The total amount of fluid administered is associated with postoperative complications in head and neck cancer surgery.

Objective: Patients with head and neck cancer often undergo extensive ablative and reconstructive surgery. Many risk factors are unalterable, but some operative variables are possible to adjust. The goal of this study was to estimate the association between operative variables and the incidence of perioperative complications in a contemporary tertiary care university-based head and neck patient population and a Veteran Administration hospital head and neck patient population from an earlier time period. Methods: We retrospectively reviewed all patients who underwent major head and neck surgery. Results: Two-hundred-two university patients and 122 veteran patients were reviewed. On multivariable analysis, the total amount of intravenous (IV) fluid received during the procedure was associated with postoperative complications as were patients' weight, American Society of Anesthesiologists (ASA) score, and adult comorbidity evaluation-27 (ACE-27) score. These associations did not depend on whether the patient was treated at the university or veteran hospital. Conclusion: Our study suggests that the odds of a postoperative complication increase as the total amount of IV fluid increases.

Free Flap Outcomes for Head and Neck Surgery in Patients with COVID-19.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state. METHODS: This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022. RESULTS: Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period. CONCLUSION: Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 2023.

Current practices regarding middle turbinate resection among otolaryngologists.

Objectives: Resection of the middle turbinate (MT) during endoscopic sinus surgery (ESS) has been a controversial topic among otolaryngologists for many years. Some studies advocate resection and have shown improved outcomes postoperatively, while studies favoring preservation show a decreased incidence of postoperative complications. The current practice pattern regarding this subject is unknown. The goal of this study was to learn the current practice of MT resection during ESS among otolaryngologists. Method: We performed an electronic anonymous survey of practicing otolaryngologists. Results: We found that the majority of the 252 responders stated that they will perform an MT resection in certain clinical situations, while there is a small subset that advocates never resecting the MT for inflammatory sinus disease (n = 6, 2.4%). Participants were significantly more likely to perform MT resection in patients undergoing revision compared to primary ESS for all conditions included. The complication of greatest concern among participants was iatrogenic frontal sinus obstruction, while empty nose was of the least concern. The majority of participants responded that MT resection was of extreme or moderate benefit for improved visualization and drug delivery postoperatively. When compared to general otolaryngologists, fellowship-trained rhinologists were less concerned about potential complications following MT resection and were more likely to perceive an extreme or moderate benefit from turbinate resection postoperatively. Conclusion: There remains debate over MT resection among otolaryngologists, but the results of this study show that the majority of participating otolaryngologists will perform a resection in certain clinical situations.

Risk Factors for Recurrence and the Role of Radiotherapy in Low-grade Myofibroblastic Sarcoma: A Systematic Review.

Low-grade myofibroblastic sarcoma (LGMS) is a rare malignancy that commonly occurs in the head and neck region. The role of radiotherapy has been unclear in treating LGMS and the risk factors for recurrence have remained undefined. The objective of this study is to determine risk factors for the recurrence of LGMS in the head and neck as well as the role of radiotherapy in the treatment of LGMS. A comprehensive review of the literature was performed through Pubmed leading to the inclusion of 36 articles after our inclusion and exclusion criteria were applied. Continuous variables were analyzed with a 2-tail unpaired t test. Categorical variables were assessed with the χ 2 test or Fisher exact test. Logistic regression and multivariable logistic regression analysis with 95% CIs were used to obtain odds ratios. LGMS most commonly occurred in the oral cavity (49.2%). Half of all recurrences occurred in the paranasal sinuses/skull base. LGMS occurring at the paranasal sinuses/skull base had a significantly increased risk of recurrence compared with other subsites within the head and neck (odds ratio: -40; 95% CI: 2.190, 762.005; P = 0.013). The average time to recurrence of LGMS was 19.2 months. Adjuvant treatment with radiation did not improve recurrence rates. Sex, tumor size, or bony involvement were not found as risk factors for recurrence. Patients with LGMS of the paranasal sinuses and skull base are at high risk for recurrence and should be monitored closely. The role of adjuvant radiation treatment in these patients remains unclear.

Assessing the Risk of Adjuvant Radiotherapy Initiation Delays With Social Support Surveys.

