcome was achievement of restored dental occlusion after jaw free flap reconstruction. RESULTS: A total of 48 patients with a mean age of 59.8 ± 16.4 years underwent jaw reconstruction from 2017 to 2022. Ten patients (20.8%) received osteointegrated dental implants. Two patients received a temporary dental prosthesis, 12 ± 4 months after initial reconstruction. Three patients received a final prosthesis, with a mean time to final prosthesis of 17.7 ± 12.4 months. Five patients did not receive any prosthesis despite placement of implants. CONCLUSION: A minority of patients received dental implant placement with free flap jaw reconstruction and only a small subset of these received a definitive dental prosthesis.

Comparison of Postoperative Outcomes in Cystic Versus Solid Vestibular Schwannoma in a Multi-institutional Cohort.

OBJECTIVE: Cystic vestibular schwannomas (cVSs) have more variable and less favorable clinical outcomes after microsurgical resection compared with solid VS (sVS). This study compares the preoperative presentation and postoperative outcomes between cVS and sVS. STUDY DESIGN: Retrospective cohort study. SETTING: Two tertiary skull base referral centers. METHODS: Consecutive adult patients who underwent VS resection from 2016 to 2021 were included. Univariate and multivariate analyses compared differences in baseline symptoms and postoperative outcomes between cVS and sVS. RESULTS: There were a total of 315 patients (64% female; mean age, 54 yrs) and 46 (15%) were cystic. cVS were significantly larger than sVS (maximum diameter, 28 vs. 18 mm, p < 0.001) and had higher rates of dysphagia and dysphonia preoperatively (p < 0.02). cVSs were more likely to undergo translabyrinthine resection (76 vs. 50%, p = 0.001) and have a higher rate of subtotal resection (STR) compared with sVS (30 vs. 13%, p = 0.003). At latest follow-up, fewer cVS achieved good facial nerve (FN) outcome (House-Brackmann [HB] I/II) (80 vs. 90%, p = 0.048). Subanalysis of cVS and sVS matched in tumor size, and surgical approach did not show differences in the rate of STR or FN outcomes (HB I/II, 82 vs. 78%, p = 0.79). CONCLUSION: In this large multi-institutional series, cVSs represent a distinct entity and are characterized by larger tumor size and higher incidence of atypical symptoms. Although cVSs were more likely to undergo STR and portend worse FN outcomes than sVSs, this may be due to their larger tumor size rather than the presence of the cystic component.

Reducing Risks for Local Skin Flap Failure.

Local tissue flaps are a fundamental technique in cutaneous reconstruction. Reducing the risk of flap failure is of critical importance. The intrinsic vascularity of a flap is the most important determinant of success. Good surgical techniques, including flap design, delicate tissue handling, and tension-less closure, help reduce the risk of flap compromise. Determining the etiology of compromise, including arterial, venous, hematologic, or infectious, is the first step in salvaging a failing flap. Common causes include pedicle kinking, hematoma, pressure/tension, systemic patient factors, and poor surgical technique. Swift action to restore perfusion or venous outflow through numerous strategies is required.

Bilateral Vocal Fold Granuloma and Anterior Glottic Web After Papilloma Excision.

We present a case of delayed vocal process granulomas and anterior glottic web after treatment of vocal fold papillomas with a laryngeal microdebrider and CO2 laser ablation. This case highlights a risk of vocal fold granuloma in the setting of recurrent respiratory papillomatosis and microdebrider use, warranting close follow-up and consideration of prophylactic voice therapy, anti-reflux medications, and steroid injection in cases of violation of vocal cord epithelium.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review of 2021.

