The use of Montgomery salivary bypass tubes and pharyngocutaneous fistula following salvage laryngectomy.

Objectives: Pharyngocutaneous fistula (PCF) is the most common complication to follow total laryngectomy (TL) and is associated with increases in length of hospital stay and with a need for revision surgery or readmission, as well as with delays in return to oral diet. Patients who require salvage TL (STL) or primary (chemo)radiation therapy are at higher risk for developing PCF. Due to the quality-of-life burden of PCF on patients, limiting this occurrence is crucial. Methods: We conducted a retrospective cohort study of patients undergoing STL with placement of Montgomery salivary bypass tube (MSBT)™ for at least 2 weeks duration between 2013 and 2017 at a single institution. Our patients all underwent free flap reconstruction. Our primary outcome of interest was development of PCF. Secondary outcomes included demographics, previous treatment, base of tongue (BOT) involvement, extent of defect, concurrent neck dissection (ND), and margin status. Univariate χ 2 analysis was used to evaluate factors associated with PCF. Results: Forty-four patients underwent STL with Montgomery tube placement and free flap reconstruction. Eight developed PCF (18.2%). The average age was 61.6 years; 36 patients were male (81.8%), whereas eight patients were female (18.2%). There was no association between PCF and previous chemoradiation versus radiation (15.8% vs. 33.3%, P < 0.30), BOT involvement versus not (11.1 vs. 22.2%, P < 0.38), circumferential versus partial defect (18.8% vs. 17.9%, P < 0.94), ND versus none (10% vs. 25%, P < 0.20), or margin status. Conclusion: PCF complicated 18.2% of STL cases at our institution and was not associated with differences in primary treatment modality, presence of concomitant ND, extent of pharyngeal defect, BOT involvement, or positive frozen or permanent surgical margin.

Head and Neck Ultrasound Utilization Rates: 2012 to 2019.

Objective: We measured utilization of clinician-performed head and neck ultrasound among otolaryngologists, endocrinologists, and general surgeons, using Medicare Provider Utilization and Payment Data. Study Design: Retrospective analysis of Medicare billing database. Setting: University. Methods: For each year, the files were filtered to include 4 provider types: Diagnostic Radiology (DR), Endocrinology (ENDO), General Surgery (GS), and Otolaryngology (OTO). Billable procedures are listed by Healthcare Common Procedure Coding System code and a filter was applied to include 76536 Ultrasound, soft tissues of the head and neck. Results: In 2019, OTOs submitted charges for 2.1% of all head and neck diagnostic ultrasounds (76536) performed on Medicare beneficiaries. For each year 2012 to 2019, DRs submitted the most charges, followed by ENDOs, and then OTO and GS. Charges for all groups increased in a proportional manner across the 8-year period. 14.5% of OTOs submitted more than 100 charges apiece during 2019, that is, "super users." The percentage of super users within each specialty increased from 2012 to 2019. Overall, the data support an ever-increasing use of head and neck ultrasound (HNUS) among all provider types. Conclusion: Even with increased use among OTOs, this specialty only accounted for a small percentage of head & neck diagnostic ultrasounds performed on Medicare beneficiaries in 2019. Changes in volume of nonradiology point-of-care HNUS was not associated with changes in DR volume. A greater proportion of OTOs than DRs are "super users" among the ultrasound users within their specialty, performing more than 100 exams/year. Level of Evidence: V.

Oropharyngeal Squamous Cell Carcinoma Outcomes by p16INK4a Antigen Status in a Veteran Population.

Background: The correlation between head and neck squamous cell carcinoma (SCC) and human papillomavirus (HPV) has been of great interest. We aimed to study immunoexpression of the p16INK4a (p16) antigen, a surrogate marker for high-risk HPV infection, in oropharyngeal SCC among veterans to estimate HPV-related cancer and survival. Secondary aims included stratification of race and ethnicity, degree of tobacco and alcohol use, tumor location, stage, and age at diagnosis. Methods: A retrospective electronic health record review was performed between January 1, 2000, and December 31, 2008, at a tertiary-level US Department of Veterans Affairs (VA) medical center for veterans who were treated for oropharyngeal SCC, had follow-up for a minimum of 2 years, and for whom paraffin-embedded tissue was available. Paraffin-embedded tissue was analyzed for p16 expression. Results: We identified 66 veterans who met the inclusion criteria. p16 expression was observed in 29% of the patients. All patients were male with no difference in age at diagnosis between the groups. Among patients with p16-negative status, 60% were African American, whereas among patients with p16-postive status, 32% were African American (P = .04). Among patients with p16-postive status, 22% were tobacco-naïve, and 18% were alcohol-naïve vs 0% and 4%, respectively, of patients with p16-negative status (P = .005 and P = .12, respectively). Two-year survival was the same for both groups (P = .52). Conclusions: We observed p16 expression in 29% of VA patients with oropharnygeal SCC, which was less than observed in non-VA populations. At presentation, both groups demonstrated a predilection for tonsil location and late stage without significant difference in age or disease-specific survival. Disparities in racial distribution and tobacco use between patients with and without p16-positive status appear like that reported in non-VA populations; however, the frequently reported younger age at presentation, lower stage, and improved prognosis were not observed.

