The effect of transfusion on survival in head and neck cancer after free tissue reconstruction.

Objective: To examine if perioperative blood transfusion affects overall survival (OS) and recurrence-free survival (RFS) in head and neck cancer patients who undergo free tissue reconstruction. Design: Retrospective cohort study. Methods: The medical records of free tissue flaps between 2007 and 2010 were reviewed. Differences in demographics and clinical factors based on the level of transfused packed red blood cells (PRBC) were examined using chi-squared tests, Kruskal-Wallis tests, and/or ANOVA tests. Survival time was compared using a Cox proportional hazard model. Results: Data were available for 183 patients. Patients who had PRBC transfusion significantly differed from the non-transfused group by flap type, flap with bone, Charlson Comorbidity Index (CCI), and hemoglobin and hematocrit. When stratified into three groups based on units of PRBC; flap type, flap with bone, CCI, preoperative hemoglobin, and hematocrit were found to differ significantly. The 2-year Kaplan-Meier plot demonstrated improved OS for those who did not receive any PRBC transfusion. The use of more than 3 units of blood decreased 2-year OS significantly when compared to the non-transfused group. Finally, after adjusting for CCI using a Cox proportional hazard model, survival was significantly affected by CCI. Conclusion: After controlling for patient age, oncologic stage, cancer subsite, histology, type of free flap, vascularized bone-containing flap, recurrence type, CCI, and preoperative hemoglobin and hematocrit, patients who received 3 or more units of PRBC in the perioperative period had significantly decreased OS. RFS did not differ between the transfused versus non-transfused groups. Level of Evidence: Level 4.

Sternocleidomastoid Tendon as a Consistent Landmark for Identifying the Spinal Accessory Nerve: A Case Series.

Objective: We propose a standardized approach of using the tendon of the sternocleidomastoid (SCM) muscle to locate the spinal accessory nerve (SAN) in neck dissection. Study Design: Cross-sectional anatomic study. Setting: Tertiary academic medical center. Methods: Adult patients aged ≥18 years undergoing primary neck dissection for head and neck cancer were included. Anatomic measurements included the length of the SCM tendon, the distance from the mastoid tip to the entrance of the SAN into the SCM, the distance from the SAN to the distal edge of the SCM tendon, and the perpendicular distance from the anterior edge of the SCM to the SAN. Five cadaveric specimens also underwent bilateral modified radical neck dissections with the same anatomic measurements taken. Results: Twenty-two living subjects and 5 cadavers were included. No statistical correlation was noted between patient demographics and any measurement. The mean (SD) length of the SCM tendon was 63.7 mm (11.8) in living subjects and 61.5 mm (10.4) in cadaveric specimens. The average distance from the mastoid tip to the entrance of SAN into the SCM was 51.6 mm (12.2) in living subjects and 51.6 mm (7.1) in cadaveric subjects. The distance of the SAN insertion into the SCM muscle from the anterior edge was 8.9 mm (3.4) in living subjects and 16.2 mm (7.2) in cadaver specimens. Laterality was compared in the cadaveric specimens; there was no statistically significant difference in any of the measurements between sides. Conclusion: This study demonstrates the SCM tendon to be a reliable and safe surgical landmark to identify and preserve the SAN during neck dissection.

Peritonsillar Abscess Simulator: A Low-Cost, High-Fidelity Trainer.

