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.

Facial Nerve Preservation With Inferior Long-Axis Dissection of Large Vestibular Schwannomas.

OBJECTIVE: To describe a tumor resection using the inferior long-axis (ILA) technique for cisternal facial nerve dissection in large vestibular schwannomas (VS). STUDY DESIGN: Retrospective case series from 2018 to 2021. SETTING: Tertiary academic medical center. PATIENTS: Patients who underwent surgical resection with ILA facial nerve dissection of VS (>2.0 cm measured parallel to the petrous ridge) and had at least 3-month follow-up. INTERVENTIONS: Cisternal facial nerve dissection during retrosigmoid or translabyrinthine approach using standardized ILA technique developed by author R.N. MAIN OUTCOME MEASURES: Immediate postoperative and last follow-up facial nerve function with House-Brackmann scores of I to II defined as "good" facial nerve function and House-Brackmann scores III to VI defined as "poor" function. Extent of resection was also assessed. RESULTS: A total of 48 patients underwent large VS resection with ILA dissection of tumor off of the facial nerve from 2018 to 2021. Mean (standard deviation) tumor size was 3.11 (0.76) cm. Mean (standard deviation) follow-up was 9.2 (9.0) months. Gross-total resection or near-total resection were achieved in 75% (radiographic estimate) to 83% (surgeon estimate) of cases. End-of-case facial nerve stimulation at 0.05 mAmp with a response of at least 240 mV was achieved in 80.4% of patients. Good facial nerve function was observed in 72% immediately postoperatively, 70% 1-month postoperatively, and 82% of patients at last follow-up. CONCLUSIONS: The ILA technique is now the method of choice of the senior surgeon (R.N.) when performing microsurgical dissection of the cisternal facial nerve, with which he has achieved high rates of total or near-total resection with excellent facial nerve preservation.

Evaluating the risks and benefits of ketorolac in transoral robotic surgery.

Transoral Robotic Surgery (TORS) is increasingly used for oropharyngeal neoplasms and obstructive sleep apnea. Post-operative pain and bleeding remain concerns. Ketorolac has proved to be a safe alternative or addition to narcotics in other operations, but has not been thoroughly evaluated in TORS. A retrospective review was carried out on all TORS cases at our institution between April 2012 and March 2019, with the vast majority of cases performed starting in 2017. Post-operative bleed rates were compared between those who received Ketorolac and those who did not. Secondary outcomes evaluated included post-operative pain scores and need for feeding tube upon discharge. A total of 81 TORS cases were evaluated, with 37 patients receiving Ketorolac. Six (7.4%) patients reported post-operative bleeding, with one major and five minor bleeds. The patient with major bleeding requiring operative intervention did not receive Ketorolac. All five patients with minor bleeding received Ketorolac, but no bleeds occurred in the immediate post-operative setting while receiving Ketorolac. The average time of bleeding was 8 days post-operative. There were no significant differences in pain scores or time to feeding tube removal. This preliminary study shows that Ketorolac use in the postoperative pain management after TORS does not increase major bleeding risk without benefits in pain management. There was increased risk of minor bleeding not requiring intervention, but this was not significant. Future prospective studies are needed to determine if it improves pain and swallowing and decreases narcotic requirements following TORS.

Flap demise reversed after central venous access device removal: A case report.

Patients undergoing head and neck free flap reconstruction should be evaluated for radiation-induced venous stenosis and presence of central venous port as a potential risk for flap failure.

Facial nerve repair utilizing intraoperative repair strategies.

OBJECTIVES: To determine whether functional and anatomical outcomes following suture neurorrhaphy are improved by the addition of electrical stimulation with or without the addition of polyethylene glycol (PEG). METHODS: In a rat model of facial nerve injury, complete facial nerve transection and repair was performed via (a) suture neurorrhaphy alone, (b) neurorrhaphy with the addition of brief (30 minutes) intraoperative electrical stimulation, or (c) neurorrhaphy with the addition electrical stimulation and PEG. Functional recovery was assessed weekly for 16 weeks. At 16 weeks postoperatively, motoneuron survival, amount of regrowth, and specificity of regrowth were assessed by branch labeling and tissue analysis. RESULTS: The addition of brief intraoperative electrical stimulation improved all functional outcomes compared to suturing alone. The addition of PEG to electrical stimulation impaired this benefit. Motoneuron survival, amount of regrowth, and specificity of regrowth were unaltered at 16 weeks postoperative in all treatment groups. CONCLUSION: The addition of brief intraoperative electrical stimulation to neurorrhaphy in this rodent model shows promising neurological benefit in the surgical repair of facial nerve injury. LEVEL OF EVIDENCE: Animal study.

