Sphenoid Sinus Giant Cell Tumor: A Case Report and Literature Review.

We describe a 27-year-old female with a giant cell tumor of her sphenoid sinus, presenting with nasal obstruction and cranial neuropathies. Both the surgical and subsequent medical management are reviewed. Additionally, we review the overall presentation, pathophysiology, and management of giant cell tumors of the skull base. Current treatment recommendations are presented.

Anatomical Variations of the Superficial Radial Nerve Encountered during Radial Forearm Free Flap Elevation.

A frequently encountered anatomical structure in the elevation of a radial forearm free flap is the superficial branch of the radial nerve. This structure has a relatively consistent anatomic location, but variations do occur. We present a case where the superficial branch of the radial nerve was in an usual position but remained superficial to the brachioradialis throughout its course. Two previous reports also describe the superficial branch of the radial nerve remaining superficial to the brachioradialis, although, in these reports, the nerve was more medial than is typical. We postulate that one of the most common anatomic variations of the superficial branch of the radial nerve is for it to remain superficial to the brachioradialis. As this variation could potentially be confused with the medial or lateral antebrachial cutaneous nerves, it is important for the reconstructive surgeon to be aware of this to prevent inadvertent injury.

Superficial Temporal Versus Cervical Recipient Vessels in Maxillary and Midface Free Vascularized Tissue Reconstruction: Our 14-Year Experience.

PURPOSE: The aims of this study are to review our surgical experience in maxillary and midface reconstruction using free vascularized tissue and to compare the postoperative outcomes based on superficial temporal versus cervical recipient vessels. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent maxillary and midface reconstruction with free vascularized tissue from March 2001 to July 2014. Two groups were analyzed: those in whom superficial temporal vessels were used as the recipient vessels and those in whom cervical vessels were used as the recipient vessels. Patient gender and age, cause and classification of the defect, flap choice for reconstruction, recipient vessels, postoperative course, and complications also were recorded and analyzed. A 2-tailed Fisher exact test was used to compare outcomes between the 2 groups. RESULTS: On the basis of the different recipient vessels, 94 patients were divided into 2 groups: those with superficial temporal recipient vessels (n = 44) and those with cervical recipient vessels (n = 50). The overall flap survival rate was 99.0%. The overall complication rate for vascular anastomoses was 5.3%. The complication rate in patients with cervical recipient vessels was higher than the complication rate in those with superficial temporal recipient vessels (8.0% vs 2.27%, P = .37). In addition, in patients in the group with superficial temporal recipient vessels, the postoperative scar in the pre-tragal region was rated as more satisfactory than the postsurgical scar in those in the cervical recipient vessel group. CONCLUSIONS: We recommend that the superficial temporal vessels be the first option for recipient vessels in free vascularized tissue maxillary and midface reconstruction because of proximity, superficial positioning, and suitability for anastomosis and monitoring and because these vessels are rarely compromised by prior operations or radiotherapy.

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

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

Profunda Artery Perforator Flaps From the Posteromedial Region of the Thigh for Head and Neck Reconstruction.

OBJECTIVE: Profunda femoris artery perforator flaps (PAPFs) have not been widely used in head and neck reconstructions. The feasibility and outcomes of PAPFs for various head and neck reconstructions need to be investigated. STUDY DESIGN: Retrospective analysis. SETTING: A single-institution review. METHODS: PAPFs were utilized in head and neck reconstructions from 2019 to 2021. Local anatomy, surgical technique, and complications were discussed. Chimeric PAPF applications with muscle components were described for coverage of extensive multiunit defects. Additionally, aesthetic and functional outcomes were compared with anterolateral thigh perforator flaps. RESULTS: A total of 33 cases were included. The average age was 54.2 years (range, 30-74). The most common underlying pathology was oral squamous cell carcinoma (n = 26, 78.8%), while the mean ± SD body mass index was 25.4 ± 2.8 kg/m2 . Middle perforators (n = 14, 42.4%) were the most commonly utilized ones. The perforator-based chimeric/composite applications were used in 9 (27.3%), with the muscular components consisting of gracilis (n = 3, 9.1%), adductor magnus (n = 5, 15.2%), or semimembranosus muscles (n = 1, 3.0%). Venous thromboses of the PAPFs were found in 2 (6.1%), though salvaged. The occurrence of postoperative 90-day morbidity (complication) was related to mandibulectomy/maxillectomy (P = .020). Postoperative validated questionnaires showed a trend of intermediate to high scores, indicating noninferior outcomes in several categories, when compared with the anterolateral thigh perforator flap counterparts. CONCLUSION: PAPFs are a good reconstructive alternative for intermediate to large head and neck reconstructions. Besides, PAPFs can provide sufficient tissue volume and versatility of potentially incorporating adjacent muscle components.