OBJECTIVE: In patients with head and neck squamous cell carcinoma (HNSCC), initiating postoperative radiotherapy (PORT) greater than 42 days after surgery is associated with a higher risk of poor survival outcomes. Social support has been shown to modulate behaviors related to care-seeking and treatment adherence. In this study, we sought to determine the relationship between social support metrics and PORT delays. STUDY DESIGN: Prospective cohort study. SETTING: Single tertiary medical center. METHODS: Patients with HNSCC who underwent primary surgical excision requiring PORT were prospectively enrolled. Patient-perceived social support metrics were assessed using the Medical Outcomes Study Social Support Survey (MOS-SSS) at initial presurgical evaluation. Associations with PORT delays were evaluated via univariable and multivariable logistic regression analysis. RESULTS: A total of 111 patients met the inclusion criteria for the study. An additional 28 patients were recommended to receive PORT but did not initiate treatment and were included for secondary analysis. All four subscales of the MOS-SSS (positive social interaction, affectionate support, tangible support, and emotional/informational support) were significantly associated with PORT initiation delays on univariable analysis. On multivariable analysis, the overall MOS-SSS score (odds ratio [OR] 2.08, 1.15-4.35, p = .028) was significantly associated with PORT initiation delays. On secondary analysis, lower tangible support was associated with a lack of PORT initiation (OR 1.63, 1.05-2.54, p = .028). CONCLUSION: Social support metrics were significantly associated with PORT delays, which may help promote tighter scheduling and closer monitoring of high-risk patients.

Relationship Between Worst Pattern of Invasion and Extranodal Extension in Oral Tongue Squamous Cell Carcinomas.

BACKGROUND: Oral tongue squamous cell carcinoma (OTSCC) is a common malignancy of the oral cavity with poor survival rates. The aim of this project is to investigate the relationship between certain histopathological factors such as Worst Pattern of Invasion (WPOI) and Extranodal Extension (ENE) in patients with oral tongue squamous cell carcinoma (OTSCC) who underwent surgical resection at Loyola University Medical Center. METHODS: This was a retrospective cohort study at a tertiary care academic medical center. All patients that underwent primary surgical resection of OTSCC between 1/1/2015 and 1/1/2022 were reviewed. Patients were identified using the Cerner CoPath Laboratory Information System. RESULTS: A total of 82 patients met inclusion criteria and were included in the study. Higher grades of WPOI (WPOI 5) were not significantly associated with the presence of ENE in our study (P = 0.82), regardless of the presence of major or minor ENE. WPOI 5 was associated with a higher incidence of local recurrence (P = 0.011). CONCLUSIONS: Higher grades of WPOI were not found to correlate with the presence of ENE, a common histopathological factor that is used as an important prognostic indicator in OTSCC. It is important for clinicians to consider these factors separately when determining whether a patient is high-risk and would benefit from aggressive multimodal treatment.

Idiopathic Facial Vein Aneurysm: A Case Report and Review of the Literature.

Venous aneurysms of the head and neck, and in particular the facial vein, are rare lesions that present as soft, compressible masses. We describe a case of an idiopathic aneurysm of the facial vein. A comprehensive literature review of this entity was conducted to better understand the disease process. A 51-year-old female presented with a one-year history of a prominent but painless right submandibular mass that was more noticeable with maneuvers such as straining. An exam showed a painless, soft, compressible, right level 1b neck mass that enlarged with Valsalva. A computed tomography scan of the neck revealed a 2.7 cm enhancing mass adjacent to the right submandibular gland. Further workup included a direct puncture venography, which demonstrated an unruptured 3 cm venous aneurysm involving the right facial vein. Surgical excision was offered to the patient, which was completed without complications. Histopathology of the mass was consistent with a facial vein aneurysm and confirmed the suspected diagnosis. The patient was seen postoperatively in follow-up and was healing well. While facial vein aneurysms are rare, it is important to recognize, work up, and treat them appropriately. A painless compressible mass that enlarges with Valsalva is suggestive of the diagnosis. Management may vary on a case-by-case basis with surgical resection being the definitive treatment of choice.

Prognostic Implications of Skin Invasion in Locally Advanced Oral Cavity Squamous Cell Carcinoma.

OBJECTIVE: To evaluate the effect of histopathologic skin invasion on 2- and 5-year disease-free survival (DFS) and overall survival (OS) in patients treated with primary surgery for locally advanced oral cavity squamous cell carcinoma (OCSCC). STUDY DESIGN: A retrospective case-control study was performed comparing previously untreated patients with pT4a OCSCC with and without skin invasion. SETTING: Academic medical center. METHODS: Propensity score-matched cohorts were derived by age, sex, surgical margins, pathologic N classification, adjuvant treatment, and primary tumor site. The Kaplan-Meier method was used to evaluate 2- and 5-year OS and DFS, which were compared between cohorts via the log rank (Mantel-Cox) test statistic. RESULTS: Overall 25 patients were identified to have pathologic skin invasion, and 50 were selected for the matched control group. OS was significantly lower for patients with skin invasion as compared with controls at 2 years (30.8% vs 53.3%, P = .018) and 5 years (16.6% vs 42.2%, P = .01). DFS was significantly lower for patients with skin invasion vs controls at 2 years (23.7% vs 47.7, P = .037) and 5 years (15.8% vs 41.4%, P = .024). CONCLUSION: Histopathologic skin invasion in OCSCC is associated with dismal prognosis in patients who underwent primary surgical treatment. OS outcomes for patients with skin invasion are comparable to survival of patients with recurrent/metastatic disease and T4N2 disease.

