Near-total mandibular reconstruction following osteoradionecrosis with double scapula tip free flap: A case report.

Near-total mandibular reconstruction poses many challenges to reconstructive surgeons. The purpose of this article is to present a challenging case in a patient with osteoradionecrosis of the mandible requiring a near-total mandibular reconstruction using bilateral scapula tip free tissue reconstruction. A 68-year-old African-American male with a history of T2N0M0 squamous cell carcinoma of the tonsil presented with advanced stage osteoradionecrosis of the mandible. Reconstruction was planned using 3D Systems (Denver, CO), mandibular osteotomies were planned inferior to the sigmoid notch on the ascending rami. Neither fibula flap was amenable for harvesting due to poor vasculature of the patient's lower extremities, and bilateral scapula tip free flaps were subsequently planned. The post-operative course was complicated by venous congestion in the right scapula flap which required revision to the venous anastomosis on POD 1. The patient had intraoral breakdown that required debridement in the operating room and application of a cellular matrix. The patient fully recovered from the acute surgery and was discharged home without a tracheostomy. At the last follow up visit, the patient was taking 100% of diet peroral and had no signs of oral incompetence, mental projection was satisfactory, and the ability to verbally communicate was unimpaired. We report a complex case of near-total mandibular reconstruction using simultaneous bilateral scapula tip free flaps. While we do not advocate simultaneous bilateral scapula tip free flaps as the standard of care for large mandibulectomy defects, it may be considered for patients in which traditional osseous free flaps are not available.

Enhancing nasal endoscopy: Classification, detection, and segmentation of anatomic landmarks using a convolutional neural network.

KEY POINTS: A convolutional neural network (CNN)-based model can accurately localize and segment turbinates in images obtained during nasal endoscopy (NE). This model represents a starting point for algorithms that comprehensively interpret NE findings.

Features of Importance in Nasal Endoscopy: Deriving a Meaningful Framework.

OBJECTIVE: Critical components of the nasal endoscopic examination have not been definitively established for either the normal examination or for clinical disorders. This study aimed to identify concordance among rhinologists regarding the importance of examination findings for various nasal pathologies. STUDY DESIGN: A consortium of 19 expert rhinologists across the United States was asked to rank the importance of findings on nasal endoscopy for 5 different sinonasal symptom presentations. SETTING: An online questionnaire was distributed in July 2023. METHODS: The questionnaire utilized JotForm® software and featured 5 cases with a set of 4 identical questions per case, each covering a common indication for nasal endoscopy. Rankings were synthesized into Normalized Attention Scores (NASs) and Weighted Normalized Attention Scores (W-NASs) to represent the perceived importance of each feature, scaled from 0 to 1. RESULTS: General concordance was found for examination findings on nasal endoscopy within each case. The perceived features of importance differed between cases based on clinical presentation. For instance, in evaluating postnasal drip, the middle meatus was selected as the most important structure to examine (NAS, 0.73), with mucus selected as the most important abnormal finding (W-NAS, 0.66). The primary feature of interest for mucus was whether it was purulent or not (W-NAS, 0.67). Similar analyses were performed for features in each case. CONCLUSION: The implicit framework existing among rhinologists may help standardize examinations and improve diagnostic accuracy, augment the instruction of trainees, and inform the development of artificially intelligent algorithms to enhance clinical decision-making during nasal endoscopy.

Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction.

OBJECTIVES: Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time. METHODS: Retrospective chart review of patients receiving STFF from January 2014-January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18). RESULTS: Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to -54% (median -0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption. CONCLUSIONS: STFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2597-2602, 2023.

Symptom Localization May Differentiate Subtypes of Eustachian Tube Dysfunction.

OBJECTIVE: To evaluate the predictive ability of symptom self-localization to distinguish obstructive eustachian tube dysfunction from non-obstructive salpingitis. METHODS: Adult (age ≥18 years) patients with a primary complaint of aural discomfort who underwent diagnostic nasal endoscopy and tympanometry at a tertiary academic center were enrolled. Symptoms were self-localized by using a single finger on the affected side. All patients completed the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and underwent scoring of eustachian tube inflammation using the Endoscopic Evaluation of the Eustachian Tube (3ET) system. RESULTS: Seventy-three patients were included in the study. Symptoms were localized to the external auditory canal (EAC) in 28 (38.4%), to the infratemporal fossa (ITF) below the lobule in 37 (50.7%), and to the preauricular region in 8 (11.0%). Demographics and medical history were similar between groups. The EAC group had significantly more negative tympanometric peak pressure (TPP) (median, -92.0 daPa; IQR, 95.5) and higher 3ET scores. In contrast, the ITF group had normal TPP (median, -2.0 daPa; IQR, 7.0) and higher 3ET scores. The preauricular group was more likely to have temporomandibular joint or pterygoid muscle pain. ETDQ-7 scores did not differ significantly between groups. CONCLUSION: Symptom localization is associated with specific objective findings in the evaluation of aural discomfort. Patients with pain localizing to the ITF are more likely to have findings of eustachian tube salpingitis without obstruction whereas patients with symptoms deep in the EAC are more likely to have findings consistent with obstructive eustachian tube dysfunction. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1818-1823, 2023.