Thyroid Abscess: A Case Series and Literature Review.

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

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

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

Transverse cervical artery anterior perforator flap for head and neck oncological reconstruction: Preliminary study.

BACKGROUND: To describe the indications, technique, and our experience in the application of the transverse cervical artery anterior perforator flap (ap-TCAF) for reconstruction of head and neck oncological defects. METHODS: From September 2016 to September 2019, 11 patients underwent surgical treatment for head neck squamous cell carcinoma and were subsequently reconstructed with ap-TCAFs. The clinical details were recorded, and the postoperative appearance and function were analyzed. RESULTS: The ap-TCAF was used to reconstruct intraoral defects in eight patients and to repair an oropharyngeal defect in one patient. In two remaining patients, the ap-TCAF was divided into two to restore defects with both an intraoral and extraoral component. The flap size ranged from 6 × 4 cm to 15 × 9 cm. All flaps healed uneventfully. There was no delayed wound healing or dysfunction at the donor site. CONCLUSIONS: The ap-TCAF is reliable with characteristics making it useful for head and neck oncological reconstruction, especially in male patients.

A novel application of superior thyroid artery perforator flaps for medium-sized intraoral reconstructions: Retrospective analysis of 12 cases.

BACKGROUND: To describe the indications, technique, and preliminary experience in the application of the superior thyroid artery perforator flap (STAPF) for the reconstruction of various medium-sized intraoral defects. METHODS: From September 2018 to September 2019, 12 consecutive cases of oral squamous cell carcinoma underwent reconstruction with a STAPF. Clinical details were collected, and postoperative function was analyzed. RESULTS: The venous drainage of the STAPF is variable with drainage into the internal jugular vein in six cases, into both the internal and external jugular veins in four cases, and into the external jugular vein in two cases. Ten cases were harvested as pedicled flaps, while two cases required a venous anastomosis due to inadequate length of the venous pedicle. Ten flaps survived completely, whereas two flaps had partial necrosis that ultimately resolved with secondary healing. CONCLUSIONS: STAPF is a reliable method for the reconstruction of medium-sized intraoral defects.

Awake thyroidectomy.

OBJECTIVE: In this article, we present a series of 28 patients who underwent thyroid surgery using local anesthesia. We describe our technique, report outcomes, and assess how well the procedure was tolerated from a patient perspective. METHODS: Three surgeons performed awake thyroidectomies and recorded data, including the patient's age and gender, surgery being performed, operative time, weight of the surgical specimen, quantity and type of local anesthetic used, additional medications, patient-reported pain assessment, and any complications. RESULTS: Twenty-seven of 28 patients (96%) successfully underwent awake thyroidectomy. One patient had to be converted to general anesthesia due to airway concerns. There were no complications; however, one patient had a panic attack. Based on a 0 to 10 scaled pain score, the average amount of pain reported was 3.4. The amount of pain the patient reported was significantly dependent on the amount of experience the operating surgeon had with this technique. Seventy-one percent of patients tolerated surgery with local anesthesia only and did not require additional medications. CONCLUSION: Awake thyroidectomy is a well-tolerated and safe procedure in appropriately selected patients, with many potential benefits over general anesthesia. In most cases, only local anesthesia is required. Increased experience with this technique may be associated with increased patient comfort. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:685-690, 2020.

