Utility of video fluoroscopic swallow study in advancing oral diet post TORS for oropharyngeal malignancies.

OBJECTIVE: TORS is a minimally invasive surgical alternative to chemoradiotherapy for oropharyngeal malignancies. While early postoperative oropharyngeal dysphagia is linked to TORS, this study explores both subjective and objective swallowing outcomes. STUDY DESIGN: Retrospective and prospective review of the patients who underwent TORS for oropharyngeal malignancy from 2018 to 2023. SETTING: Single tertiary referral center. METHODS: Postoperative transnasal feeding tubes were administered to 142 patients undergoing TORS. Data on oncological, clinical, surgical, and pathological parameters, including VFSS records, pain with swallow, and feeding tube removal timing, were collected. Clinical swallow exam (CSE) was conducted on POD-1, with a formal swallow study pursued if inconclusive. Once a safe swallow was confirmed, oral diets were initiated, and the feeding tube removed, with most patients discharged on POD-2. RESULTS: At an average age of 59.3 years on the day of operation, the palatine tonsil (N = 101) was the predominant subsite. A dobhoff feeding tube was intraoperatively placed in 98 % of patients (N = 139). On POD-1, CSE was conducted in 119 patients, with 26 % (37/119) cleared for total oral diet (NOMS ≥ 4). Additionally, 30 out of 73 VFSS patients were cleared for total oral diet. A total of 54.9 % (78/142) had the feeding tube removed before discharge on POD-2, with a mean time of 6.5 ± 6.6 days. Overall, 71.1 % (101/142) achieved a total oral diet within one week after TORS. CONCLUSION: Early post-TORS swallowing is vital for oropharyngeal malignancies. VFSS assesses post-operative swallowing safety, allowing most patients to resume total oral nutrition shortly after TORS.

Virtual surgical planning for mandibular reconstruction in an abbreviated admission pathway.

OBJECTIVES: Virtual Surgical Planning (VSP) creates individualized surgical plans for free flap reconstruction of mandibular defects. Prior studies indicate that VSP can offer cost benefits due to reduced operative time and length of stay (LOS). We assessed the impact of VSP in the context of a validated postoperative abbreviated LOS clinical pathway. METHODS: This study assessed patients undergoing VSP vs conventional fibular free flap reconstruction for mandibular defects (12/2015-10/2020) and their operative time, ischemia time, and LOS were evaluated. RESULTS: Forty-four patients underwent VSP reconstruction, while 52 patients underwent conventional reconstruction for mandibular defects. VSP was associated with significantly lower total operative time (6 h and 57 mins vs 7 h and 54 mins, p = 0.011), but not length of stay or ischemia time. Total OR time was significantly increased with increasing number of segments needed in both the VSP group (p = 0.002) and the conventional group (p = 0.015). CONCLUSION: Shorter operative times and LOS have been attributed to the use of VSP in free tissue transfers. It is argued that these reductions offset the added cost of VSP. Our study indicates that there is no cost benefit for VSP utilization due to a significantly reduced operative time with no impact on length of admission in an abbreviated admission clinical pathway following free tissue transfer.

Routine Contrasted Chest CT Accurately Identifies Anatomic Variations of the Proximal Subscapular System.

OBJECTIVE: The vascular anatomy of the proximal subscapular artery has been previously classified into 2 major types depending on the presence of a common subscapular trunk. The purpose of this study was to determine the utility, reliability, and cost of routine chest imaging to identify these anatomical variations. METHODS: Data were collected retrospectively at a tertiary medical center for patients who were undergoing CT chest for various indications between October 2019 and October 2020. Two independent and blinded readers interpreted CT chest with contrast of 52 patients for a total 104 sides. RESULTS: The proximal branching pattern of the subscapular system was identified to have a common trunk in 99 (95%) sides. The remaining five sides (5%) demonstrated two arterial pedicles; with one patient exhibiting the variant anatomy bilaterally. CONCLUSION: Preoperative CT chest with contrast can accurately identify anatomic variation of the subscapular vascular system. For complex reconstruction requiring a single anastomosis in the vessel depleted neck, preoperative imaging can assure selection of a type I vascular anatomy of the proximal subscapular system. Preoperative imaging with contrasted CT has value in assessing this anatomy when planning for chimeric flaps involving circumflex scapular and thoracodorsal arteries. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:684-687, 2024.