Reconstruction of oral cavity defects using myogenous-only scapular tip free-flaps.

Background: Oral cavity reconstruction is very challenging anatomical subsite to reconstruct. Large defects often require free tissue reconstruction to provide the best chance of form and function. Additionally, free tissue reconstruction aids to prevent fistula formation. We aimed to determine outcomes of oral cavity defect reconstruction using scapular tip free flaps with a myogenous intraoral component. Methods: All patients with a mandibular or maxillary bony defect that included a disruption of the intraoral mucosa component between 07/1/14 and 07/31/17. Patients were reconstructed with a scapular tip free flap, which included a muscular component that was used to recreate the oral mucosa. The primary study outcomes were flap success rates, development of orocutaneous or oronasal fistula, rate of resuming oral diet as well as the occurrence of medical and surgical complications in the first month following surgery. The tested hypothesis was formulated before data collection began. Results: Twenty-five patients were identified by the study criteria. There was one (4%) flap that failed, while orocutaneous fistula occurred in two patients (8%). Prior history of osteoradionecrosis was a statistically significant predictor of overall complication (p < .05). Conclusions: Intraoral myogenous reconstruction allows for re-mucosalization of the oral cavity defect and is associated with high viability and low-complication rates. In patients with amenable oral mucosal defects, a myogenous scapular tip free flap is a suitable reconstructive option.

Knowledge Gaps among Patients and Providers in HPV-Related Oropharyngeal Cancer: A Systematic Review.

OBJECTIVE: To describe the level of knowledge of human papillomavirus (HPV) and HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) among the general population and health care providers. DATA SOURCES: Systematic search was performed on December 20, 2018, using MEDLINE (1966 to December 2018), EMBASE (1975 to December 2018), Web of Science (1900 to December 2018), and CENTRAL (1996 to December 2018) databases. English-language literature involving human subjects was used, and studies were limited to case series, case-control, cohort, and randomized controlled trial designs. REVIEW METHODS: Studies were included if they assessed knowledge of HPV and HPV-associated OPSCC. The primary outcome measure was the knowledge of HPV-associated OPSCC among the general population and with health care providers. Meta-analysis of proportions was attempted using random-effects model. The PRISMA guidelines were used for accuracy of reporting. RESULTS: Thirty-two studies were included with 17,288 participants. There was a high degree of heterogeneity preventing completion of a meta-analysis. Knowledge of HPV and HPV-associated OPSCC varied between the general population and health care providers. The proportion of the general population and health care providers with knowledge of HPV ranged from 16% to 75% and 21% to 84%, respectively. Knowledge of HPV-associated OPSCC was greater in health care providers and ranged from 22% to 100% compared with the general population, which ranged from 7% to 57%. CONCLUSION: There is a knowledge gap of HPV-associated OPSCC for both the general population and health care providers. Additional education may not only increase awareness but may also result in prevention and earlier detection.

Intramuscular Corticosteroids for Acute Upper Respiratory Infections Affects Healthcare Utilization.