A novel transpalatal-transoral robotic surgery approach to clival chordomas extending into the nasopharynx.

BACKGROUND: In this paper, we present three cases where a novel transoral robotic surgery (TORS) approach was used to resect clival chordomas extending into the nasopharynx to demonstrate progress in the evolution of robotic surgery of the head and neck. METHODS: The first patient had a history of metastatic chordoma resection and presented with trismus and dysphagia; the second and third patients had first presentation with nasal congestion and facial numbness, respectively. All patients underwent a novel transpalatal-TORS resection. RESULTS: Total resection was achieved in the first patient and near-total resections were achieved in the second and third patients. All patients had minimal postoperative morbidity and no patients experienced significant adverse events. CONCLUSION: Clival chordomas are rare, potentially dangerous lesions with a high rate of recurrence. The novel transpalatal-TORS approach to these tumors presented in this series represents advancement in the realm of minimally invasive surgery of the head and neck. This approach offers patients total or near-total control of these lesions with minimal intraoperative and postoperative side effects.

Postcricoid vascular abnormalities: hemangiomas, venous malformations, or anatomic variant.

OBJECTIVE: Ten children with pressure-dependent postcricoid masses (PDPCM) previously referred to in the literature as hemangiomas or vascular malformations are presented. We propose these lesions represent an anatomic variant. We review previously reported cases, and report the presentation, diagnosis, and management of the patients in our series, the largest series to date. METHODS: Ten patients, aged five weeks to nine months, were diagnosed, and treated or observed. Of the patients undergoing intervention, one was treated with a gastrostomy tube, fundoplication, and Propranolol therapy; and the other with CHARGE association underwent a tracheotomy. RESULTS: No PDPCMs demonstrated significant interval change in size or appearance, and eight of ten patients did well with observation. CONCLUSION: Based on current information, the majority of PDPCMs likely represent an anatomic variant rather than a hemangioma or vascular malformation. Diagnosis is most readily made with awake flexible fiberoptic laryngoscopy. Because the incidence of synchronous airway pathology is high, direct laryngoscopy and bronchoscopy without routine biopsy is recommended for symptomatic patients. Imaging should be individualized and may be helpful for ambiguous cases. Although numerous treatment modalities have been advocated based on the presumptive diagnosis of a hemangioma, treatment of PDPCMs is not necessary in the majority of cases, as most patients may be safely observed.

Reconstruction of complex nasal dorsal and sidewall defects: is the nasal sidewall subunit necessary?

OBJECTIVE: To demonstrate that by the extended use of cheek advancement flaps, the need to maintain the nasal dorsal side unit is obviated. DESIGN: Retrospective case series. SETTING: Tertiary care clinic and hospital. PATIENTS: Twelve patients aged 48 to 88 years who underwent Mohs micrographic surgery for nasal skin neoplasms, presenting with dorsal sidewall and nasal dorsal cutaneous defects. INTERVENTION: All patients underwent nasal reconstruction with adjacent tissue cheek advancement flaps with or without contralateral nasal dorsal and sidewall advancement flaps. MAIN OUTCOME MEASURES: Avoidance of ipsilateral nasal sidewall scars to allow a natural-appearing transition between the cheek and nose and avoidance of forehead flap morbidity. Results Satisfactory results were achieved in all but 1 patient who had partial flap necrosis. CONCLUSIONS: To maintain the nasal dorsal sidewall unit, superior, central dorsal, and nasal sidewall defects have traditionally been reconstructed using a variety of techniques, including skin grafts and regional flaps, such as glabellar flaps and frontal flaps. We demonstrate that creation of the nasal dorsal sidewall unit is often not necessary, and excellent results can be achieved through the expanded use of cheek advancement flaps.