Correlating area deprivation index with initial stage at presentation and with follow up and recurrence within an advanced practice provider-led survivorship clinic.

INTRODUCTION: Living in disadvantaged neighborhoods has been shown to result in worse healthcare outcomes. The Area Deprivation Index (ADI) is a metric that ranks neighborhoods by socioeconomic disadvantage utilizing numerous factors including income, education, employment, and housing quality. METHODS: A retrospective review of all patients who underwent surveillance in an APP-led head and neck cancer survivorship clinic from Dec 2016 to Oct 2020 at an academic tertiary care center were included. Tumor characteristics, visit frequency, recurrence, number of missed appointments, loss of follow up, and ADI scores were collected. RESULTS: 543 patients were included in the study. A majority were male (69.9 %) and white race (84.9 %) with an average age of 64.6 years old. Average ADI national percentile score was 71.6(range: 17 to 100). ADI national percentile score was not predictive of tumor characteristics at initial presentation: lymphovascular invasion (p = 0.940; OR 1.0 [95 % CI: 0.9 to 1.1]), extranodal extension (p = 0.576; OR 1.0 [95 % CI: 0.9 to 1.2]), positive margins (p = 0.069; OR 0.9 [95 % CI: 0.9 to 1.0]). ADI national percentile score was not significantly correlated with loss to follow up (p = 0.153; OR 1.2 [95 % CI: 0.9 to 1.7] or cancer recurrence (p = 0.594; OR 1.0 [95 % CI: 0.9 to 1.1]). Missing one or more clinic visits was correlated with loss to follow up (p = 0.029; OR 13.1 [95 % CI: 1.3 to 131.7]. CONCLUSION: Living in a disadvantaged neighborhood did not correlate with negative tumor characteristics, loss to follow up, or recurrence within an APP-led survivorship head and neck cancer clinic.

Comparing donor site morbidity in osteocutaneous radial forearm versus fibula free flap for mandibular reconstruction.

PURPOSE: The osteocutaneous radial forearm free flap has gained popularity as a less morbid option for oromandibular reconstruction compared to the fibular free flap. However, there is a paucity of data regarding direct outcome comparison between these techniques. METHODS: Retrospective chart review of 94 patients who underwent maxillomandibular reconstruction intervened from July 2012-October 2020 at the University of Arkansas for Medical Sciences. All other bony free flaps were excluded. Endpoints retrieved encompassed demographics, surgical outcomes, perioperative data, and donor site morbidity. Continuous data points were analyzed using independent sample t-Tests. Qualitative data was analyzed using Chi-Square tests to determine significance. Ordinal variables were tested using the Mann-Whitney U test. RESULTS: The cohort was equally male and female, with a mean age of 62.6 years. There were 21 and 73 patients in the osteocutaneous radial forearm free flap and fibular free flap cohorts, respectively. Excluding age, the groups were otherwise comparable, including tobacco use, and ASA classification. Bony defect (OC-RFFF = 7.9 cm, FFF = 9.4 cm, p = 0.021) and skin paddle (OC-RFFF = 54.6 cm2, FFF = 72.21 cm2, p = 0.045) size were larger in the fibular free flap group. However, no significant difference was found between cohorts with respect to skin graft. There was no statistically significant difference between cohorts regarding the rate of donor site infection, tourniquet time, ischemia time, total operative time, blood transfusion, or length of hospital stay. CONCLUSIONS: No significant difference in perioperative donor site morbidity was found between patients undergoing fibular forearm free flap and osteocutaneous radial forearm flap for maxillomandibular reconstruction. Osteocutaneous radial forearm flap performance was associated with significantly older age, which may represent a selection bias.

Early postoperative complications following tracheotomy: Does suturing technique influence outcomes?

