Posterior Tracheal Diverticulum in a Patient Undergoing Tonsillectomy.

This case report describes a male patient in his 20s who presented with bilateral palatine tonsil enlargement and history of infections 4 to 5 times per year and was subsequently found to have tracheal diverticulum.

Optimization of Opioid Discharge Prescriptions Following Thyroid and Parathyroid Surgery.

OBJECTIVE: To evaluate the impact of a quality improvement bundle on opioid discharge prescribing following thyroidectomy and parathyroidectomy. METHODS: This before-and-after study included patients undergoing thyroidectomy or parathyroidectomy at an academic medical center. The quality improvement bundle included a patient education flyer, electronic health record order sets with multimodal analgesia regimens, and provider education. The preimplementation cohort included patients treated from January 2018 to December 2019. The postimplementation cohort included patients treated from June 2021 to August 2021. The primary outcome was the proportion of patients who received new opioid discharge prescriptions. RESULTS: A total of 160 patients were included in the preimplementation cohort, and the first 80 patients treated after bundle implementation were included in the postimplementation cohort. Patients receiving new opioid discharge prescriptions decreased from 80% (128/160) in the preimplementation cohort to 35% (28/80) in the postimplementation cohort with an unadjusted absolute reduction of 45% (95% CI, 33%-57%; P < .001; number needed to treat = 3) and an adjusted odds ratio (OR) of 0.08 (95% CI, 0.04-0.19; P < .001). The bundle was associated with reductions in opioid discharge prescriptions that exceeded 112.5 oral morphine milligram equivalents (33% pre- vs 10% postimplementation; adjusted OR, 0.20; P = .001) or 5 days of therapy (17% pre- vs 6% postimplementation; adjusted OR, 0.34; P = .049). DISCUSSION: Implementation of a pain management quality improvement bundle reduced opioid discharge prescribing following thyroidectomy and parathyroidectomy. IMPLICATIONS FOR PRACTICE: Unnecessary opioid prescriptions generate unused opioids in patients' homes that can lead to opioid misuse. We believe that this bundle reduced the risk for opioid misuse in our community. REGISTRATION: The study was registered at ClinicalTrials.gov (NCT04955444) before implementation.

Multifocal Paraganglioma Including the Cervical Sympathetic Chain.

Multifocal head and neck paragangliomas are exceptionally rare. We present a patient with 4 synchronous tumors including a sympathetic chain lesion. This is a case report and literature review conducted from September 2021 to the present. Our 69-year-old male patient presented to the clinic with multifocal paraganglioma involving the right carotid body, right cervical sympathetic trunk, right glomus jugulare, and left glomus tympanicum. After preoperative embolization, successful surgical resection was performed for the right sympathetic trunk and right carotid body tumor. Postoperatively, the patient had a right Horner's syndrome but a strong voice and intact recurrent laryngeal nerve function. He also had first-bite syndrome and right cranial nerve XII weakness which resolved. Of interest, patient also has a strong family history of paragangliomas: his sister has malignant paragangliomas with lymph node involvement and his mother and nephew have non-malignant paragangliomas. To our knowledge, multifocal tumors including synchronous carotid body, sympathetic chain, glomus jugulare, and glomus tympanicum lesions occurring in 1 person have not been reported until now. As a result of this study, there is new light shed on the treatment and evaluation of patients who present with multifocal paraganglioma involving the sympathetic chain.

Repairing angle of the mandible fractures with a strut plate.