Survival and functional outcomes after total glossectomy with total laryngectomy: Case series from a high-volume tertiary institution.

OBJECTIVES: Total glossectomy with total laryngectomy (TGTL) is indicated for some cases of advanced oral squamous cell carcinoma. However, this procedure is rarely performed, as quality of life outcomes are often considered poor. Consequently, few studies to date have reported survival and functional outcomes in patients undergoing TGTL. Here, we present the largest cases series to date of TGTL patients and provide relevant data on survival and functional outcomes. METHODS: Patients met inclusion criteria if they underwent TGTL (concurrent or staged) indicated for head and neck squamous cell carcinoma. Patient demographics and disease characteristics, survival outcomes, functional oral intake scores, time to oral intake, gastrostomy tube dependence, and communication methods post-surgery were retrospectively extracted from the electronic medical record. RESULTS: Survival in patients undergoing TGTL was poor. Most patients in this study were eventually approved for some oral intake of restricted consistencies but remained gastrostomy tube dependent for most of their nutritional needs. Baseline oral intake was suboptimal in most patients but often re-achieved approximately 12 months following surgery. Communication methods following surgery included writing, text-to-speech, and augmentative and alternative communication devices. CONCLUSION: Our data provide new insights comparing survival and functional outcomes of patients undergoing TGTL. Additional investigation particularly on patient-perceived quality of life following TGTL is needed to better understand the risks and benefits for patients who are candidates for TGTL.

Oropharynx cancer after sleep apnea surgery.

Surgery can treat sleep apnea. An elderly male underwent lingual/palatine tonsillectomy for OSA. He was then found to have T3N2 p16+ squamous cell carcinoma. He is receiving chemoradiation. Recognition of occult malignancy in tonsillectomy specimens may facilitate early diagnosis and treatment for patients following sleep apnea surgery.

The submental flap: Be wary.

The submental island flap (SIF) is as an alternative to free flaps in head and neck reconstruction. 10 patients underwent submental flaps. All ten patients suffered failure of SIF as the definitive reconstructive procedure. Despite comparing favorably to free tissue transfer in published reports, our SIF had high failure rate.

Factors predictive of an academic otolaryngologist's scholarly impact.

OBJECTIVES: Describe the h index as a bibliometric that can be utilized to objectively evaluate scholarly impact. Identify which otolaryngology subspecialties are the most scholarly. Describe if NIH funding to one's choice of medical school, residency, or fellowship has any impact on one's scholarly output. Determine other factors predictive of an academic otolaryngologist's productivity. STUDY DESIGN: Analysis of bibliometric data of academic otolaryngologists. METHODS: Active grants from the National Institutes of Health (NIH) to otolaryngology departments were ascertained via the NIH Research Portfolio Online Reporting Tools Expenditures and Reports database. Faculty listings from these departments were gleaned from departmental websites. H index was calculated using the Scopus database. RESULTS: Forty-seven otolaryngology programs were actively receiving NIH funding. There were 838 faculty members from those departments who had a mean h index of 9.61. Otology (h index 12.50) and head and neck (h index 11.96) were significantly (P < 0.0001) more scholarly than the rest of subspecialists. H index was significantly correlative (P < 0.0001) with degree of NIH funding at a given institution. H index was not significantly higher for those that attended medical school (P < 0.18), residency (P < 0.16), and fellowship (P < 0.16) at institutions with NIH funding to otolaryngology departments. CONCLUSIONS: H index is a bibliometric that can be used to assess scholarly impact. Otology and head and neck are the most scholarly subspecialists within otolaryngology. NIH funding to an individual's medical school, residency, or fellowship of origin is not correlative with one's scholarly impact, but current institutional affiliation and choice of subspecialty are.

The utility of handheld ultrasound as a point-of-care screening tool to assess vocal fold impairment following congenital heart surgery.