Introduction: Tracheotomy is one of the most commonly performed procedure by otolaryngologists, but no consensus exists on the effect of suturing techniques on postoperative complications. Stay sutures and Bjork flaps are utilized frequently for securing the tracheal incision to the neck skin in order to create a tract for recannulation. Methods: Retrospective cohort study of tracheotomies performed by Otolaryngology-Head and Neck Surgery providers (May 2014 to August 2020) was conducted to determine the effect of suturing technique on postoperative complications and patient outcomes. Patient demographics, medical comorbidities, indication for tracheostomy, and postoperative complications were analyzed with a statistical alpha set of .05. Results: Out of 1395 total tracheostomies performed at our institution during the study period, 518 met inclusion criteria for this study. Three hundred and seventeen tracheostomies were secured by utilizing a Bjork flap, while 201 were secured with up and down stay sutures. Neither technique was noted to be more commonly associated with tracheal bleeding, infection, mucus plugging, pneumothorax, or false passage of the tracheostomy tube. One mortality was noted following decannulation during the study period. Conclusion: Though various techniques exist; adverse outcomes are not associated with the manner in which a new tracheostomy stoma is secured. Medical comorbidities and the indications for tracheostomy likely play a more significant role in postoperative outcomes and complications. Level of evidence: Level 3.

Remote smart pill cap monitoring of post-surgical pain management in thyroid and parathyroid surgery.

BACKGROUND: With recent efforts to decrease opioid use following surgery, this study aims to answer: what pain regimen do patients follow at home? Is it controlling pain? METHODS: This is a prospective, pilot study of thyroid and parathyroid surgery patients. Patients were prescribed acetaminophen, ibuprofen, and tramadol dispensed in smart pill (Pillsy) bottles that record "events" corresponding to medication use. Patients received messages querying their current pain level. Patients were compared to historical controls. RESULTS: 26 patients were in the Pillsy group and 30 in the control group. In the Pillsy group, pain scores averaged 3.67 out of 10 in the first 24 h after surgery and decreased each day. Patients took an average of 6.45 doses of acetaminophen, 6.64 doses of ibuprofen, and 1.82 doses of tramadol in the first week. CONCLUSIONS: Pain scores are highest in the first 24 h after surgery and decrease thereafter. This acceptable level of pain can be achieved with non-opioid medications.

Risk Stratification of Acute Invasive Fungal Rhinosinusitis in Patients With Hematologic Pathology.

OBJECTIVE: The purpose of this study is to identify objective perioperative diagnostic factors for acute invasive fungal rhinosinusitis (AIFS) to create a diagnostic scoring system using objective criteria. METHODS: Retrospective case-control study performed at an academic, tertiary care center. Biopsy-proven cases of AIFS identified from pathology records (2015-2019) were compared to patients the otolaryngology service was consulted to "Rule out AIFS" in the year 2019, only including those with underlying hematologic malignancy. Eighteen patients with AIFS and 20 patients without were included. One and two tailed T-tests were used for p-values. Receiver operating characteristic curves were generated for the significant data, and Youden's J-statistic was used to create the ideal cutoff values for each. Likelihood ratios were used to give a power for the scoring system. RESULTS: Compared to patients with non-hematologic malignancy-related AIFS, patients with hematologic malignancy-related AIFS have significantly elevated C-reactive protein (CRP) and blood glucose; while albumin, hematocrit, platelet count, and absolute neutrophil count (ANC) were found to be significantly lower. In addition, Lund-Mackay score asymmetry, extra-sinus spread, aspergillus antigen, and pre-existing diabetes mellitus correlated with disease. A scoring system with three categories: AIFS Unlikely, Indeterminate/AIFS Suspicious, and AIFS Highly Likely was developed. CONCLUSION: Patients with hematologic malignancy-related AIFS have measurable differences in lab values and standard imaging that could be used in determining the diagnostic probability of AIFS including: CRP, albumin, hematocrit, platelets, ANC, blood glucose, aspergillus antigen, Lund-Mackay score asymmetry, extra-sinus spread, and pre-existing diabetes mellitus. A novel scoring system was proposed that will require prospective validation. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1059-1064, 2023.

A novel algorithm to reduce bias and improve the quality and diversity of residency interviewees.

Objective: Improve the quality and diversity of candidates invited for the Otolaryngology-Head and Neck Surgery residency match by reducing geographical and inter-rater bias with a novel geographic distribution algorithm. Methods: Interview applicants were divided into geographic regions and assigned to reviewers. Each reviewer selected by force-ranking a pre-determined number of applicants to invite for interviews based on the percentage of applications received for each region. Our novel geographic distribution algorithm was then applied to maintain the geographic representation and underrepresented minority status of invited applicants to match the applicant pool. Results: Analysis of previous interview selection methods demonstrated a statistically significant overrepresentation of local applicants invited for interviews. In 2022, 324 domestic applications were received for the otolaryngology match, which were divided into six geographic regions. There was no significant difference in USMLE scores between regions. The implementation of our distribution algorithm during applicant selection eliminated local overrepresentation in the invited pool of applicants and maintained the representation of underrepresented minority applicants. Following the match, reviewers indicated that implementation of the geographic distribution algorithm was simple and improved the quality and diversity of the group of interviewed applicants. Conclusion: Traditional methods of scoring and inviting otolaryngology residency applicants can be confounded by regional and inter-rater biases. Employing a geographic distribution algorithm improves the quality and diversity of invited applicants, eliminates bias, and maintains the representation of underrepresented minority applicants.