OBJECTIVE: To examine the use of intramuscular corticosteroid (IMCS) injections for treatment of acute upper respiratory infections (URI) and the influence on healthcare utilization. METHODS: This retrospective cohort study used patient encounter data from a large multicenter regional health care system between 2013 and 2017. Adult patients diagnosed with acute URI (acute pharyngitis, acute sinusitis, acute otitis media, and URI not otherwise specified) during ambulatory encounters were included. Follow-up encounters for a diagnosis of acute URI within 60 days were identified and patient characteristics, encounter details, and procedure codes were retrieved. Frequency data was used to calculate IMCS injection administration prevalence, utilization trends, and associations with covariates. Follow-up data for return encounters within 60 days for the same diagnosis was examined. RESULTS: Of the 153 848 initial encounters, 34 600 (22.5%) patients received IMCS injection for acute URI. Injection rates varied from 0.85% to 49.1% depending on specialty and practitioner type. Internal medicine, family medicine, urgent care, and otorhinolaryngology clinics most commonly administered IMCS. 3788 patients returned for a second encounter of which 751 (19.8%) received an injection. IMCS injection during the first encounter was associated with increased odds of repeat visit within 60 days (OR: 1.74; 95% CI: 1.61-1.88). CONCLUSION: IMCS use in the treatment of acute URI is highly prevalent despite lack of evidence for impact and safety. Prevalence is variable across multiple medical and surgical specialties including otorhinolaryngology. Administration of IMCS injection may contribute to the likelihood of a subsequent healthcare visit for the same indication.

Management of Rhinitis Medicamentosa: A Systematic Review.

OBJECTIVE: Rhinitis medicamentosa (RM) is a common condition resulting from overuse of topical nasal decongestants. Despite the prevalence in otolaryngologic practice, a clear treatment protocol has not been established. Our objective was to review the current published literature pertaining to the treatment of RM with the possibility of finding data that support one treatment over another. DATA SOURCES: PubMed, Embase, Cochrane, and Web of Science databases were examined for patients diagnosed with RM resulting from chronic use of topical nasal decongestants. REVIEW METHODS: The PRISMA standard (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was utilized to identify English-language studies reporting treatment of patients with the primary diagnosis of RM after chronic use of a topical decongestant. Outcome measures of interest included patient-reported symptom relief and objective parameters. MINORS criteria (methodological index for nonrandomized studies) were used to assess the quality of articles. RESULTS: A total of 350 articles were identified, 9 of which met final inclusion criteria for qualitative analysis. Outcomes defined in each publication were highly varied and relied on several unstandardized measures. The most commonly reported treatment option was topical nasal steroids, although overall there was limited evidence on which to base treatment recommendation. CONCLUSIONS: There is not adequate evidence to develop a standardized treatment protocol for RM. The development of a uniform questionnaire, standard outcomes to be measured, and a method of assessing such outcomes is necessary. Prospective randomized controlled studies are warranted to determine the optimal treatment regimen following diagnosis of RM.

Delayed Metastatic Melanoma to the Pharyngeal Tonsil in an African American Female.

Background: Metastatic melanoma to the mucosa of the upper aerodigestive tract is extremely rare, accounting for <0.6% of known metastasis to the head and neck region. We present a case of delayed metastatic melanoma to the pharyngeal tonsil. Case Report: A 57-year-old African American female presented for evaluation of a rapidly enlarging unilateral tonsil mass. Three years prior to presentation, she had undergone primary resection of and systemic therapy for cutaneous melanoma on the sole of her right foot. Tonsillectomy confirmed the diagnosis of metastatic melanoma. Because of the poor prognosis of the disease, the patient was referred for palliative chemotherapy but died shortly after beginning treatment. Conclusion: Metastatic melanoma is a rare disease in African Americans, and the presence of metastatic lesions is a significant prognostic indicator for long-term patient survival. Meticulous head and neck examinations should be performed during the follow-up period, and any pigmented lesion should have a high suspicion for metastasis in any patient with a history of cutaneous melanoma.

Intraoperative Cryoanalgesia for Reducing Post-Tonsillectomy Pain: A Systemic Review.

OBJECTIVE: Summarize the effectiveness of intraoperative cryoanalgesia in the management of postoperative pain among patients undergoing palatine tonsillectomy. METHODS: A systematic review of PubMED, MEDLINE, EMBASE, Google Scholar, and Cochrane trial registries was performed through January 2017 using the PRISMA standards. We included English-language randomized controlled trials evaluating patients of all age groups with benign pathology who underwent tonsillectomy with cryoanalgesia versus without. RESULTS: Three limited quality randomized controlled trials involving 153 participants (age range, 1-60 years) were included. Cryoanalgesia was performed with a cryotherapy probe (-56°C) in 1 trial and ice-water cooling (4°C to 10°C) in 2. In the 3 trials reviewed, patients who received cryoanalgesia reported 21.38%, 28.33%, and 31.53% less average relative postoperative pain than controls on the visual analog scale. Review of secondary outcomes suggested no significant difference in time to resume normal diet (2 studies) or postoperative bleeding (2 studies) between the 2 groups. Cryoanalgesia allowed patients to return to work 4 days earlier than controls in 1 study. Two studies reported a trend toward less postoperative analgesia use among the treatment group; however, no statistical conclusions could be drawn. CONCLUSION: The available evidence suggests that patients undergoing tonsillectomy with cryoanalgesia experience less average postoperative pain without additional complications.