INTRODUCTION: Vocal fold motion impairment (VFMI) is a known potential complication of congenital heart surgery (CHS). Flexible nasolaryngoscopy (FNL) is the gold standard for evaluation of vocal fold movement but has risks, including epistaxis, desaturation, and changes in heart rate. Laryngeal ultrasound (LUS) has begun to emerge as a diagnostic tool and has been shown to have high accuracy in the evaluation of VFMI. We sought to assess the utility of hand-held LUS as a point-of-care screening tool to assess VFMI in pediatric patients following congenital heart surgery. METHODS: Using a prospective cohort design, children under 18 years who were undergoing congenital heart surgery at a tertiary care pediatric hospital were enrolled. All patients underwent postoperative LUS and FNL. All studies were reviewed by two otolaryngology reviewers blinded to the clinical diagnosis. Higher quality studies were reviewed by two cardiology reviewers also blinded to the clinical diagnosis. Accuracy and inter-rater reliability were calculated. RESULTS: Sixty-two children were screened. Fourteen children with VFMI were identified via FNL. When comparing LUS and FNL, both individual accuracy (90.3% and 75.8%) and interrater agreement (79% overall, 96% for high quality videos) were high for the otolaryngology reviewers. The cardiology reviewers were able to obtain 100% accuracy for high quality videos. CONCLUSION: Handheld LUS has utility as a point-of-care screening tool to assess VFMI. This may have benefit in low-resource settings, for universal screening in cardiac intensive care units, or in settings where otolaryngology consultation may be difficult to obtain.

Lateral approach improves surgical access to the superior pole in giant endemic goiters.

BACKGROUND: Surgical management of mega-goiters in endemic areas with extreme iodine deficiency presents unique challenges. Based on our initial 5-year experience (2007 to 2011) operating on mega-goiters in Gitwe, Rwanda, Africa, we modified our technique to a lateral approach which affords better exposure of the superior pole vessels and other vital neurovascular structures, thereby improving safety. We describe this lateral approach technique and review outcomes compared to the standard technique. METHODS: From 2007 to 2019, we have conducted 13 annual surgical missions to low resource setting in Gitwe, Rwanda. Retrospective chart review of surgeries between 2012 and 2019 was performed to study outcomes using standard approach and lateral technique during the same time period. RESULTS: Over a period of 8 years (2012 to 2019), out of 192 total cases, lateral approach was used in 35 patients. No patient experienced significant intra-operative blood loss requiring transfusion. One patient had a post-operative hematoma requiring surgical intervention. Vocal cord mobility testing by transcutaneous laryngeal ultrasound was implemented in 2016. Of all patients, incidence of vocal cord weakness was 8.0% (11/137 patients tested) with less than 1/3 of these symptomatic. There was no statistically significant difference in vocal cord weakness noted in the two approaches (3/23 in lateral approach and 8/114 in standard approach) by Fisher's exact test (P=0.34). CONCLUSIONS: Lateral approach, by affording optimal exposure of the great vessels and the laryngeal nerves, reduces the risk of bleeding and nerve injury. Furthermore, inferiorly based strap muscle flap provides excellent coverage and cosmetic outcome.

Chyloma formation after anterior cervical disc fusion.

Chyle leak from iatrogenic thoracic duct injury is a rare but serious complication of head and neck surgery. The chyloma in this case took months to recognize and required open thoracic ligation. He fully recovered.

African Head and Neck Society Clinical Practice guidelines for thyroid nodules and cancer in developing countries and limited resource settings.

BACKGROUND: International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources. METHODS: Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined. RESULTS: Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines. CONCLUSIONS: Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources.

Thyroid surgery YouTube videos: estimating quality by surgeon characteristics and view rate.

BACKGROUND: With readily available material online we aimed: (I) to estimate the volume of thyroid surgery-related video content readily available to the surgical trainee; (II) to stratify the sources of thyroid surgery-related video content by source (patient, institution, surgeon, or other) and (III) to estimate the quality of the surgeon source by related scholarly output. METHODS: A search of YouTube, a widely used source of open-access video content, was undertaken using "thyroidectomy" as the search term. The first 100 "hits" were analyzed for source. When the video was surgeon-sourced, the surgeon's name was used in a PubMed author query for "thyroidectomy" and publications noted. RESULTS: Approximately 7,260 videos were returned using "thyroidectomy" as the search term. The first 100 "hits" were stratified by source, assuming the typical surgical trainee would not delve further into the list. The sources were primarily surgeons, followed by patient testimonials, and institutions. The surgeons were stratified by related publications listed in PubMed. The majority of surgeons were not published in thyroid surgery-related topics. CONCLUSIONS: Internet video content is an increasingly utilized source of surgical education. Since video content can be posted without peer review or confirmation of veracity, this study measures the variety of sources of thyroid surgery information. Individuals without thyroid surgery publication history posted the majority of surgeon-sourced video content, although this history serves only as a surrogate for an academic career. Trainees and educators alike should critically analyze the quality of video content.