IMPORTANCE: Despite multiple fixation techniques, the optimal method of repairing mandibular angle fractures remains controversial. OBJECTIVE: To evaluate the outcomes when using a 3-dimensional, curved strut plate in repair of angle of the mandible fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center at an academic institution in Harris County, Texas. PARTICIPANTS: Patients with diagnostic codes involving angle of the mandible fractures that were repaired by the otolaryngology-head and neck surgery service from February 1, 2006, through February 28, 2011. EXPOSURE: Open reduction internal fixation using either a 3-dimensional curved strut plate or any other type of repair technique for angle of the mandible fractures. MAIN OUTCOMES AND MEASURES: Complication rates, postoperative complaints, and operative characteristics. RESULTS: Ninety patients underwent qualifying procedures during the study period. A total of 68 fractures (76%) were repaired using the 3-dimensional curved strut plate and 22 (24%) were repaired using other methods. The revision surgery rate was 10% for the strut plate group (7 patients) and 14% for the non-strut plate group (3 patients), with no significant differences in rates of infection (3 [4%] vs 2 [9%]), dehiscence (4 [6%] vs 2 [9%]), malunion (1 [1%] vs 2 [9%]), nonunion (3 [4%] vs 0), hardware failure (1 [1%] vs 1 [5%]), malocclusion (2 [3%] vs 2 [9%]), and injury to the inferior alveolar nerve (1 [1%] vs 1 [5%]). The most common postoperative complaints were pain (13 [19%] vs 6 [27%]), followed by numbness (5 [7%] vs 2 [9%]), trismus (4 [6%] vs 3 [14%]), edema (3 [4%] vs 3 [14%]), and bite deformity (2 [3%] vs 2 [9%]), with a mean (range) follow-up time of 54.7 (2-355) days for the strut plate group vs 46.8 (8-308) days for the non-strut plate group. CONCLUSIONS AND RELEVANCE: The 3-dimensional curved strut plate is an effective treatment modality for angle fractures, with comparable infection rates, low incidence of alveolar nerve injury, and trends for decreased length of operation, complications, and infections compared with other techniques.

Malignant paraganglioma of the thyroid gland with synchronous bilateral carotid body tumors.

We describe a case of primary malignant paraganglioma of the thyroid gland that was found in a 55-year-old woman who had undergone surgery for bilateral carotid body tumors. The paraganglioma was treated with a total thyroidectomy followed by radiation therapy, and the patient was disease-free after more than 2 years of follow-up. Malignant paragangliomas of the thyroid gland are extremely rare. The diagnosis of malignancy is based on histopathologic findings, tumor behavior, and metastasis. These tumors can be misdiagnosed as other types of thyroid malignancies, thus resulting in less than optimal treatment. A genetic etiology was suspected in our patient.

Primary intraosseous carcinoma of the anterior maxilla: an unusual case and review of the literature.

Primary intraosseous carcinoma of the head and neck is rare, and lesions isolated to the anterior maxilla are obviously even more rare. The diagnosis of intraosseous carcinoma can be difficult, and it must be based on strict criteria. We report the case of a 40-year-old man who was referred for definitive treatment of a cancerous lesion of the anterior maxilla. The patient's mass had initially been thought to be a benign odontogenic cyst. The patient was treated with surgery and prosthetic rehabilitation. We describe the clinical presentation, pertinent workup including imaging, and the treatment of this case, and we review the literature.

Management of the difficult pediatric airway: efficacy of airway exchange catheters with rigid bronchoscopy.

The airway exchange catheter can be used both to ventilate the lungs and to act as a guide for reintubation in patients of all ages who have a tenuous airway. We report the case of a 2-year-old boy with an anatomically challenging airway in whom both an airway exchange catheter and a rigid bronchoscope were used to visualize and maintain a secure airway. We also review the literature as it pertains to the management of the difficult pediatric airway.

Knowledge of head and neck cancer among medical students at 2 Chicago universities.

