Triple Layer Oronasal Fistula Repair Using Local Endonasal Flaps: Case Series of Three Patients.

Oronasal fistula (ONF) is a common complication encountered after palatoplasty. Repair is indicated when symptoms impact speech and swallowing. In spite of the variety of surgical approaches described to repair these defects, recurrence rates remain high. Traditionally, successful closure is said to be achieved in using a double-layered approach due to the three-dimensional aspect of the defect. The extent of the fistula into the nasal cavity has incited an increased curiosity in using local endonasal flaps. In recent years, endonasal reconstructive procedures have seen increased interest and application, from cranial base defect repairs to orbital reconstruction and beyond. The nasoseptal (NSF) and inferior turbinate flaps (ITF) possess a robust arterial supply and an exceptional reach with excellent results demonstrated in large defect repair. However, the use of these flaps in ONF repair is scarcely discussed in the literature, and their effectiveness is relatively undetermined. In this manuscript, we present a series of three patients who underwent a triple layer ONF closure, with the oral portion incorporating a turn-in mucosal flap plus a local palate rotation flap or greater palatine artery pedicled-rotation flap, and a NSF or an ITF for the nasal portion of the defect.

The posterior ligament of the incus ("white dot"): A reliable surgical landmark for the facial recess.

OBJECTIVE: There is a void in the literature describing reliable surgical landmarks that aid in the dissection of the facial recess in the absence of skeletonizing the mastoid segment of the facial nerve. The posterior ligament of the incus is a readily distinguishable "white dot" along the incus buttress that has been used to guide dissection in a safe and efficient manner. The goal of our study is to describe a surgical approach that utilizes this surgical landmark to drill the facial recess and to take anatomical measurements demonstrating the safety and reliability of this approach. MATERIALS AND METHODS: After cortical mastoidectomies were performed in 10 cadaveric temporal bones, the white dot was identified at the junction of short process of the incus and the incus buttress. Using the white dot for anatomical reference, a 2 mm diamond drill bit was used to open the facial recess without first identifying the facial nerve or chorda tympani nerve. After photographs were taken, the facial and chorda tympani nerves were definitively identified and skeletonized to delineate the confines of the facial recess. Photographs were once again acquired in a consistent manner for comparison. Finally, calibrated anatomic measurements were acquired from the 10 distinct image sets. RESULTS: The facial recess was successfully drilled in 10 temporal bones using the posterior ligament as a surgical landmark without injury to the chorda tympani or facial nerve. The median angle taken from the axis of the short process of the incus to the facial nerve - chorda tympani junction was 139.2° (IQR 136.8-141). At the widest point in the facial recess, median distances anterior and posterior to an imaginary line connecting the white dot to the facial nerve - chorda tympani junction were 1.6 mm (IQR 1.5-1.7) and 1.6 mm (IQR 1.6-1.7; p = 0.57), indicating at this point, the white dot reference reliably bisects the facial recess width. Similarly, at the level of the round window niche, median anterior and posterior distances from an imaginary line connecting the white dot to the facial nerve - chorda tympani junction were 1.1 mm (IQR 1.1-1.3) and 1.3 mm (IQR 1.1-1.7; p = 0.07), respectively, once again demonstrating the white dot reliably bisecting the facial recess. CONCLUSIONS: The white dot, representing the posterior ligament of the incus, is a reliable surgical landmark that aids in safe and efficient drilling of the facial recess without first skeletonizing the facial nerve.

Patterns of recurrence and disease progression in patients with positive-margin olfactory neuroblastoma following primary resection.