A Case of Panophthalmitis Secondary to Odontogenic Maxillary Sinusitis.

Endogenous endophthalmitis is a bacterial or fungal infection within the eye that includes the vitreous and aqueous humors. Panophthalmitis is a subtype of endogenous endophthalmitis that also includes infection of the adjacent soft tissue of the orbit. We present a case of a 91-year-old female who initially presented with left eye pain and decreased vision. She was found to have panophthalmitis secondary to odontogenic maxillary sinusitis. To our knowledge, there has not been a case reported in the literature before that has established this association between panophthalmitis and odontogenic maxillary sinusitis.

Assessment of conditions leading to lost-to-follow-up of head and neck cancer patients.

PURPOSE: Head and neck cancer patients require close clinical follow up to monitor and address sequelae of treatment and for adequate cancer surveillance. The goal of this study is to determine barriers and risk factors for head and neck cancer patients who are lost-to-follow-up. MATERIALS AND METHODS: A chart review of the Head and Neck Cancer Registry was performed to identify patients who were lost-to-follow-up (LTF). LTF was defined as missing two consecutive appointments as recommended by their oncologic surgeon. Those identified as LTF were contacted via email and phone to complete a 16-question survey addressing possible barriers to follow up. RESULTS: Of the 353 patients reviewed, 53 met the criteria for LTF (15%). Forty-eight participants were contacted, and 23 surveys were completed (48%). Of the 23 patients that responded, 22% reported difficulty scheduling an appointment, 30% had transportation barriers, 22% had personal or work obligations that prevented follow up, 17% did not follow up because they "felt better," and 39% were following up with an otolaryngologist or oncologist closer to home. Only three participants (13%) were aware of the recommended 5-year surveillance period. CONCLUSION: Head and neck cancer patients have a variety of reasons they are lost to follow-up. Understanding these barriers is critical to creating a patient-centered model that balances both clinical surveillance needs and reasonable expectations for patients. Improvements can be made to educate patients on the recommended length of follow-up and its importance.

Salvage Total Laryngectomy Swallowing Outcomes Based on Flap Reconstruction: Onlay vs Incorporated Technique.

After a salvage total laryngectomy, one of patients' primary goals is to resume oral intake. This retrospective chart review included all patients who underwent a salvage total laryngectomy with free or pedicled flap reconstruction to compare swallowing outcomes in those with an incorporated flap or primary pharyngeal closure with an onlay flap. There was no significant difference in the ability to achieve complete feeding tube independence or the time that it took to achieve independence. Patients with an onlay flap had significantly lower rates of subjective dysphagia and stricture as compared with patients with incorporated flaps. Incorporated fasciocutaneous flaps showed no significant difference from onlay flaps in terms of outcomes. However, incorporated musculocutaneous flaps showed higher rates of subjective dysphagia and stricture when compared with onlay flaps. Patients undergoing a salvage total laryngectomy and reconstruction with an onlay flap had significantly less postoperative dysphagia and stricture than patients with a musculocutaneous incorporated flap.

Long-Term Outcome and Role of Biology within Risk-Adapted Treatment Strategies: The Austrian Neuroblastoma Trial A-NB94.

We evaluated long-term outcome and genomic profiles in the Austrian Neuroblastoma Trial A-NB94 which applied a risk-adapted strategy of treatment (RAST) using stage, age and MYCN amplification (MNA) status for stratification. RAST ranged from surgery only to intensity-adjusted chemotherapy, single or multiple courses of high-dose chemotherapy (HDT) followed by autologous stem cell rescue depending on response to induction chemotherapy, and irradiation to the primary tumor site. Segmental chromosomal alterations (SCAs) were investigated retrospectively using multi- and pan-genomic techniques. The A-NB94 trial enrolled 163 patients. Patients with localized disease had an excellent ten-year (10y) event free survival (EFS) and overall survival (OS) of 99 ± 1% and 93 ± 2% whilst it was 80 ± 13% and 90 ± 9% for infants with stage 4S and for infants with stage 4 non-MNA disease both 83 ± 15%. Stage 4 patients either >12 months or ≤12 months but with MNA had a 10y-EFS and OS of 45 ± 8% and 47 ± 8%, respectively. SCAs were present in increasing frequencies according to stage and age: in 29% of localized tumors but in 92% of stage 4 tumors (p < 0.001), and in 39% of patients ≤ 12 months but in 63% of patients > 12 months (p < 0.001). RAST successfully reduced chemotherapy exposure in low- and intermediate-risk patients with excellent long-term results while the outcome of high-risk disease met contemporary trials.