Audience: Our reusable low-cost peritonsillar abscess simulator (PTA) simulator is designed to train emergency medicine (EM) residents, fellows, and medical students. Trainees who are interested in otolaryngology (OTL) or this specific disease may also benefit from this simulator. Introduction: Peritonsillar abscess is one of the most common deep infections 1 of the head and neck, accounting for 7589 consultations and 11069 hospital bed days in the UK between 2009-2010.1,2 Emergency medicine physicians commonly treat this pathology with surgical and medical modalities. Not only is this a common diagnosis, but there is a significant cost associated with the evaluation and management of primary PTA. 3Demands for high-volume patient care and good patient outcomes are increasing in a medical climate of limited financial resources and resident work hours. Given these complexities, medical education is viewing simulation training, with proven success in various surgical specialties, as a valuable addition to resident education and patient safety. 3-5The PTA is the collection of pus in the space between the palatine tonsil and its capsule. Successfully locating the abscess is crucial because it prevents the unwanted damage of nearby vascular structures, patient discomfort, and failure to treat the infection. Management of peritonsillar abscess is primarily surgical and includes incision and drainage (I & D), needle aspiration, or Quinsy tonsillectomy.The simulator provides a realistic characteristic of typical PTA presentations, such as uvula deviation, swelling, trismus, and purulence during aspiration. While learning to drain a PTA, trainees must locate the infection with a needle without injury to the surrounding structures of the oral cavity and deep structures of the neck. The discomfort caused during this procedure can be unsettling for both physician and patient. Simulation use and testing enable the trainee to develop familiarity with handling instruments, increase comfort with the sequence of a procedure, and improve confidence in the ability to perform a procedure safely.6,7,8 Simulators provide improved patient outcomes and increased EM residents' comfort level. Educational Objectives: By the end of this training session, learners will be able to: 1) locate the abscess, 2) perform needle aspiration, and 3) develop dexterity in maneuvering instruments in the small three-dimensional confines of the oral cavity without causing injury to local structures. Educational Methods: Our PTA simulator was fabricated with a low-cost, non-degradable material and is the first known PTA simulator that used a validated survey for fidelity assessment. The simulator was fabricated using a silicone mold to mimic the oral cavity and oropharynx. A simulated abscess pocket consisting of saline encased in balloon material was placed in the proper anatomic location, allowing for abscess simulation on either side of the oropharynx model. The time to fabricate the model averaged 20 hours. The simulator was manufactured with low-cost materials at an expense of 45 USD and could be easily reproduced by any EM residency program. Research Methods: Twenty-one participants were instructed to expose and drain the simulated abscess. The model was evaluated using The Michigan Standard Simulation Experience Scale (MiSSES).7 Participants scored the simulator in five categories: Self-efficacy, fidelity, educational value, teaching quality, and the overall rating on a 5-point Likert scale of simulator. Overall rating and global evaluation scores were compared by groups (Group 1, Group 2) between training level (residents and attendings), specialty (emergency and otolaryngology), and previous experience (<5 or ≥5 drainages).Convenience sampling was used to determinate the sample. Variables were summarized using the mean and standard deviation for continuous variables and percentages and frequencies for categorical variables. The MiSSES was scored as previously described in the literature.7 The Kolmogorov-Smirnov test was used to test for normal distribution of the variables. T-test for independent samples was performed to determinate if there exists a difference between groups in perception of a PTA simulator. The statistical analyses were performed using SPSS version 20.0 Armonk, NY: IBM. Results: Twenty-one participants were enrolled in the study: residents (n=15) and attending (n=6) from OTL and EM departments. The simulator's plasticity allowed multiple attempts of needle aspiration and drainage without degradation and received high ratings on teaching quality, fidelity, and educational value. This PTA simulator achieved high fidelity ratings in the standard simulator's assessment survey for realism of environment, simulation of trismus, uvular deviation, and realism of the mucosal surfaces. On the MiSSES, the model received positive ratings (range 3.6 to 4.9). The highest rating was on teaching quality (4.9), fidelity (4.6), and educational value (4.5) (Table 1). We found that self-efficacy and teaching quality sections were rated higher for those who had less experience (≥5 PTA drainage), while fidelity was rated higher for OTL. The overall rating average was 4 and was higher of attendings, OTL, and those with less experience. All comparisons between groups were not statically significant (Table 2). About 76% of participants found that the simulator can be used in training with slight improvement or no improvement needed. (Table 3). Discussion: With favorable participant ratings and comments, we believe that this tool can offer high-fidelity simulation at a low cost. Widespread use may be possible, allowing training of EM residents in performing instrumentation of PTA in a controlled simulation environment. We have created a reusable low-cost PTA simulator that achieved a high score fidelity in a standard simulator's assessment survey. Topics: Peritonsillar abscess, oropharynx, emergency medicine residency, otolaryngology residency training.

Sexuality after treatment of head and neck cancer: findings based on modification of sexual adjustment questionnaire.

OBJECTIVES/HYPOTHESIS: Evaluate sexual dysfunction in patients after treatment for head and neck cancer. STUDY DESIGN: Single-institution cross-sectional study. METHODS: Our modified Sexual Adjustment Questionnaire was administered to 42 patients (mean age, 55.1 years) and included seven questions (total score, 7-35). Based on sexual satisfaction ratings, we categorized three groups as unsatisfied (7-16), satisfied (17-25), and very satisfied (26-35). Clinical information was obtained by reviewing medical records. Bivariate analysis tested associations between sexual satisfaction and patient-related factors (e.g., sex, age, site/cancer stage, treatment, time between treatment and survey, partner, alcohol/tobacco consumption). Pearson correlation was used to analyze two continuous variables, and multivariate logistic regression analysis was used to evaluate the independent impact of each factor. RESULTS: All 42 patients rated that head and neck cancer negatively impacted their sexual relationships, including 21 (50%) rating effects as negative or extremely negative. Men reported higher satisfaction scores with sexual function (mean ± standard deviation) than women (19.9 ± 5.0 vs. 16.3 ± 6.5, respectively; P = .06). Respondents with partners reported higher scores than those without partners (19.9 ± 5.3 vs. 14.1 ± 4.4, respectively; P = .01). When the survey was administered (median, 12 months; range, 4-33 months) after the first treatment, mean score was 19; 57% of respondents were sexually satisfied, 31% were unsatisfied, and 12% were very satisfied. Instrument reliability was .82 (Cronbach alpha). CONCLUSIONS: Patients who are male and ≤ 60 years have a higher probability of sexual satisfaction during recovery. Our sexual dysfunction questionnaire will be administered in further prospective studies in patients with head and neck cancer.

Parálisis facial permanente: corrección quirúrgica con la técnica de Labbé / Permanent facial paralysis: surgical correction with Labbe's technique

La parálisis facial genera un gran déficit estético y funcional. Las diversas técnicas quirúrgicas han ido evolucionando, a fin de corregir este defecto de la forma más estructural y fisiológica posible. Consideramos que la mioplastia de alargamiento del temporal constituye actualmente la técnica de elección para corregir los casos de parálisis facial permanente.

Facial paralysis causes a large aesthetic and functional defect. Different surgical techniques may be used to repair this defect. Some of them have focused instructural and physiological aspects. We consider that temporalis lengthening myoplasty is currently the most important technique for permanent facial paralysis repair.

Parálisis vocal permanente: corrección quirúrgica con tiroplastia tipo I / Permanent vocal paralysis: type I thyroplasty surgical correction

La parálisis vocal permanente es causa de disfonía y episodios repetitivos de aspiración. Hacemos una revisión breve de la fisiopatología así como del procedimiento quirúrgico correctivo, conocido como tiroplastia.

Permanent vocal cord paralysis causes dysphonia and repetetive aspiration episodes. We review vocal cord paralysis pathophysiology and the corrective surgical procedure known as thyroplasty.