OBJECTIVE: Olfactory neuroblastoma (ONB) is a rare, malignant tumor of the sinonasal tract that arises from olfactory epithelium. Although surgery is the preferred first-line treatment, tumor involvement of adjacent structures may preclude the ability to achieve negative margins during initial resection. Herein, the authors examine the oncological outcomes of patients with positive margins after primary resection of ONB, with the aim of determining predictors of disease progression and patterns of recurrence. METHODS: The authors performed an institutional review of 25 patients with positive-margin ONB after resection. Cox survival analyses were used to determine any statistically significant predictors of worse progression-free survival (PFS) and overall survival (OS). RESULTS: A total of 93 patients who were diagnosed with ONB were identified, of whom 25 patients had positive margins following their primary resection. Eleven (44%) had a delayed finding of positive margins that were initially negative in the operating room but returned as positive on final pathology. Four patients had subtotal resection (STR), whereas the remaining patients underwent gross-total resection. Twenty-four patients received adjuvant radiotherapy (96%), and 15 additionally received adjuvant chemotherapy (60%). Fourteen patients (56%) experienced recurrence/progression at a median time of 35 months following resection (IQR 19-70 months). Local recurrence occurred in 10 patients (40%), regional in 9 (36%), and distant metastasis in 2 (8%). In Cox survival analyses, the 5-year PFS and OS were 55.1% and 79.2%, respectively. Kadish stage D was predictive of worse PFS in univariate (hazard ratio [HR] 15.67, 95% CI 3.38-72.61, p < 0.001) and multivariate (HR 15.46, 95% CI 1.45-164.91, p = 0.023) analyses. Hyams grade, adjuvant chemotherapy, and primary radiotherapy were not associated with PFS. Furthermore, Kadish stage D and STR were predictive of worse OS in univariate analysis (HR 12.64, 95% CI 2.03-78.86, p = 0.007; HR 7.31, 95% CI 1.45-36.84, p = 0.016; respectively). However, local and regional recurrence was not associated with worse OS. CONCLUSIONS: Approximately half of patients with positive-margin ONB may experience disease recurrence. Patients with an advanced disease stage (Kadish D) may have a higher likelihood of developing recurrence/progression. Furthermore, patients with tumor burden following resection (STR and Kadish D) may have worse OS. However, in positive-margin ONB with no gross disease following initial resection, the presence of disease recurrence does not significantly alter survival when receiving salvage therapy.

Radiographic predictors of occult intracranial involvement in olfactory neuroblastoma patients.

BACKGROUND: Traditional management of olfactory neuroblastoma (ONB) includes margin-negative resection with removal of cribriform plate, dura, and olfactory bulb, regardless of intracranial disease. This approach may be overtreating certain patients. Our investigation examines risk factors associated with occult intracranial disease to optimize therapeutic outcomes. METHODS: This retrospective, multi-institutional cohort study examined clinical covariates associated with occult intracranial involvement. Patient demographics, staging, Hyam's grade, and pathologic involvement of dura, olfactory bulb/tract, and brain were collected. Diagnostic imaging was reviewed. Positive and negative predictive value (NPV) were estimated along with effect size estimates. Cox hazard regression examined associations with overall survival (OS) and disease-free survival (DFS). RESULTS: A total of 224 subjects with new diagnoses of ONB (2005-2021) were identified. Skull base bone involvement on computed tomography (CT) had the highest NPV for pathologic dura (88.0%), olfactory bulb (88%), and brain involvement (97.3%). Hyam's grade category was significantly associated with dural involvement (φC  = 0.26; 95% confidence interval [CI]: 0.16, 0.42). Subjects without radiologic skull base involvement (n = 66) had pathologic positivity of 12.1%. Within this subgroup, Hyam's grade was clinically significant for dural positivity (φ = 0.34; 95% CI: -0.12, 0.71) with 28.6% involvement in high grade tumors. Neither clinical nor pathologic positivity of intracranial structures were associated with significantly different OS or DFS. CONCLUSIONS: Both CT and magnetic resonance imaging (MRI) had reasonably good NPV for involvement of dura and olfactory bulb. Higher Hyam's grade was associated with dural involvement. Patients with low-grade tumors not involving the skull base may be suitable for avoiding skull base resection; however, further investigation is warranted.

Real-Time Dual Video Conferencing of Simulated Tracheostoma Maturation During Residency Interviews.