Sigmoid Sinus Patency following Vestibular Schwannoma Resection via Retrosigmoid versus Translabyrinthine Approach.

Introduction The treatment options for acoustic neuromas are observation with serial imaging, stereotactic radiation, or surgical resection. The most common surgical approaches are the translabyrinthine (TL), the retrosigmoid (RS), and the middle cranial fossa. During the TL approach the sigmoid sinus is decompressed with bipolar cautery to allow greater medial exposure. It is unknown if this causes any long-term narrowing or thrombus of the sigmoid sinus. Methods We performed a retrospective review of patients who underwent acoustic neuroma resection to determine if patients undergoing a TL approach for acoustic neuroma resection develop radiographic evidence of sigmoid sinus stenosis or thrombosis compared with patients undergoing a RS approach. Results A total of 128 patients were included in this study, 56 patients underwent a TL approach and 72 patients underwent a RS approach. We compared the preoperative and postoperative diameter of the ipsilateral and contralateral sigmoid sinus at proximal, midpoint, and distal locations on magnetic resonance imaging examinations. There was no significant difference between the preoperative and postoperative diameter of the ipsilateral or contralateral sigmoid sinus based on surgical approach. Conclusion Decompression of the sigmoid sinus during the TL approach does not have a significant postoperative effect on the dural venous sinus patency.

Tarik Syndrome: Reversible Postoperative Blindness Secondary to Occipital Seizures.

BACKGROUND: Postoperative blindness is a devastating surgical complication. Although usually associated with prolonged cardiac and prone spinal operations, it may follow other procedures as well. Postoperative blindness is most commonly caused by a vascular etiology, but it can more rarely be caused by status epilepticus. We have previously reported a case of this phenomenon following a staged spinal deformity surgery. CASE DESCRIPTION: Here we report 2 additional cases following a skull base procedure and a single stage lumbar spine surgery. In all instances, rapid recognition that the patients' blindness was due to occipital seizures resulted in acute antiepileptiform treatment and full restoration of vision. CONCLUSIONS: Although a rare phenomenon, this syndrome, first recognized and described by Tarik F. Ibrahim, should be considered in any patient with postoperative visual impairment.

Oral tongue cancer in a patient with hereditary nonpolyposis colorectal cancer: A case report and review of the literature.

Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant disorder characterized by mutations of mismatch repair genes leading to the early development of multiple malignancies. The most common malignancy is colorectal cancer but there is a strong association with malignancies of the ovary, endometrium, small intestine, stomach, skin, brain, and pancreas. We report a case of a 35-year-old female with a history of known HNPCC who presented with adenocarcinoma of the small intestine as well as a synchronous oral tongue squamous cell carcinoma. The patient underwent a combined oncologic surgery involving a hemiglossectomy, selective neck dissection, and partial small bowel resection. Despite the wide range of malignancies seen in patients with HNPCC, no cases of oral cavity cancer have previously been reported. This represents the first case in the literature of oral cavity cancer in a patient with HNPCC.

Postoperative Tachycardia in Head and Neck Microvascular Free Flap Patients.

OBJECTIVE: The goal of this study was to determine the incidence of postoperative tachycardia and its predictive value of complications in patients following microvascular free flap surgery in the head and neck. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care academic medical center. SUBJECTS AND METHODS: All patients who underwent a microvascular free flap of the head and neck by surgeons in the department of otolaryngology from 2013 to 2017 were included in this study. RESULTS: Of the 344 who patients met inclusion criteria, 40.4% had a maximum heart rate (HR) of the hospitalization over 110 beats per minute (bpm). Patients with a maximum HR greater than 110 bpm were 19 times more likely to experience a composite vascular complication (myocardial infarction, myocardial necrosis, or pulmonary embolism) than patients with a maximum HR <110 bpm ( P = .0063). Patients with a history of chronic kidney disease were also noted to have an increased risk of experiencing a postoperative composite vascular event. CONCLUSION: Postoperative tachycardia is significantly associated with adverse outcomes and should not be dismissed as a normal variant. Identifying patients at an increased risk of having an underlying complication can help guide interpretation, workup, and management of postoperative patients in the head and neck population.