OBJECTIVE: To assess the knowledge of first- (M1) and fourth- (M4) year medical students regarding head and neck cancer (HNC) risk factors, signs, symptoms, and frequency; designated oral screening recommendations; head and neck physical examination techniques; and medical school curriculum on this subject. DESIGN: Cross-sectional cohort study using a survey questionnaire. SETTING: Two metropolitan-area medical schools in Chicago, Illinois. PARTICIPANTS: Of 601 M1 and M4 medical students, 304 completed the survey. MAIN OUTCOME MEASURES: Percentage of medical students from 2 classes at 2 different universities who knew baseline knowledge about HNC. RESULTS: The response rate was approximately 50% for each class from each university. The M1 students from the 2 institutions differed on identifying a lump in the neck and voice changes among the signs and symptoms associated with HNC and American Cancer Society examination recommendations. The M4 students did not differ between the 2 schools and were more knowledgeable than the M1 students on risk factors, signs, symptoms, most frequent histologic type, American Cancer Society recommendations, and common subsites of HNC. Curricular experiences, as expected, varied between M1 and M4 students. CONCLUSIONS: This study demonstrates an increase in knowledge about HNC in M4 students compared with M1 students. Yet, graduating students are still deficient regarding certain risk factors, oral screening guidelines, head and neck examination techniques, and medical school curriculum. Further efforts should be aimed at expanding head and neck education for medical students.

Branchial anomalies in the pediatric population.

OBJECTIVE: We sought to review the presentation, evaluation, and treatment of branchial anomalies in the pediatric population and to relate these findings to recurrences and complications. STUDY DESIGN AND SETTING: We conducted a retrospective study at a tertiary care pediatric hospital. PATIENTS: Ninety-seven pediatric patients who were treated for branchial anomalies over a 10-year period were reviewed. Patients were studied if they underwent surgical treatment for the branchial anomaly and had 1 year of postoperative follow-up; 67 children met criteria, and 74 anomalies were studied. RESULTS: Patients with cysts presented at a later age than did those with branchial anomaly fistulas or sinus branchial anomalies. 32% of branchial anomalies were previously infected. Of these, 71% had more than one preoperative infection. 18% of the BA were first arch derivatives, 69% were second arch derivatives and 7% were third arch derivatives. There were 22 branchial cysts, 31 branchial sinuses and 16 branchial fistulas. The preoperative and postoperative diagnoses differed in 17 cases. None of the excised specimens that contained a cystic lining recurred; all five recurrences had multiple preoperative infections. CONCLUSIONS: Recurrence rates are increased when there are multiple preoperative infections and when there is no epithelial lining identified in the specimen.

Comparison of radial forearm with fibula and scapula osteocutaneous free flaps for oromandibular reconstruction.

OBJECTIVE: To compare our experience with the osteocutaneous radial forearm free flap (group 1) (n = 108) with other commonly used osteocutaneous free flaps (group 2) (n = 56) such as the fibula and scapula in single-stage oromandibular reconstruction. DESIGN: Retrospective case review. SETTING: Tertiary-care academic medical center. PATIENTS: One hundred sixty-three consecutive patients who underwent 164 mandibular reconstructions with osteocutaneous free flaps. MAIN OUTCOME MEASURES: Assessment of preoperative and intraoperative variables for both groups. We compared recipient-site complication rate, intensive care unit stay, total hospital stay, and postoperative function. RESULTS: The most common donor site used was the radius (n = 108 [66%]), followed by the fibula (n = 36 [22%]) and scapula (n = 20 [12%]). Mean follow-up was 29 months (range, 1-116 months). Group 2 patients had larger soft tissue and/or bony defects. Surgical and medical complication rates and major donor site morbidity in group 1 were similar or better when compared with those in group 2. The lengths of the intensive care unit (4 vs 7 days; P = .009) and hospital stays (13 vs 15 days; P = .06) were shorter in group 1. Although the microvascular success rate was similar in both groups, the local wound complication rate was significantly better for group 1. The difference for the length of intensive care unit stay was statistically significant and potentially amounts to more than 6000 dollars of savings. Functional outcomes, including the ability to tolerate oral diet, tracheostomy presence, and dental rehabilitation, were similar between the groups. CONCLUSIONS: The primary site long-term morbidity, donor site morbidity, and postoperative function of osteocutaneous radial forearm free flaps are comparable to those of other commonly used osteocutaneous free flaps such as the fibula and scapula when used in single-stage oromandibular reconstruction.