Postoperative and 1-Year Functional Outcomes After Free Flap Surgery Among Patients 80 Years or Older.

OBJECTIVE: To evaluate the postoperative and 1-year functional outcomes after free flap surgery among patients ≥80 years old. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care center. METHODS: We conducted a retrospective review of 596 patients who underwent head and neck ablation and reconstruction with free tissue over a 7-year period. Patients ≥80 years of age were included. RESULTS: Fifty patients were ≥80 years old, with an average age of 83.7 years. Ninety-day mortality was 12.0%, and those who died were of older age (87.5 vs 83.1 years, P = .036). Prior radiation therapy (odds ratio, 6.8 [95% CI, 1.1-42.7]) and a Charlson Comorbidity Index ≥3 (odds ratio, 10.0 [95% CI, 1.5-67.0]) were associated with an increased risk of 90-day mortality. Overall 21 (42.0%) patients experienced a 30-day complication; 7 (14.0%) were readmitted within 30 days; and 5 (10.0%) underwent additional flap-related operations. Flap failure occurred in 2 (4.0%) patients. Before surgery, 45 (90%) patients were living independently or within assisted living; among these, 19.5% declined to dependent functional status at 90-day follow-up. At 90 days, 2 (8.3%) of 24 patients remained tracheostomy dependent, and 20 (66.7%) of 30 patients required feeding tube supplementation. Among 42 patients, 36 (85.7%) had unrestricted or modified oral diets at 90 days. Charlson Comorbidity Index ≥2 was associated with an increased risk of 1-year mortality (odds ratio, 5.1 [95% CI, 1.4-18.6]). CONCLUSION: The potential for functional decline and risk of 90-day mortality should be discussed with patients aged ≥80 years.

Breast and thyroid cancer: A multicenter study with Accrual to Clinical Trials Network.

OBJECTIVE: To investigate a possible link between breast and thyroid cancer. METHODS: A multicenter retrospective review of patients in the electronic medical records of six Accrual to Clinical Trial (ACT) institutions with both breast cancer and thyroid carcinoma. Each center queried its data using a predefined data dictionary. Information on thyroid and breast cancer included dates of diagnosis, histology, and patient demographics. RESULTS: A random-effects model was used. There were 4.24 million women's records screened, 44 605 with breast cancer and 11 846 with thyroid cancer. The relative risks observed at each institution ranged from 0.49 to 13.47. The combined risk ratio (RR) estimate was 1.77 (95% confidence interval: 0.50-5.18). CONCLUSION: There was no association between the risk of developing thyroid cancer and being a breast cancer survivor compared to no history of breast cancer, but the range of relative risks among the participating institutions was wide. Our findings warrant further study of more institutions with larger sample size. Additionally, further analysis of the significance of regional RR differences may be enlightening.

Comparative Morbidity Profile of Elective vs Therapeutic Neck Dissection.

OBJECTIVE: Neck dissection (ND) is one of the most commonly performed procedures in head and neck surgery. We sought to compare the morbidity of elective ND (END) versus therapeutic ND (TND). STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary care center. METHODS: Retrospective chart review of 373 NDs performed from January 2015 to December 2018. Patients with radical ND or inadequate chart documentation were excluded. Demographics, clinicopathologic data, complications, and sacrificed structures during ND were retrieved. Statistical analysis was performed with χ2 and analysis of variance for comparison of categorical and continuous variables, respectively, with statistical alpha set a 0.05. RESULTS: Patients examined consisted of 224 males (60%) with a mean age of 60 years. TND accounted for 79% (n = 296) as compared with 21% (n = 77) for END. Other than a significantly higher history of radiation (37% vs 7%, P < .001) and endocrine pathology (34% vs 2.6%, P < .001) in the TND group, no significant differences in demographics were found between the therapeutic and elective groups. A significantly higher rate of structure sacrifice and extranodal extension within the TND group was noted to hold in overall and subgroup comparisons. No significant difference in rate of surgical complications was appreciated between groups in overall or subgroup analysis. CONCLUSION: While the significantly higher rate of structure sacrifice among the TND population represents an increased morbidity profile in these patients, no significant difference was found in the rate of surgical complications between groups. The significant difference seen between groups regarding history of radiation and endocrine pathology likely represents selection bias.