Body Mass Index and Parotidectomy Outcomes.

Multiple specialties have demonstrated increased risk of certain postoperative complications in patients with an increased body mass index (BMI). The goal of this study was to understand the outcomes of patients undergoing parotidectomy with an increased BMI and to identify any other patient risk factors for postoperative complications. This study was a retrospective chart review of 432 patients. Patient variables collected included BMI, age, gender, history of diabetes mellitus, type of parotidectomy, and pathology. Outcomes reviewed included facial nerve weakness, hematoma or seroma formation, and wound infection. The results showed that BMI had no statistically significant effect on complications. However, patients undergoing a total parotidectomy, malignant pathology, and patients with a history of diabetes mellitus had significantly more postoperative facial weakness. In conclusion, BMI does not influence postoperative complications in patients undergoing parotidectomy. Patients with diabetes, those undergoing total parotidectomies, and patients with malignant pathology have significantly more facial weakness and should be counseled accordingly.

Safety and Efficacy of Outpatient Parotidectomy.

PURPOSE: Given the increasing costs of medical care, there has been a shift to outpatient elective surgeries in certain patient populations among all surgical specialties. The goal of this study was to compare the safety and efficacy of outpatient parotidectomy with traditional inpatient parotidectomy. MATERIALS AND METHODS: This is a retrospective chart review of all patients who underwent a parotidectomy at a single tertiary academic center from 2007 through 2017. RESULTS: There were 568 patients who met the inclusion criteria. There was no difference in demographics or patient comorbidities between the inpatient and outpatient groups. There was no increased incidence of postoperative complications or extent of postoperative care in patients who underwent outpatient parotidectomy. On average at the authors' institution, the direct outpatient parotidectomy cost was $1,200 less than the inpatient equivalent. CONCLUSION: Outpatient parotidectomy can be performed safely and cost effectively with no increased risk of complications.

Neurological Complications of Acute and Chronic Sinusitis.

PURPOSE OF REVIEW: Acute and chronic sinusitis can give rise to a wide array of intracranial and orbital complications. These complications include brain abscess, subdural empyema, epidural abscess, meningitis, venous sinus thrombosis, frontal bone osteomyelitis, and orbital cellulitis and abscess. Despite numerous medical advances, these complications carry a risk of mortality and significant morbidity. RECENT FINDINGS: Recent studies have shown improvement in both the mortality and the morbidity associated with the neurologic complications of acute and chronic sinusitis. However, there are still a large portion of patients with long-term sequelae, and the literature reports a morbidity rate of approximately 30%. The most common post-treatment morbidities include permanent changes in vision, seizures, and hemiparesis. Although the overall incidence of neurologic complications from a sinogenic source are rare, the potential long-term complications can be devastating making prompt diagnosis and treatment vital to improving outcomes.

Impact of Disseminated Neuroblastoma Cells on the Identification of the Relapse-Seeding Clone.

Purpose: Tumor relapse is the most frequent cause of death in stage 4 neuroblastomas. Since genomic information on the relapse precursor cells could guide targeted therapy, our aim was to find the most appropriate tissue for identifying relapse-seeding clones.Experimental design: We analyzed 10 geographically and temporally separated samples of a single patient by SNP array and validated the data in 154 stage 4 patients.Results: In the case study, aberrations unique to certain tissues and time points were evident besides concordant aberrations shared by all samples. Diagnostic bone marrow-derived disseminated tumor cells (DTCs) as well as the metastatic tumor and DTCs at relapse displayed a 1q deletion, not detected in any of the seven primary tumor samples. In the validation cohort, the frequency of 1q deletion was 17.8%, 10%, and 27.5% in the diagnostic DTCs, diagnostic tumors, and DTCs at relapse, respectively. This aberration was significantly associated with 19q and ATRX deletions. We observed a significant increased likelihood of an adverse event in the presence of 19q deletion in the diagnostic DTCs.Conclusions: Different frequencies of 1q and 19q deletions in the primary tumors as compared with DTCs, their relatively high frequency at relapse, and their effect on event-free survival (19q deletion) indicate the relevance of analyzing diagnostic DTCs. Our data support the hypothesis of a branched clonal evolution and a parallel progression of primary and metastatic tumor cells. Therefore, searching for biomarkers to identify the relapse-seeding clone should involve diagnostic DTCs alongside the tumor tissue. Clin Cancer Res; 23(15); 4224-32. ©2017 AACR.