Correlations in Trends of Sinusitis-Related Online Google Search Queries in the United States.

BACKGROUND: Online search query trends have been shown to correlate with real-life epidemiologic phenomena. OBJECTIVE: The aim of this study was to analyze correlations in trends in Google online search volumes of sinusitis-related terms, including symptomatology and similar disease states. METHODS: Terms clinically associated with "sinusitis" were determined by consensus. Terms of symptomatology were derived from the validated 22-item sinonasal outcome test (SNOT-22) as well as terminology encountered with the authors' clinical experience. Terms of disease states that could overlap in symptomatology with sinusitis were then chosen. Google Trends, an online tool for extracting relative frequencies from a public database of search queries, was used to query normalized monthly volumes in the United States from January 2004 to September 2017 of searches related to the topics decided upon by consensus. Bivariate Pearson correlation was used to compare the search queries. RESULTS: Online search volumes of "sinusitis" have a distinct seasonal variation, with consistent annual peaks and troughs. In terms of symptomatology, "postnasal drip," "nasal congestion," "cough," "rhinorrhea," and "sore throat" most highly correlated with "sinusitis" search volumes with statistical significance. "sinusitis" search query volume had a higher positive correlation with "common cold" and "acute sinusitis" than "chronic sinusitis" with regard to disease states. CONCLUSIONS: Trends in Google online search volumes over time of "sinusitis" symptomatology mimic real-world clinical phenomena and provide insight into the issues affecting the general population.

Functional and Anatomical Outcomes of Facial Nerve Injury With Application of Polyethylene Glycol in a Rat Model.

IMPORTANCE: Functional and anatomical outcomes after surgical repair of facial nerve injury may be improved with the addition of polyethylene glycol (PEG) to direct suture neurorrhaphy. The application of PEG has shown promise in treating spinal nerve injuries, but its efficacy has not been evaluated in treatment of cranial nerve injuries. OBJECTIVE: To determine whether PEG in addition to neurorrhaphy can improve functional outcomes and synkinesis after facial nerve injury. DESIGN, SETTING, AND SUBJECTS: In this animal experiment, 36 rats underwent right facial nerve transection and neurorrhaphy with addition of PEG. Weekly behavioral scoring was done for 10 rats for 6 weeks and 14 rats for 16 weeks after the operations. In the 16-week study, the buccal branches were labeled and tissue analysis was performed. In the 6-week study, the mandibular and buccal branches were labeled and tissue analysis was performed. Histologic analysis was performed for 10 rats in a 1-week study to assess the association of PEG with axonal continuity and Wallerian degeneration. Six rats served as the uninjured control group. Data were collected from February 8, 2016, through July 10, 2017. INTERVENTION: Polyethylene glycol applied to the facial nerve after neurorrhaphy. MAIN OUTCOMES AND MEASURES: Functional recovery was assessed weekly for the 16- and 6-week studies, as well as motoneuron survival, amount of regrowth, specificity of regrowth, and aberrant branching. Short-term effects of PEG were assessed in the 1-week study. RESULTS: Among the 40 male rats included in the study, PEG addition to neurorrhaphy showed no functional benefit in eye blink reflex (mean [SEM], 3.57 [0.88] weeks; 95% CI, -2.8 to 1.9 weeks; P = .70) or whisking function (mean [SEM], 4.00 [0.72] weeks; 95% CI, -3.6 to 2.4 weeks; P = .69) compared with suturing alone at 16 weeks. Motoneuron survival was not changed by PEG in the 16-week (mean, 132.1 motoneurons per tissue section; 95% CI, -21.0 to 8.4; P = .13) or 6-week (mean, 131.1 motoneurons per tissue section; 95% CI, -11.0 to 10.0; P = .06) studies. Compared with controls, neither surgical group showed differences in buccal branch regrowth at 16 (36.9 motoneurons per tissue section; 95% CI, -14.5 to 22.0; P = .28) or 6 (36.7 motoneurons per tissue section; 95% CI, -7.8 to 18.5; P = .48) weeks or in the mandibular branch at 6 weeks (25.2 motoneurons per tissue section; 95% CI, -14.5 to 15.5; P = .99). Addition of PEG had no advantage in regrowth specificity compared with suturing alone at 16 weeks (15.3% buccal branch motoneurons with misguided projections; 95% CI, -7.2% to 11.0%; P = .84). After 6 weeks, the number of motoneurons with misguided projections to the mandibular branch showed no advantage of PEG treatment compared with suturing alone (12.1% buccal branch motoneurons with misguided projections; 95% CI, -8.2% to 9.2%; P = .98). In the 1-week study, improved axonal continuity and muscular innervation were not observed in PEG-treated rats. CONCLUSIONS AND RELEVANCE: Although PEG has shown efficacy in treating other nervous system injuries, PEG in addition to neurorraphy was not beneficial in a rat model of facial nerve injury. The addition of PEG to suturing may not be warranted in the surgical repair of facial nerve injury. LEVEL OF EVIDENCE: NA.