Background: There are few reports of dexterity tests being done in a distance telecommunication setting for residency applicant evaluation. Objective: To report the feasibility and suitability of a virtual suturing skills assessment during residency interviews when added to the standard assessment process. Methods: A suturing simulation was developed and implemented during otolaryngology-head and neck surgery (OHNS) residency interviews for the 2020-2021 cycle at one program. On the day of the interview, the activity was completed in real time using 2-camera video conferencing with the 2 resident assessors providing a numerical assessment based on an adapted scoring rubric from prior suturing activities at the institution. The exercise involved suturing a 3/4-inch Penrose drain circumferentially with half-vertical mattress stitches to simulate the maturation of a tracheostoma. The residency selection committee then completed a 7-item Likert-type survey, developed by the authors, to evaluate the simulation exercise. Results: Fifty-one applicants representing all interviewees in the cycle successfully completed this assessment without technologic disruptions. The total cost associated with obtaining and providing the necessary supplies to applicants was $34.78 per interviewee. Time required to complete the suturing task was estimated to range from 10 to 20 minutes. The residency selection committee viewed this exercise as a success (14 of 16, 87.5%) and viewed the results as a valuable adjunct in the overall assessment of candidates (15 of 16, 93.8%). Conclusions: A simple motor exercise completed over real-time telecommunication was feasible and perceived as helpful to the residency selection committee when assessing OHNS residency candidates.

Second Primary Tumors in Patients Presenting With Unilateral HPV-Associated Tonsillar Squamous Cell Carcinoma.

OBJECTIVE: To describe and compare rates of metachronous and synchronous second primaries of the contralateral tonsil in patients with primary HPV(+) tonsillar squamous cell carcinoma (SCC). STUDY DESIGN: Retrospective cohort study. MATERIALS AND METHODS: This is a single tertiary care center retrospective case series, from 2006 to 2019, of HPV(+) tonsillar SCC patients who underwent primary surgical resection with unilateral wide-field tonsillectomy or bilateral tonsillectomy for diagnostic or therapeutic purposes. A metachronous second primary is one diagnosed >6 months after completion of surgical treatment. A synchronous second primary is one diagnosed during bilateral tonsillectomy for unilateral HPV(+) tonsillar SCC. Rates of second primary and patient characteristics were compared using chi-square tests. RESULTS: About 303 patients underwent unilateral surgical resection +/- adjuvant therapy for HPV(+) tonsillar SCC. One (0.3%) developed a metachronous second primary in the contralateral tonsil 11.9 years following treatment. Fifty-seven patients with HPV(+) tonsillar SCC underwent bilateral tonsillectomy, and 37/57 (65%) had no clinical signs for contralateral disease. Of these, only 1/37 (2.7%) was incidentally found to have a synchronous second primary. Twenty patients underwent bilateral tonsillectomy due to clinical concern for contralateral disease. Of these, 3/20 (15%) were found to have a synchronous HPV(+) SCC in the contralateral tonsil. CONCLUSIONS: The prevalence of metachronous second primary after appropriate treatment of HPV(+) tonsillar SCC is very low (0.3%) and so is the chance of incidentally discovering a synchronous second primary during bilateral tonsillectomy (2.7%). We do not recommend bilateral tonsillectomy as a part of the routine algorithm in the surgical management of these patients. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:332-338, 2022.

Long-term oncologic outcomes in esthesioneuroblastoma: An institutional experience of 143 patients.

OBJECTIVE: Esthesioneuroblastoma (ENB) is a rare malignant neoplasm arising from the olfactory epithelium of the cribriform plate. The goal of this study was to update our oncologic outcomes for this disease and explore prognostic factors associated with survival. MATERIALS AND METHODS: We performed a retrospective analysis of patients with ENB treated at a single tertiary care institution from January 1, 1960, to January 1, 2020. Univariate and multivariate analysis was performed. Overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival (DMFS) were reported. RESULTS: Among 143 included patients, the 5-year OS was 82.3% and the 5-year PFS was 51.6%; 5-year OS and PFS have improved in the modern era (2005-present). Delayed regional nodal metastasis was the most common site of recurrence in 22% of patients (median, 57 months). On univariate analysis, modified Kadish staging (mKadish) had a negative effect on OS, PFS, and DMFS (p < 0.05). Higher Hyams grade had a negative effect on PFS and DMFS (p < 0.05). Positive margin status had a negative effect on PFS (p < 0.05). Orbital invasion demonstrated worsening OS (hazard ratio, 3.1; p < 0.05). On multivariable analysis, high Hyams grade (3 or 4), high mKadish stage (C+D), and increasing age were independent negative prognostic factors for OS (p < 0.05). High Hyams grade (3+4), high mKadish stage (C+D), age, and positive margin status were independent negative prognostic factors for PFS (p < 0.05). High Hyams grade (3+4) was an independent negative prognostic factor for DMFS (p < 0.05). CONCLUSIONS: Patients with low Hyams grade and mKadish stage have favorable 5-year OS, PFS, and DMFS.