Association of Continued Preoperative Aspirin Use and Bleeding Complications in Patients Undergoing Thyroid Surgery.

IMPORTANCE: No evidence exists to direct the management of preoperative aspirin (acetylsalicylic acid) use in patients undergoing thyroid surgery. Nevertheless, a considerable number of patients interrupt receiving aspirin therapy during the preoperative period to minimize bleeding complications despite the increased risk of experiencing major adverse cardiac events. OBJECTIVE: To determine whether aspirin therapy continued preoperatively increases bleeding complications in patients undergoing thyroid surgery. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a consecutive sample of 570 patients, aged 18 to 100 years, who underwent thyroid surgery for benign and malignant disease from January 1, 2010, to December 31, 2015, by a single surgeon at a tertiary referral hospital center in New Orleans, Louisiana. EXPOSURES: Patients receiving aspirin therapy and patients not receiving aspirin therapy (aspirin naive) preoperatively. MAIN OUTCOMES AND MEASURES: Comparison of estimated blood loss, substantial blood loss, operative hematoma, nonoperative hematoma, and recurrent laryngeal nerve injury. RESULTS: Of 570 patients who underwent thyroid surgery, 106 (18.6%) were performed in patients receiving aspirin; of these, 23 (21.7%) were men and 105 (99.1%) were older than 45 years. Those receiving aspirin therapy displayed a 14.4-year difference in age (95% CI, 11.6-17.1). The aspirin group displayed a 20.3% absolute increase (95% CI, 9.3-30.7) in African American patients. Aspirin therapy was not associated with a statistically significant or clinically meaningful increase in intraoperative blood loss (2.5 mL; 95% CI, -0.4 to 5.3). Aspirin therapy was associated with a statistically significant increase in total hematoma formation (3.3%; 95% CI, 0.4-9.0), but the results were inconclusive. Aspirin therapy was not associated with a statistically significant increase in recurrent laryngeal nerve injury (2.6%; 95% CI, -1.1 to 8.6), but the results were inconclusive. CONCLUSIONS AND RELEVANCE: These results suggest that aspirin therapy can be maintained prior to thyroid surgery without increased intraoperative bleeding. Further research with a larger sample size and more outcome events are required to make definitive conclusions regarding the association between aspirin use and complications, including hematoma and recurrent laryngeal nerve injury.

The Submental Island Flap Is a Viable Reconstructive Option for a Variety of Head and Neck Ablative Defects.

BACKGROUND: The submental island flap (SIF) is a pedicled flap based upon the submental artery and vein. Its utility in reconstruction following ablative head and neck procedures has been applied to various subsites including skin, lip, buccal mucosa, retromolar trigone, parotidectomy defects, and tongue. We review our experience using the SIF for reconstruction following tumor ablation. METHODS: This prospective case series with medical record review includes consecutive patients undergoing SIF reconstruction following ablative surgery for malignancy at a single tertiary care facility between November 2014 and November 2016. We examined preoperative variables, surgical procedures, and postoperative outcomes. RESULTS: Thirty-seven patients met inclusion criteria. Twenty-nine were male; the average age was 64.3 (±12.4) years. Seventeen cancers involved the oral cavity, 11 involved the skin, 8 were in the oropharynx, and 1 was in the paranasal sinus. The average size of the SIF was 38.8 cm2 (±17.6 cm2). Four partial flap losses occurred; none required revision surgery. The average length of stay for these patients was 7.2 (±6.1) days. CONCLUSION: The SIF is a robust flap that can be reliably used for a variety of head and neck defects following tumor ablation with an acceptable rate of donor- and flap-related complications.

Pharmacotherapy for Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema: A Systematic Review.