Bibliometric analysis of authorship trends and collaboration dynamics over the past three decades of BONE's publication history.

The existence of a gender gap in academia has been a hotly debated topic over the past several decades. It has been argued that due to the gender gap, it is more difficult for women to obtain higher positions. Manuscripts serve as an important measurement of one's accomplishments within a particular field of academia. Here, we analyzed, over the past 3 decades, authorship and other trends in manuscripts published in BONE, one of the premier journals in the field of bone and mineral metabolism. For this study, one complete year of manuscripts was evaluated (e.g. 1985, 1995, 2005, 2015) for each decade. A bibliometric analysis was then performed of authorship trends for those manuscripts. Analyzed fields included: average number of authors per manuscript, numerical position of the corresponding author, number of institutions collaborating on each manuscript, number of countries involved with each manuscript, number of references, and number of citations per manuscript. Each of these fields increased significantly over the 30-year time frame (p<10-6). The gender of both the first and corresponding authors was identified and analyzed over time and by region. There was a significant increase in the percentage of female first authors from 23.4% in 1985 to 47.8% in 2015 (p=0.001). The percentage of female corresponding authors also increased from 21.2% in 1985 to 35.4% in 2015 although it was not significant (p=0.07). With such a substantial emphasis being placed on publishing in academic medicine, it is crucial to comprehend the changes in publishing characteristics over time and geographical region. These findings highlight authorship trends in BONE over time as well as by region. Importantly, these findings also highlight where challenges still exist.

Identification of Targetable ERBB2 Aberrations in Head and Neck Squamous Cell Carcinoma.

IMPORTANCE: ERBB2 (formerly HER2) is an important drug target in breast cancer, where anti-ERBB2 therapy has been shown to lead to improvements in disease recurrence and overall survival. ERBB2 status in head and neck squamous cell carcinoma (HNSCC) has not been well studied. Identification of ERBB2-positive tumors and characterization of response to ERBB2 therapy could lead to targeted treatment options in HNSCC. OBJECTIVE: To identify ERBB2 aberrations in HNSCCs and investigate the potential for ERBB2-targeted therapy in HNSCCs. DESIGN, SETTING, AND PARTICIPANTS: A retrospective case series of patients with laryngeal (42 tumor specimens) and oral cavity (94 tumor specimens) SCC enrolled in the University of Michigan Head and Neck Specialized Program of Research Excellence was conducted. Publicly available sequencing data (The Cancer Genome Atlas), as well as data from other studies, were reviewed to identify additional mutations and overexpression in ERBB2 in HNSCC. Established HNSCC cell lines were used for follow-up in vitro analysis. The study was conducted from October 1, 2014, to August 30, 2015. INTERVENTIONS: With the use of targeted, amplicon-based sequencing with the Oncomine Cancer Panel, the copy number and mutation status of commonly altered genes in HNSCCs were assessed. Immunohistochemical staining was performed on tissue microarrays of HNSCCs to assess the expression of ERBB2. Western blotting for HNSCC cell line ERBB2 expression and cell survival assays after treatment with ERBB2 inhibitors were performed. MAIN OUTCOMES AND MEASURES: The prevalence of ERBB2 genetic aberrations and ERBB2 overexpression in laryngeal and oral cavity SCCs, prevalence of ERBB2 aberrations in HNSCC in The Cancer Genome Atlas, ERBB2 protein expression in HNSCC cell lines, and response of HNSCC cell lines to targeted ERBB2 inhibitors. RESULTS: Of the 42 laryngeal SCC samples screened by targeted sequencing, 4 (10%) were positive for ERBB2 amplification. Two of these samples showed ERBB2 overexpression on immunohistochemistry. Two of the 94 oral cavity SCC samples (2%) were positive for ERBB2 on immunohistochemistry. Analysis of 288 patients from publicly available HNSCC sequencing data revealed 9 amplifications (3%) in ERBB2. Protein expression was variable across HNSCC cell lines, and a subset of these cell lines showed responsiveness to anti-ERBB2 therapy. CONCLUSIONS AND RELEVANCE: ERBB2 aberrations were identified in a subset of HNSCCs. These tumors may be responsive to targeted therapy against ERBB2. Screening for ERBB2 aberrations and applying targeted therapy in ERBB2-positive patients may be useful in personalized therapy trials, particularly in patients who are refractory to current treatment paradigms.