Management of Enlarging Tracheoesophageal Fistula with Voice Prosthesis in Laryngectomized Patients.

Management of Enlarging tracheoesophageal fistula (TEF) with Voice Prosthesis in Laryngectomized Head and Neck Cancer Patients. OBJECTIVES: An enlarging TEF following voice prosthesis placement impacts patient quality of life, risks airway compromise, and can lead to aspiration pneumonia. Pharyngoesophageal strictures have previously been reported to be associated with TEF enlargement and leakage. We describe a series of patients with enlarging TEFs after Tracheoesophageal puncture (TEP) for voice prosthesis who required pharyngoesophageal reconstruction. METHODS: Retrospective case series of laryngectomized H&N cancer patients with primary or secondary TEP who underwent surgical management for enlarging TEF site between 6/2016-11/2022. RESULTS: Eight patients were included. The mean age was 62.8 years old. Seven patients had a history of hypothyroidism. Of seven with prior H&N radiation history, two had both historical and adjuvant radiation. Two of the eight TEPs were placed secondarily. Mean time from TEP to enlarging TEF diagnosis was 891.3 days. Radial forearm-free flaps were used in five patients. Six had stenosis proximal to the TEF whereas one had distal stenosis and one had no evidence of stenosis. Mean length of stay was 12.3 days. Mean follow-up was 400.4 days. Two required a second free flap for persistent fistula. CONCLUSION: Surgical reconstruction of enlarging TEFs due to TEP/VP placement is effective in combination with addressing underlying pharyngeal/esophageal stenosis contributing to TEF enlargement and leakage. Radial forearm-free flaps have the additional benefit of a long vascular pedicle to access more distant and less-irradiated recipient vessels. Many fistulae are resolved after the first flap reconstruction, but some may require subsequent reconstruction in case of failure. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:198-206, 2024.

Equipping your facial plastic clinic for office-based procedures.

Office-based procedures can be a fulfilling part of the facial plastic practice with the right tools, personnel, and preparation. Equipping the clinic for office-based procedures has several unique considerations that ultimately impact its success. It is important to strategize preemptively regarding what treatments will be offered and the respective equipment that will allow the safe, cost-effective, and high-quality delivery of those treatments. Most procedures in the office-based setting are cosmetic in nature and there are often overlapping treatment modalities that target similar outcomes. Patient selection and counseling is a crucial step in preparing for office-based procedures in the effort to maximize patient satisfaction. Nearly all the most common facial plastic procedures can be delivered in the office-based based setting under local anesthesia and moderate sedation, depending on the expertise of the surgeon. To enable these and other categories of treatments, there are certain expensive pieces of technology that one might consider for their office-based practice and other fundamental supplies that are necessary for almost all practices. Though the initial investment in equipment can be costly, this article also discusses more affordable alternatives or third-party sales of devices and equipment. The field of facial plastic surgery is very dynamic and having both peer and mentorship networks is invaluable in navigating some of the financial decisions discussed herein. This article also briefly covers personnel, training, and accreditation considerations.

Relationship Between the Thickness of Cortical Bone at Maxillary Mid-palatal Area and Facial Height Using CBCT.

INTRODUCTION: Orthodontic mini-implants have been incorporated into orthodontic treatment modalities. Adequate bone at mini-implant placement site can influence the success or failure of anchorage. The present study was to determine the thickness of cortical bone in the maxillary mid-palatal area at predetermined points for the placement of orthodontic mini-implants using Cone Beam CT technique in order to evaluate the relationship of these values with the facial height. Materials and Methods : A total of 161 patients, consisting of 63 males (39.13%) and 98 females (60.87%), were evaluated in the present study; 38% of the subjects had normal facial height, 29% had short face and 33% had long face. In order to determine which patient belongs to which facial height category, i.e. normal, long or short, two angular and linear evaluations were used: the angle between S-N and Go-Me lines and the S-Go/N-Me ratio. Twenty points were evaluated in all the samples. First the incisive foramen was located. The paracoronal cross-sections were prepared at distances of 4, 8, 16 and 24 mm from the distal wall of the incisive foramen and on each cross-section the mid-sagittal and para-sagittal areas were determined bilaterally at 3- and 6-mm distances (a total of 5 points). The thicknesses of the cortical plate of bone were determined at the predetermined points. Results : There was a significant relationship between the mean cortical bone thickness and facial height (p<0.01), with significantly less thickness in long faces compared to short faces. However, the thickness of cortical bone in normal faces was similar to that in long and short faces. Separate evaluation of the points showed that at point a16 subjects with short faces had thicker cortical bone compared to subjects with long and normal faces. At point b8 in long faces, the thickness of the cortical bone was significantly less than that in short and normal faces. At point d8, the thickness of the cortical bone in subjects with short faces was significantly higher than that in subjects with long faces. Conclusion : At the point a16 the cortical bone thickness in short faces was significantly higher than normal and long faces. The lower thickness of the cortical bone in the palatal area at points b8 and d8 in subjects with long faces might indicate a lower anchorage value of these points in these subjects.