Objective: To evaluate new medical devices and drugs pertinent to otolaryngology-head and neck surgery that were approved by the Food and Drug Administration (FDA) in 2021. Data Sources: Publicly available FDA device and drug approvals from ENT (ear, nose, and throat), anesthesia, neurosurgery, plastic surgery, and general surgery FDA committees. Review Methods: FDA device and therapeutic approvals were identified and reviewed by members of the American Academy of Otolaryngology-Head and Neck Surgery's Medical Devices and Drugs Committee. Two independent reviewers assessed the relevance of devices and drugs to otolaryngologists. Medical devices and drugs were then allocated to their respective subspecialty fields for critical review based on available scientific literature. Conclusions: The Medical Devices and Drugs Committee reviewed 1153 devices and 52 novel drugs that received FDA approval in 2021 (67 ENT, 106 anesthesia, 618 general surgery and plastic surgery, 362 neurosurgery). Twenty-three devices and 1 therapeutic agent relevant to otolaryngology were included in the state of the art review. Advances spanned all subspecialties, including over-the-counter hearing aid options in otology, expanding treatment options for rhinitis in rhinology, innovative laser-safe endotracheal tubes in laryngology, novel facial rejuvenation and implant technology in facial plastic surgery, and advances in noninvasive and surgical treatment options for obstructive sleep apnea. Implications for Practice: FDA approvals for new technology and pharmaceuticals present new opportunities across subspecialties in otolaryngology. Clinicians' nuanced understanding of the safety, advantages, and limitations of these innovations ensures ongoing progress in patient care.

The Feasibility of Outpatient Type I Thyroplasty with Laryngeal Reinnervation.

Type I thyroplasty has increasingly been performed on an outpatient basis. Laryngeal reinnervation is recognized for its long-term and functional benefits but is typically performed inpatient under general anesthesia. Herein we report the first published outpatient type I thyroplasty with laryngeal reinnervation performed under monitored anesthesia care (MAC). Three adults underwent type I thyroplasty with ansa cervicalis to recurrent laryngeal nerve (RLN) reinnervation. A 23-year-old female with a history of generalized idiopathic epilepsy s/p vagal nerve stimulator implantation presented with persistent dysphonia. She developed longstanding left vocal fold paralysis. She underwent left type I thyroplasty with silastic implant and ansa cervicalis to RLN neurorrhaphy under MAC-local anesthesia. The patient was discharged home on the day of surgery. Two additional patients underwent the same procedure, including a 58-year-old male with postsurgical dysphonia who was admitted for overnight observation due to a small amount of incisional crepitus and a 23-year-old female with postsurgical vocal cord paralysis who was admitted overnight due to multiple comorbidities. Both were discharged on post-operative day one without issue and demonstrated improvement in voice at follow up. Outpatient type I thyroplasty with laryngeal reinnervation under MAC is feasible with proper patient selection.

Local Tumor Behavior Associated With Survival Among Patients With Paraganglioma of the Head and Neck.

Objective: The purpose of this study was to evaluate the utility of ICD-O-3-classified local tumor behavior as a prognosticator of head and neck paraganglioma (HNP) outcomes. Study Design: Retrospective cohort study. Setting: National Cancer Database between 2004 and 2016. Methods: This study included patients aged ≥18 years who were diagnosed with HNP. Clinical outcomes and clinicopathologic features were compared with regard to local tumor behavior. Results: Our study included 525 patients, of which the majority had HNP classified as locally invasive (45.9%) or borderline (37.9%). The most common anatomic sites involved were the carotid body (33.7%), intracranial regions (29.0%), or cranial nerves (25.5%). Carotid body tumors were exclusively locally invasive, whereas intracranial and cranial nerve HNP were overwhelmingly benign or borderline (94% and 91%, respectively). One-fourth of patients underwent pathologic analysis of regional lymph nodes, of which the majority were positive for metastasis (80.6%). Metastasis to distant organs was twice as common in patients with locally invasive tumors vs benign (15% vs 7.1). For benign disease, surgery with radiotherapy (adjusted hazard ratio [aHR], 40.45; P = .006) and active surveillance (aHR, 24.23; P = .008) were associated with worse survival when compared with surgery alone. For locally invasive tumors, greater age (aHR, 1.07; P < .0001) and positive surgical margins (aHR, 4.13; P = .010) were predictors of worse survival, while combined surgery and radiotherapy were predictors of improved survival vs surgery alone (aHR, 0.31; P = .027). Conclusion: While criteria for tumor behavior could not be defined, our results suggest that such a classification system could be used to enhance HNP risk stratification and guide clinical management decisions.