Objective Angioedema is a potentially life-threatening complication of angiotensin-converting enzyme inhibitor (ACEI) use, occurring in up to 0.5% of users. Although the pathophysiology of ACEI-induced angioedema is attributable to elevated serum bradykinin, standard management typically includes corticosteroids and antihistamines. We sought to summarize the evidence supporting pharmacotherapy for ACEI-induced angioedema. Data Sources PubMed, MEDLINE, and Embase portals. Methods A systematic literature review was conducted according to the PRISMA guidelines. Databases were queried by 3 independent reviewers for English-language studies published between 1980 and 2017. The initial search screened for all occurrences of "angioedema" and then was further refined to include studies of ACEI-related cases and exclude hereditary angioedema. Results Five articles representing 218 cases were identified, including 3 randomized controlled trials and 2 prospective case series with historical controls. One of 2 studies of icatibant (bradykinin B2 receptor antagonist) found more rapid symptom improvement than that with a control group of corticosteroids and antihistamines. Two studies of ecallantide (plasma kallikrein inhibitor) and 1 study of C1 inhibitor replacement found no significant benefit over control. No studies were identified that compared the efficacy of corticosteroids with antihistamines, of one dose with another, of fresh frozen plasma, or of combination therapy. Conclusion The efficacy of treatment of ACEI-induced angioedema with bradykinin antagonists, kallikrein inhibitor, and C1 inhibitor warrants further study. Although consistent benefit of these medications has not been demonstrated, their use has not caused harm. One study examining off-label use of icatibant has demonstrated efficacy over control. In addition, further study is needed to establish the efficacy and mechanism of action of standard pharmacotherapy such as corticosteroids and antihistamines in treatment of this condition.

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review.

OBJECTIVE: Postoperative use of anticoagulation after free tissue transfer in head and neck ablative procedures is common practice, but a clear protocol has not been well established. The outcome measures including total flap failure, thrombosis, and hematoma formation for different anticoagulation regimens in free tissue transfer in the head and neck were reviewed. DATA SOURCES: PubMed, Ovid, and Cochrane databases were examined for patients who underwent free tissue transfer following head and neck ablative procedures. REVIEW METHODS: Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting anticoagulation regimens following free tissue transfer in head and neck ablative procedures. Outcomes included total flap failure, thrombosis, and hematoma formation. Two independent reviewers assessed the quality of the articles by using the Methodological Index for Non-Randomized Studies. RESULTS: A total of 368 articles were identified. An additional 36 articles were identified through screening of reference lists. Twenty-one of these studies met final inclusion criteria for qualitative analysis. Outcome data on total flap failure, thrombosis, and hematoma formation were extracted and analyzed for comparison against all anticoagulation regimens. Total flap failure, thrombosis, and hematoma formation rates were 4.4%, 4.5%, and 2.2%, respectively. Individual study rates ranged from 0.0% to 10.7%, 0.0% to 10.4%, and 0.6% to 7.2%, respectively. CONCLUSIONS: There is not adequate evidence to develop a standardized anticoagulation protocol for head and neck free flap procedures. Comparable flap complications were reported between all the employed anticoagulation methods studied, though significant variability in study design among articles existed. Prospective, randomized studies are warranted to determine the optimal postoperative anticoagulation regimen following free tissue transfer of the head and neck. Laryngoscope, 128:412-421, 2018.

Minimum lymph node yield in elective level I-III neck dissection.

OBJECTIVES/HYPOTHESIS: Unlike lymphadenectomy at other sites, there is no discrete lymph node count defining an adequate neck dissection. The purpose of this study was to determine the minimum lymph node yield (LNY) of an elective level I-III neck dissection required to reliably capture any positive nodes present in these nodal basins. STUDY DESIGN: Retrospective single-institution analysis. METHODS: All patients with the diagnosis of head and neck squamous cell carcinoma who underwent elective level I-III neck dissection between 2004 and 2015 at our institution were analyzed. Preoperatively, patients had no clinical or radiographic evidence of lymphadenopathy. Patients with unknown number of lymph nodes on pathology report were excluded. Age, gender, race, history of radiation, tumor subsite, stage, surgeon, LNY, and number of positive nodes were recorded; bilateral neck dissections were reported separately. RESULTS: One hundred eighteen level I-III neck dissections met criteria and were included in the study. Mean LNY was 21.15, and metastatic disease was present in 24.5% of cases, with 8.4% of cases being N2. The highest portion of positive lymph nodes was present in the group with 18 to 24 lymph nodes (36%), which was significantly higher than the group with <18 (14.89%) (P = .044). CONCLUSIONS: Although there is no accepted minimum for LNY in level I-III neck dissection, at least 18 nodes may be considered an adequate LNY. Such a yield reliably allows for capture of occult disease within these nodal basins. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2070-2073, 2017.

Invasive Insular Thyroid Carcinoma Presenting as Nonparalytic Dysphonia.