The effect of intrathyroidal versus intraperitoneal bevacizumab on thyroid volume and vasculature flow in a rat model.

BACKGROUND: Several clinical conditions increase thyroid gland vascularity, impacting surgical blood loss. Bevacizumab has been observed to reduce thyroid function, possibly through its effect on gland angiogenesis. This study aimed to determine if bevacizumab has any effect on thyroid vascularity as measured by gland volume and superior thyroid artery (STA) flow velocity in the normal rat thyroid. METHODS: Sixteen adult female Sprague-Dawley rats were placed under general anesthesia to measure baseline thyroid gland characteristics. A Vevo 2100 high-frequency ultrasound with 40 mHz transducer was used to obtain STA flow measurements and thyroid gland dimensions. Four rats served as controls. Six rats received intrathyroidal (IT) injections and 6 received intraperitoneal (IP) injections of bevacizumab (4-5 mg/kg). After two weeks ultrasound measurements were repeated. RESULTS: Pretreatment animals displayed similar thyroid volume and vascularity. Thyroid volume decreased (62.583 vs. 42.161, P=0.004) after IP administration of bevacizumab, and blood flow measurements did not change [peak velocity 75.896 vs. 76.7, P=0.96, average velocity 45.748 vs. 43.867, P=0.88, or resistivity index (RI) 30.345 vs. 25.32, P=0.60]. IT bevacizumab did not change thyroid volume (55.229 vs. 58.16, P=0.64). The average peak (73.191 vs. 100.589 cm/s, P=0.03) and mean (45.047 vs. 62.843 m/s, P=0.03) velocities were increased, but did not differ in the RI (0.619 vs. 0.632, P=0.82). No differences were noted on VEGF or CD 31 immunohistochemical analysis. CONCLUSIONS: Single systemic administration of bevacizumab appears to decrease thyroid volume without an effect on STA flow, VEGF or CD31 staining. These preliminary findings support further study of pharmacologic intervention in thyroid conditions characterized by increased angiogenesis and vascularity, such as iodine deficiency, Graves disease, and hypothyroidism.

Intratonsillar abscess: A not-so-rare clinical entity.

OBJECTIVE: To report the prevalence of intratonsillar abscess in the pediatric population at our institution and demonstrate that intratonsillar abscess is a more commonly encountered diagnosis than previously reported. METHODS: A retrospective chart review was performed that included patients presenting to our pediatric tertiary referral academic emergency department from January 1, 2014 to December 31, 2014 diagnosed with intratonsillar abscess on computed tomography. RESULTS: In the year 2014, 22 children were diagnosed with intratonsillar abscess by radiological criteria. The majority of patients (82%) required no surgical intervention and were successfully treated with antibiotics and supportive measures. All patients recovered from the infection uneventfully, and there were no treatment complications recorded. CONCLUSION: Even in recent literature, intratonsillar abscess is described as a rare entity, with few cases reported. In our experience, CT imaging demonstrating the presence of intratonsillar abscess is more common than previously described. Regardless of treatment method, in our experience children with intratonsillar abscess do well clinically.

Current Experience of Ultrasound Training in Otolaryngology Residency Programs.

OBJECTIVES: The applications of using ultrasound for the evaluation and management of otolaryngologic diagnoses are expanding. The purpose of this study was to evaluate the current experience of ultrasound training in otolaryngology residency programs. METHODS: All allopathic and osteopathic otolaryngology residency programs in the United States were surveyed online via an e-mailed survey link to the resident representatives of the Section for Residents and Fellows in Training of the American Academy of Otolaryngology-Head and Neck Surgery. We present a descriptive analysis of the survey results. RESULTS: A total of 110 responses were obtained from resident representatives at MD and DO otolaryngology residency programs, representing a response rate of 94.8%. Forty-four percent of residents reported that they would not feel comfortable with performing ultrasound-guided procedures after residency; 43% reported that they do not perform ultrasound procedures as a part of their residency training; and 60% of those trainees performing ultrasound procedures do not log the procedures. Twenty-three percent of residents did not have access to an ultrasound machine. Most respondents (71%) desired more exposure to diagnostic and/or interventional ultrasound training during residency. CONCLUSIONS: Although current experience is variable, there is a strong interest in increasing resident skill acquisition in ultrasound training among otolaryngology residents. Some barriers to these goals may be a lack of trained faculty members using ultrasound and insufficient recording mechanisms for residents performing ultrasound procedures.