Vascularity Outcomes of Lingual Artery Ligation in Transoral Robotic Base of Tongue Resections.

To explore the effect of lingual artery ligation on tongue vascularity, we performed an analysis of 25 patients who underwent transoral robotic surgery for base of tongue cancers (May 2011 to December 2019). Hounsfield units of the intrinsic muscles (IMs) and genioglossus muscles (GGs) were measured in postoperative imaging (mean 4 months) as a surrogate for vascularity. In ligated patients (n = 15), the values from the ligated/resected side of the tongue were compared with the contralateral side and the nonligated side of resection. Individually, IMs and GGs on the ligated side demonstrated no significant difference to the contralateral side (P = .662 and .618, respectively). Ligation produced a significant decrease in IM measurements but no difference between GG values vs nonligated patients (P = .050 and .818, respectively). No difference was appreciated in mean values for combined IMs and GGs between cohorts (P = .212). No gross tongue atrophy or complications were incurred. Future studies are warranted to delineate long-term effects.

Association of Continuous Intraoperative Vasopressor Use With Reoperation Rates in Head and Neck Free-Flap Reconstruction.

Importance: Continuous vasopressor use in free-flap reconstruction is a point of contention among microvascular surgeons despite data demonstrating safety. Objective: To investigate the association between continuous vasopressor use and the incidence of reoperation in the early postoperative period. Design, Setting, and Participants: In this cohort study, a retrospective medical record review was conducted of patients who underwent head and neck free-flap reconstructions between May 1, 2014, and October 31, 2019, in an academic tertiary care center. All patients undergoing free-flap reconstruction for head and neck defects were included. Exposures: Continuous intraoperative vasopressors. Main Outcomes and Measures: Patient medical records were queried for demographic variables; intraoperative use of vasopressors; vasopressor type, duration, and infusion rate; reoperation within the first 5 postoperative days; and reason for reoperation. Results: Four hundred forty-nine consecutive free-flap reconstructions were performed on 426 patients. The mean age was 62 years (IQR, 55.7-71.1); 293 patients were men (65.3%), 380 were White (84.6%), 55 were Black (12.2%), and 14 were of other race or ethnicity (3.1%). A total of 174 patients received a continuous vasopressor during their reconstruction. Twenty-three reoperations occurred within 5 days postoperatively, 8 of which included vasopressors during initial intervention. Vasopressor type had no association with reoperation (4.5% vs 5.5% [8/174 vs 15/275, respectively] for patients who received vasopressors vs those who did not) (dobutamine odds ratio [OR], 1.02 [95% CI, 0.21-2.91]; dopamine OR, 1.48 [95% CI, 0.33-4.26]). No difference was seen in the duration (dobutamine OR, 1.50 [95% CI, 0.78-2.90]; dopamine OR, 0.87 [95% CI, 0.59-1.28]) or infusion rate (dobutamine OR, 1.50 [95% CI, 0.99-1.02]; dopamine OR, 1.00 [95% CI, 0.99-1.01]) of vasopressors between patients who underwent reoperation and those who did not. Analysis after the exclusion of reasons for reoperation that did not represent possible microvascular anastomosis failure (eg, Doppler malfunction, donor site complications) showed no increased propensity for reoperation (OR, 1.18; 95% CI, 0.27-3.9). Conclusions and Relevance: In this cohort study, use of vasopressors for extensive periods intraoperatively during free-tissue transfer appeared to have no association with the rate of reoperation within 5 days of intervention, regardless of agent used, simultaneous use of agents, type of free-flap operation performed, or reason for reoperation. This study adds to the body of literature supporting the judicious use of vasopressors in patients requiring intraoperative pharmacological pressure support during free-flap reconstruction.