BACKGROUND: Patients with suspected thyroid malignancy often undergo preoperative laryngeal examination with a focus on vocal fold mobility. We present the unique case of a patient with invasive thyroid carcinoma who presented with dysphonia despite intact vocal fold motion. CASE REPORT: A 73-year-old female with a remote thyroid lobectomy presented with dysphonia. Thyroid ultrasound and fine-needle aspiration revealed a 1.1-cm nodule consistent with a colloid cyst. Videostroboscopy demonstrated mild laryngeal stenosis at the glottis and infraglottis with no evidence of paralysis. After failed medical therapy, the patient underwent microlaryngoscopy with biopsy of her infraglottic fullness, with histopathology reporting squamous epithelium without nucelar atypia. After several weeks of worsening dysphonia and persistent infraglottic fullness, she underwent repeat microlaryngoscopy with biopsy. On postoperative day 1, she developed dyspnea and stridor refractory to maximal medical management. To secure the airway, she underwent an awake tracheostomy, during which the thyroid isthmus was found to be densely adherent to the larynx. Histopathology identified insular thyroid carcinoma. Subsequent imaging confirmed a large, invasive thyroid tumor. Further workup revealed metastases to the bone and liver. The patient underwent a successful palliative resection of the thyroid followed by neck radiation and received palliative spinal surgery with adjuvant radiation. A clinical trial of vandetanib was initiated but withdrawn because of myelosuppression. She deferred any further treatment and was alive with few symptoms despite persistent disease 1.5 years after initial diagnosis. CONCLUSION: Physicians should consider the diagnosis of invasive thyroid carcinoma in a dysphonic patient with an infiltrative endolaryngeal process despite intact vocal fold mobility.

NSQIP as a Predictor of Length of Stay in Patients Undergoing Free Flap Reconstruction.

OBJECTIVE: The National Surgical Quality Improvement Program (NSQIP) calculator was created to improve outcomes and guide cost-effective care in surgery. Patients with head and neck cancer (HNC) undergo ablative and free flap reconstructive surgery with prolonged postoperative courses. METHODS: A case series with chart review was performed on 50 consecutive patients with HNC undergoing ablative and reconstructive free flap surgery from October 2014 to March 2016 at a tertiary care center. Comorbidities and intraoperative and postoperative variables were collected. Predicted length of stay was tabulated with the NSQIP calculator. RESULTS: Thirty-five patients (70%) were male. The mean (SD) age was 67.2 (13.4) years. The mean (SD) length of stay (LOS) was 13.5 (10.3) days. The mean (SD) NSQIP-predicted LOS was 10.3 (2.2) days (P = .027). DISCUSSION: The NSQIP calculator may be an inadequate predictor for LOS in patients with HNC undergoing free flap surgery. Additional study is necessary to determine the accuracy of this tool in this patient population. IMPLICATIONS FOR PRACTICE: Head and neck surgeons performing free flap reconstructive surgery following tumor ablation may find that the NSQIP risk calculator underestimates the LOS in this population.

Blunt Cerebrovascular Injury in Cervical Spine Fractures: Are More-Liberal Screening Criteria Warranted?

Study Design Retrospective comparative study. Objective To compare strict Biffl criteria to more-liberal criteria for computed tomography angiography (CTA) when screening for blunt cerebrovascular injury (BCVI). Methods All CTAs performed for blunt injury between 2009 and 2011 at our institution were reviewed. All patients with cervical spine fractures who were evaluated with CTA were included; patients with penetrating trauma and atraumatic reasons for imaging were excluded. We then categorized the patients' fractures based on the indications for CTA as either within or outside Biffl criteria. For included subjects, the percentage of studies ordered for loose versus strict Biffl criteria and the resulting incidences of BCVI were determined. Results During our study period, 1,000 CTAs were performed, of which 251 met inclusion criteria. Of the injuries, 192 met Biffl criteria (76%). Forty-nine were found to have BCVIs (19.5%). Forty-one injuries were related to fractures meeting Biffl criteria (21.4%), and 8 were related to fractures not meeting those criteria (13.6%). The relative risk of a patient with a Biffl criteria cervical spine injury having a vascular injury compared with those imaged outside of Biffl criteria was 1.57 (p = 0.19). Conclusions Our data demonstrates that although cervical spine injuries identified by the Biffl criteria trend toward a higher likelihood of concomitant BCVI (21.4%), a significant incidence of 13.6% also exists within the non-Biffl fracture cohort. As a result, a more-liberal screening than proposed by Biffl may be warranted.