Transoral Laser-Assisted Diverticulectomy: Swallow Study Results after Complete Endoscopic Pouch Excision for Zenker's Diverticulum.

OBJECTIVE: Transoral endoscopic laser-assisted diverticulotomy (TELD) with diverticulectomy and diverticuloplasty (TELD + DD) for the management of Zenker's diverticulum (ZD) has been utilized by our institution since 2016 in attempts to reduce residual pouch size. This technique involves complete endoscopic pouch excision with partial advancement of mucosal flaps. Our study compares the subjective outcomes, objective outcomes, and complication rates between TELD and TELD + DD. METHODS: A retrospective cohort study was performed on patients who underwent TELD or TELD + DD by a single surgeon at a tertiary academic center (2013-2019). Videofluoroscopic swallow studies (VFSS) with esophagram, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and 3 month follow-up visits. A single blinded reviewer recorded height, width, and depth of pre and postoperative pouches with volumetric analysis performed assuming an ellipsoid shape. Comorbidities, complications, postoperative course, and recurrence were recorded. RESULTS: Of the 75 patients that met criteria, 27 underwent TELD + DD and 48 underwent TELD. Eighteen TELD + DD and 37 TELD had both pre and post-operative VFSS. TELD + DD and TELD had a 96 ± 7% and 87 ± 16% reduction in pouch volume, respectively (t-test; P = .01). Complications (TELD + DD 7%, TELD 17%, fisher's exact; P = .31) and final subjective outcomes after adjusting for initial were not significantly different between methods (EAT-10 with TELD + DD ∆ + 1.3, P = .18; RSI ∆ + 1.4, P = .29; FOSS ∆-0.02, P = .91). One short-term recurrence was reported with TELD. CONCLUSION: Use of TELD + DD is associated with a statistically significantly decreased residual pouch size with no significant difference in short-term subjective outcomes. Complication rates and short-term recurrence rates are comparable. Long-term recurrence rates will require further studies to characterize. LEVEL OF EVIDENCE: Level 3.

Cricopharyngeal Myotomy in Inclusion Body Myositis: Comparison of Endoscopic and Transcervical Approaches.

OBJECTIVE: Inclusion body myositis (IBM) is a progressive inflammatory myopathy with dysphagia as a debilitating sequalae. Otolaryngologists are consulted for surgical candidacy when there are findings of cricopharyngeal dysfunction. We aim to compare transcervical cricopharyngeal myotomy (TCPM) versus endoscopic cricopharyngeal myotomy (ECPM) in the IBM population with particular focus on objective swallow study outcomes, complications, and recurrence rates. METHODS: A retrospective cohort study was performed on IBM patients who underwent TCPM or ECPM (1981-2020) in the Department of Otolaryngology at a tertiary academic center with a high volume IBM referral base. Videofluoroscopic swallow studies, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and follow-up visits. Baseline patient characteristics, intraoperative data, and postoperative course were recorded. RESULTS: Forty-one patients were identified (18 TCPM; 23 ECPM). There was no significant difference in the recurrence rates, complications, hospitalization length, operative time, or return to preoperative diet between approaches. For the 12 patients (11 ECPM; 1 TCPM) that had subjective swallow data, there was a statistically significant difference in the pre and postoperative scores for EAT-10, RSI, and FOSS (P < .05). There was a statistically significant improvement in the degree of narrowing between pre and postoperative imaging for both approaches (P < .05). CONCLUSION: Both TCPM and ECPM are safe approaches for the management of dysphagia in patients with IBM with objective evidence of cricopharyngeal dysfunction. Cricopharyngeal myotomy is a durable technique that has demonstrated improved subjective and objective outcomes in this patient population. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2426-E2431, 2021.