Pediatric Tissue Expansion: Predictors of Premature Expander Removal in a Single Surgeon's Experience with 472 Expanders.

BACKGROUND: Tissue expansion is used for soft-tissue reconstruction in pediatric patients. The expansion process can be complicated by infection and extrusion, leading to premature expander removal. The aim of this study was to identify risk factors associated with premature expander removal caused by infection or extrusion in pediatric patients. METHODS: A retrospective study of pediatric patients who underwent tissue expansion performed by the senior author (R.J.R.) over a 12-year period was performed. Predictor variables included age, sex, race, indication, anatomical location, number of expanders, serial expansion, and expander size. Bivariate and multivariate analyses were performed to identify risk factors for premature expander removal. RESULTS: A total of 139 patients with 472 expanders were included in this study. Complications occurred with 78 expanders (16.5 percent). Premature expander removal caused by infection or exposure occurred with 51 expanders (10.8 percent). In terms of location, the highest rates of premature removal occurred in the lower extremity (20.0 percent) and scalp (16.3 percent). Multivariate analysis identified younger age (0 to 6 years compared with 13 to 17 years; OR, 3.98; 95 percent CI, 1.13 to 14.08; p = 0.03), greater number of expanders (OR, 1.45; 95 percent CI, 1.03 to 2.03; p = 0.03), and lower extremity location (OR, 4.27; 95 percent CI, 1.45 to 12.53; p = 0.008) were associated with an increased odds of premature expander removal. CONCLUSIONS: Expander removal occurred in approximately 10 percent of tissue expanders. Odds of premature removal is increased with younger age, greater number of expanders, and lower extremity location. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety.

BACKGROUND: As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice. METHODS: A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge. RESULTS: In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient. CONCLUSION: A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.

An Interdisciplinary Approach to Treatment of Adult Facial Arteriovenous Malformations: A Review of the Literature and A Single Institution's Experience With "Late" Surgical Resection and Aesthetic Reconstruction.

BACKGROUND: Arteriovenous malformations (AVMs) are high flow vascular anomalies that are difficult to manage given their high recurrence rate. At this time, the optimal treatment of AVMs involves embolization and surgical resection. However, few studies have examined patient outcomes after a delayed surgical resection approach. METHODS: A retrospective chart review of all patients presenting to a single institution with vascular malformations from 2000 to 2016 was performed. Patients with facial AVMs that underwent operative management were included. Records were reviewed for patient characteristics, lesion natural history, operative timing after embolization (<72 vs >72 hours), and outcomes. RESULTS: 11 patients fulfilled the inclusion/exclusion criteria. Nine patients were female, with an average age at resection of 29.1 years. Three patients had hemi/mid-facial AVMs, 1 patient had a nasal AVM, 3 patients had labial AVMs, 1 patient had an AVM on the chin, and 1 had a periorbital AVM. Average time between embolization and primary resection was 8.6 days (range 1-24). No complications requiring reoperation occurred in any patient. Average follow-up was 32.6 months, with 2 recurrences at a mean of 47.6 months. Timing of resection, Schobinger stage, and resection completeness did not significantly affect recurrence (P >0.05). Lesion size >6 cm in any dimension was significantly associated with recurrence (P = 0.018). CONCLUSION: Compared to early resection, delayed (>72 h) surgical resection after embolization of facial AVMs is a viable treatment option and results in non-inferior recurrence rates (25 vs 14% respectively over a 40-month period).

Increased Incidence of Symptomatic Venous Thromboembolism following Pedicled Lower Extremity Flap Harvest for Abdominal and Perineal Reconstruction in Patients Receiving Mechanical Prophylaxis and Chemoprophylaxis: A Case for Heightened Awareness.