Validation of ultrasound as a diagnostic tool to assess vocal cord motion in an animal feasibility study.

BACKGROUND: Post-thyroidectomy dysphonia can result from recurrent laryngeal nerve (RLN) injury. Confirmation of postoperative recurrent nerve function has prompted many surgeons to advocate laryngoscopic examination. Indirect and flexible laryngoscopy permit visualization of vocal cord motion, but not all thyroid surgeons are skilled in these techniques. Indirect laryngoscopy has a significant failure rate due to gag reflexes or anatomical obstruction. Flexible fiberoptic laryngoscopy, the current gold standard, allows reliable visualization of the cords, but perioperative examination is not always feasible for lack of equipment or training. Recent studies suggest vocal fold ultrasound as an alternative to flexible laryngoscopy. It offers the advantages of being non-invasive and painless without radiation exposure or sedation. Whereas ultrasound has been compared to laryngoscopy in the clinical setting, there remains a need for correlation of laryngeal ultrasound results with known neurophysiology in the normal and injured state. An animal model was proposed that reproduces neck surgery-associated recurrent nerve injury. The model allowed simultaneous recording of laryngeal endoscopy and transcutaneous high-resolution ultrasound during stimulation of intact and injured RLNs. METHODS: One RLN was injured in each of 4 rats. Rats were kept anesthetized during the fiberoptic examination and laryngeal ultrasound procedures. Following surgery and subsequent imaging the rats were given a lethal anesthetic dose. Results of both imaging modalities were compared to the presence or absence of neuromuscular action potential following stimulation of the recurrent nerve. RESULTS: The investigators observed a 100% correlation between endoscopic and ultrasonographic assessments. CONCLUSIONS: This study validated the clinical use of diagnostic ultrasound in vocal cord dysfunction in a rodent model.

Ultrasound Guidance for Implantation of Hypoglossal Nerve Stimulator in a Breast Implant Patient.

The hypoglossal nerve stimulator (HGNS) is an effective treatment for obstructive sleep apnea in qualified patients. The implantation is typically performed without direct visualization or image guidance. A surgical approach utilizing ultrasound guidance has proved useful for patients with silicone breast implants, which may be at risk of rupture during insertion of the device. This surgical modification expands the population that can benefit from HGNS to now include patients with breast implants. Laryngoscope, 2651-2653, 2018.

Management protocol for primary hyperparathyroidism in a single institution: utility of surgeon performed ultrasound.

BACKGROUND: We aimed to: (I) discover preoperative diagnostic studies, intraoperative techniques, and patient factors most predictive of cure within a single hospital system; (II) establish practice guidelines for surgical treatment of primary hyperparathyroidism to maximize outcomes based on this hospital system's performance. METHODS: A retrospective chart review was undertaken of all parathyroid-related procedures from 01/01/02 to 7/31/15 at the Veteran's Administration Hospital. RESULTS: Seventy-one patients were eligible and charts available for analysis. Preoperative studies most predictive of cure were a combination of sestamibi parathyroid scan and surgeon performed ultrasound (S-US). When studies did not agree, S-US was most often correct. Intraoperative parathyroid hormone (PTH) rapid assay was helpful in predicting cure, but added an average of 33 minutes to operating room time. Patients who had two corroborating preoperative localizing studies, one of which was S-US, that agreed with intraoperative findings, and who did not undergo intraoperative PTH confirmation enjoyed equal cure rates and shorter operating room times. Successful achievement of normal calcium was high at 95.8%. Vitamin D deficiency was prevalent in this patient population, prompting more aggressive preoperative investigation and replacement. CONCLUSIONS: A management protocol was developed based on the findings of this study: (I) obtain two preoperative localization studies, one of which is surgeon-performed ultrasound; (II) obtain preoperative vitamin D levels and supplement as indicated; and (III) in select patients who have two strongly corroborating preoperative localization studies, one of which is surgeon performed ultrasound, and intraoperative findings are consistent with the localizing studies, intraoperative PTH (IOPTH) may not be necessary.