Preemptive Utilization of Anterior Belly of the Digastric Muscle Flaps in Transoral Robotic Radical Tonsillectomy.

OBJECTIVE: To demonstrate the use of an anterior belly of the digastric muscle flap (ABDMF) during transoral robotic radical tonsillectomy (TORRT) with concomitant neck dissection with the intent of preventing the formation of postoperative pharyngocutaneous fistulas. STUDY DESIGN: Retrospective study. SETTING: Single academic tertiary care center. METHODS: In this study, all patients were included who underwent TORRT plus limited pharyngectomy with concomitant neck dissection and ABDMF for the treatment of oropharyngeal squamous cell carcinoma between September 2012 and September 2020. The rate of fistula formation was assessed in patients with preemptive utilization of ABDMF. RESULTS: A total of 43 patients underwent TORRT with neck dissection and ABDMF. No patients developed a fistula in the postoperative period or associated morbidity with the use of this flap. CONCLUSION: Preemptive use of ABDMF in TORRT with concomitant neck dissection represents a reconstructive option that may help prevent the formation of pharyngocutaneous fistula by reinforcing the posteroinferior boundary of the parapharyngeal space.

Utility of intraoperative digital scintigraphy in radioguided parathyroidectomy.

BACKGROUND: Intraoperative scintigraphy (IoS) has been proposed as a tool for real-time intraoperative decision-making regarding parathyroid adenoma localization and confirmation of excision. METHODS: Retrospective review of patients who underwent minimally invasive parathyroidectomies with scintigraphy performed intraoperatively. Preoperative neck ultrasound, 4D computed tomography, as well as intraoperative parathyroid hormone (IOPTH) and gamma probe measurements were conducted per standard practice. IoS images were obtained prior to and following parathyroid excision. Cases were reviewed to determine accuracy of IoS for localizing parathyroid pathology and confirming successful excision. RESULTS: Fifty-six cases met the inclusion criteria. Twenty-nine patients (51.8%) showed confirmation of excision of an abnormal gland on post-excision IoS. There were no significant differences in IOPTH reduction and postoperative laboratory values between patients with IoS-identified resolution and those without IoS-identified resolution. CONCLUSIONS: With low accuracy in correctly localizing abnormal glands and confirming their excision, there is no appreciable benefit of IoS at this time.

Perioperative Indicators of Prognosis in Acute Invasive Fungal Sinusitis.

OBJECTIVE: The purpose of this study is to identify perioperative independent prognostic factors that are available to the consulting team to aid in determining prognosis in patients with acute invasive fungal sinusitis. STUDY DESIGN: Retrospective chart review of patients with biopsy-proven acute invasive fungal sinusitis from 2015 to 2018. SETTING: Academic tertiary care center. METHODS: Twenty-one patients were included from our single-center retrospective review. Kaplan-Meier graphs were created, and the Breslow test used to compare the curves to obtain P values. A univariate Cox regression analysis was performed on the data that were significant at 3 months from diagnosis. RESULTS: Twenty-one patients were included, and 17 (76%) had an underlying hematologic malignancy. Overall survival was 71% and 52% at 1 and 3 months, respectively, and 94% of patients with hematologic malignancy had an absolute neutrophil count ≤1 at diagnosis. Absolute neutrophil count values and fungal species were not associated with a difference in prognosis. Factors associated with decreased survival included current smoking and the absence of a rhinologist on the treatment team at the initial or subsequent debridement (hazard ratio, 3.03). Laboratory values such as beta-D-glucan and galactomannan were assessed in addition to disease extension at diagnosis. CONCLUSION: This study presents a retrospective review of a single institution's experience with acute invasive fungal sinusitis. Subspecialty level of care likely improves overall survival in these patients, whereas current smoking may imply a worse prognosis.

Predictors for Postoperative Chyle Leak Following Neck Dissection, a Technique-Based Comparison.