BACKGROUND: Postsurgical venous thromboembolism remains a leading cause of hospital morbidity. Data to support venous thromboembolism prophylaxis guidelines in lower extremity flap surgery are lacking. The purpose of this study was to explore the effect of pedicled lower extremity flap harvest on venous thromboembolism development in the setting of abdominal or perineal reconstruction. METHODS: One hundred twenty-six patients undergoing unilateral lower extremity flap harvest for abdominal or perineal reconstruction were included. The contralateral leg served as an internal control. Sixty comorbidity-matched patients who underwent abdominal/perineal resection without flap reconstruction provided an external control. Bivariate analyses included chi-square and t tests; logistic regression adjusted for confounding variables on venous thromboembolism development. RESULTS: All patients underwent flap reconstruction for an oncologic defect of the abdomen or perineum, with 80 percent undergoing perineal reconstruction. Most patients underwent anterolateral thigh (41 percent) or gracilis flap (40 percent) harvest. Eleven patients developed deep venous thromboses in one or more legs (9 percent): 10 of 11 (90.9 percent) in the donor extremity and five (45.5 percent) contralaterally (p = 0.022). Patients who underwent flap harvest had a 10-fold higher odds of venous thromboembolism formation when compared to comorbidity-matched controls without flap reconstruction (OR, 10.64; 95 percent CI, 1.11 to 102.34; p = 0.041). CONCLUSIONS: The rate of venous thromboembolism is higher than previously appreciated for reconstructive procedures of the abdomen and/or perineum that use pedicled lower extremity flaps-particularly in the operative extremity. Additional research can clarify the role for further prophylaxis or screening. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Early ambulation after colorectal oncologic resection with perineal reconstruction is safe and effective.

BACKGROUND: Post-operative bedrest is common following perineal reconstruction despite little supporting data. We sought to determine the safety of early ambulation following colorectal oncologic resection and flap-based perineal reconstruction. METHODS: A retrospective cohort study was conducted with two cohorts: standard bedrest (BC) and early ambulation (EAC). Ambulation capacity was objectively assessed. Regression analysis was performed to determine the effects of ambulation timing on 60-day reoperations or readmissions and other surgical outcomes. RESULTS: There were 57 participants. Those in the EAC were significantly more ambulatory on post-operative days one through three (p < 0.0001). There was no significant difference in 60-day reoperations (25% BC versus 9% EAC, p = 0.14) or readmissions (33% BC versus 15% EAC, p = 0.12). Early ambulation significantly reduced minor complication rates (38% BC versus 9% EAC, p = 0.02). CONCLUSIONS: Early ambulation following perineal reconstruction is safe and may potentially decrease wound complications. SUMMARY AND KEYWORDS: Institution of early ambulation protocols is rapidly becoming the standard of care for many oncological surgery patients. In cases requiring perineal reconstruction with vascularized flaps, however, there is no data to uproot the historical practice of mandatory bedrest. Our study demonstrates that the benefits of early ambulation are attainable in these patients without compromising reconstructive outcomes.

Contemporary Management of Mandibular Fracture Nonunion-A Retrospective Review and Treatment Algorithm.

PURPOSE: Nonunion is an uncommon complication after mandibular fractures. The purpose of this investigation was to compare outcomes of patients with mandibular fracture nonunion who were treated with a 1- versus 2-stage approach and propose a pragmatic treatment algorithm for surgical management based on preoperative characteristics. MATERIALS AND METHODS: The authors conducted a retrospective study consisting of patients who presented to 2 level 1 trauma centers for the management of mandibular fracture nonunion over a 10-year period. The primary predictor variable was 1- versus 2-stage treatment. Outcomes were examined to propose a treatment algorithm. RESULTS: Eighteen patients were included in the study. The sample's mean age was 44.0 ± 19.3 years and most were men (88.9%). Mandibular angle and body accounted for 77.8% of cases. A single-stage approach was used in 13 patients (72.2%). Bone grafts or vascularized bone flaps were required in 13 patients (72.2%). Patients who required 2-stage treatments had intraoral soft tissue defects. Mean length of follow-up was 13.3 ± 20.4 months. All patients achieved bony union, with complications occurring in 5 patients (27.8%). The authors' 10-year experience was used to formulate a treatment algorithm based on bony defect size and soft tissue status, which can be used to inform optimal surgical management. CONCLUSIONS: Nonunion of mandibular fractures is an infrequent and complex condition requiring careful and deliberate surgical management. A single-stage approach is appropriate in most cases and does not negatively affect outcomes. Bony defect size and soft tissue status are essential parameters for determining the approach and timing of reconstruction.