OBJECTIVE: Assess the impact of surgical technique used to address level IV on the rate of postoperative chyle leak. STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary care center. METHODS: An analysis of 436 consecutive neck dissections (NDs) in 368 patients was performed by 3 head and neck surgeons between 2014 and 2017. Variation in technique reflects individual approaches to the management of level IV and included suture ligation (SL), monopolar electrocautery (MC), and harmonic scalpel transection (HS). Data points included patient demographics, surgical technique, intraoperative findings, postoperative chyle leaks, and leak management. Correlation between variables was analyzed through χ2 test and Student t test with statistical α set at .05. RESULTS: Overall, 12 patients (3.2%) developed chyle leaks postoperatively. Nine of 12 and 3 of 12 presented with left- and right-sided leaks, respectively. Five of 12 leaks occurred following bilateral ND, 5 of 12 following left ND, and 2 of 12 following right ND. Univariate analysis showed a statistically significant difference (P = .001) favoring SL (1.0%) and MC (1.2%) techniques over the HS technique (8.6%). A statistically significant increase existed in the rate of leak with endocrine vs nonendocrine pathology (P = .003). Average duration of leak was 13.3 ± 13.5 days. Management included diet modification (n = 11, 91.6%), pressure-dressing placement (n = 7, 58.3%), and octreotide (n = 5, 41.7%). No cases required reoperation, and no mortality or severe malnutrition was observed in this series. CONCLUSIONS: SL and MC techniques demonstrated superiority over the HS technique in preventative management of chyle leak in level IV, with a significantly higher rate of chyle leak observed in endocrine-related pathology.

The Utility of the Cl:PO4 Ratio in Patients With Variant Versions of Primary Hyperparathyroidism.

OBJECTIVE: To determine the significance and impact of additional chloride testing as part of a diagnostic laboratory test battery for borderline primary hyperparathyroidism (pHPT). STUDY DESIGN: Retrospective database review of parathyroidectomy patients. SETTING: A tertiary care, academic health sciences center. SUBJECTS AND METHODS: Patients referred to a head and neck endocrine clinic for evaluation and treatment for pHPT. RESULTS: After exclusions, there were a total of 226 patients who underwent parathyroidectomy for primary hyperparathyroidism with the requisite preoperative and postoperative labs. Seventy-seven additional patients who had a thyroid operation for a nonmalignant cause were included as controls. Of the 303 total patients, 166 had normal calcium levels (<10.4 mg/dL), and 54 (32.5%) also exhibited hyperchloremia (>106 mmol/L). Of the 47 patients with normal calcium and parathyroid hormone (PTH) levels (<88 pg/mL), 6 (12.8%) had hyperchloremia, and of the 118 patients with normocalcemic pHPT, 48 (40.7%) were hyperchloremic. The area under the curve for the Cl:PO4 was 0.712. When using a cutoff of 33, the reported sensitivity and specificity of the curve were 58.4% and 28.6%, respectively. CONCLUSION: The Cl:PO4 ratio was a moderately sensitive test for the diagnosis of the borderline variants of primary hyperparathyroidism. The Ca:PO4 ratio was superior to the Cl:PO4 ratio. Our data also showed the superiority of preoperative calcium and ionized calcium over PTH when predicting the presence of pHPT.

Operative and postoperative outcomes in elderly patients undergoing endoscopic sinus surgery.

PURPOSE: Chronic rhinosinusitis (CRS) is increasingly common in the elderly population (≥ 65 years old). Compared to their younger counterparts, differences exist in the etiology of CRS and outcomes of Endoscopic Sinus Surgery (ESS) for elderly patients. The aim of this study is to determine if differences in surgical outcomes are present between these two patient populations to facilitate patient pre-operative counseling by their healthcare providers. METHODS: Retrospective chart review conducted at a single tertiary care center for patients undergoing ESS between June 2014 and June 2019. Patients were classified into two cohorts (adult and elderly) based on age (< 65 and ≥ 65 years old). Demographics, surgical, and postoperative variables were extracted from our institution's electronic medical records. ANOVA and t-test analysis were performed to determine the presence of significant differences between the two cohorts. SNOT-22 scores were used to determine QOL improvements. RESULTS: Compared to the adult cohort, elderly patients had significant QOL improvement after surgical treatment (p = 0.001), but had a similar successful response to treatment (p = 0.74). Elderly patients had no difference in the incidence of operative/perioperative complications (p = 0.89) or intraoperative or postoperative bleeding (p = 0.301, p = 0.62), but had an increased incidence of postoperative infection (p = 0.000). CONCLUSION: ESS remains an effective treatment modality for the management of CRS, and a safe practice for elderly patients despite the increase in complexity of their medical comorbidities and polypharmacy. QOL improvements are significant, though patient counseling should take into account that improvements may not be as pronounced as in younger patients.