Can the Malnutrition Universal Screening Tool (MUST) Predict Healing Complications Following Microvascular Reconstruction of the Head and Neck?

Study Design: Retrospective cohort study. Objective: Malnutrition has been found to have negative effects on the immune system and inflammatory responses, impairing the wound healing process. Free flap failure is a serious complication in patients undergoing microvascular reconstruction, as it increases patient morbidity, length of stay in the hospital, patient, and hospital costs, as well as causes the need for further surgical interventions1. Malnutrition is estimated to be present in 35-50% of head and neck cancer patients with higher rates in those experiencing hypo-oropharyngeal disease. This is often caused by functional and pain limitations from due to disease burden causing odynophagia and dysphagia. The Malnutrition Universal Screening Tool (MUST) is recommended for risk screening and provides three scores for risk classification: high, intermediate, and low2. We argue that the use of MUST as a preoperative assessment tool is useful to predict postoperative surgical site infection and delayed wound healing in patients that will undergo reconstruction with free flaps for head and neck defects. Methods: A retrospective cohort study was designed to include all subjects who underwent head and neck microvascular free tissue transfer at a single institution between 2013 and 2019. Primary and secondary reconstructions were included, for benign or malignant pathology, osteonecrosis, osteomyelitis, congenital defects, and trauma. The nutritional risk was evaluated using MUST, which analyzes body mass index, weight loss, and acute disease effect, to classify patients as low, intermediate, and high risk. We further divided the subjects into two comparison groups- low-intermediate and high risk. The primary outcome was surgical site complications and delayed wound healing. Data was analyzed as frequencies and means with standard deviations, as well as Fisher's exact test and t-test. P-values <0.05 were considered statistically significant. Analyses were done utilizing IBM SPSS Statistics Version 29. Results: 131 subjects were included for data analysis, with 54 being considered low MUST risk, 12 intermediate risk (66 low-intermediate), and 65 were high risk. The mean BMI overall was 25.5 ±5.3, and 27.2 in the low-intermediate group, and 23.7 in the high-risk group. Eighty-two subjects experienced <5-pound weight loss in the preceding 6 months to surgery, while 17 lost between 5-10 pounds, and 23 lost 10< pounds. Cancer/osteonecrosis was the etiology for 54 (82%) subjects of the low-intermediate group, and 61 (92%) of the high-risk group (P = .089). The subjects classified in High-risk group according to the MUST score had 11% more surgical site complications (P = .120) and 13.7% more delayed wound healing and dehiscence(P = .09); only 3 subjects in the study presented total flap loss and they were all in the High-risk group. Surgical site complication, delayed wound healing rates and partial or total flap loss were not increased by any specific medical comorbidity or history such as radiation or chemotherapy. Conclusions: In conclusion, Subjects with high MUST score had increased complications and poor wound healing, and subjects with acute disease effect that induces a phase of nil per os for > 5 day have higher risk of total flap loss and surgical site complication.

Speech Pathology Services Are Integral, but Underutilized in Tracheostomy Rehabilitation.

STUDY DESIGN: Retrospective case series. OBJECTIVE: Speech language pathology (SLP) is an underutilized but important component in rehabilitation after tracheostomy. The purpose of this study was to determine rates of SLP utilization and to streamline tracheostomy decannulation to be more efficient and safer through increased utilization of SLP. METHODS: Adult patients who underwent tracheostomy from April 2016 to December 2018 were evaluated. The primary outcome was completion of any SLP evaluation after tracheostomy, and secondary outcomes were duration from surgery to evaluation, speaking valve and swallow study utilization, downsize and decannulation rates, mean duration of cannulation, and complications. RESULTS: A total of 255 subjects were included, where 197 (77.3%) underwent SLP evaluation. A minority received a speaking valve (33.7%), while approximately half underwent a swallow study (52.9%). There was a delay in SLP evaluation, with mean duration from surgery to SLP evaluation of 5.9 ± 8.0 days. There was consistent improvement in downsize and decannulation rates in all cohorts that utilized SLP services. Tracheostomy indication of head and neck cancer, trauma, completing a successful swallow study conferred increased odds of eventual decannulation, while obesity and tracheostomy history conferred lower odds. An interdisciplinary decannulation pathway was created, based on literature review and results, to assist in decision-making while progressing toward decannulation. CONCLUSION: Speech language pathologists are underutilized for rehabilitation of tracheostomy patients, where they are able to offer many skills to diagnose, treat, manage, and troubleshoot, as patients advance through the decannulation process.

Airway Management for an Adult Epiglottic Abscess.

Awake intubation is frequently described in the literature as the preferred method for securing the airway in adult patients with epiglottitis, whereas children with epiglottitis are usually intubated following an inhalational induction. However, if topicalization is difficult due to the presence of an abscess or an uncooperative patient, an inhalational induction may still be a reasonable approach in the adult patient. In a review of the literature, only one recent case report had been found describing an inhalational induction with video laryngoscopy. However, this attempt was unsuccessful, mandating the need for a surgical airway. Our case report describes a successful inhalational induction and video laryngoscope intubation without the use of a paralytic agent in an adult patient with an epiglottic abscess and moderate airway stenosis.

Insurance Status, an Important Predictor of Oral Cancer Surgery Outcomes.

PURPOSE: Patients without insurance, or using Medicaid, generally have a lower socioeconomic status. They have less access to screening and regular medical care, resulting in later diagnosis of oral cancer. This study examined the association between insurance status and the likelihood of complications after head and neck cancer surgery. MATERIALS AND METHODS: A retrospective cross-sectional study was implemented to determine whether patients' insurance status is associated with increased complications and length of stay after oral cancer surgery. Patients were grouped into 4 cohorts: 1) private insurance, 2) Medicare, 3) Medicaid, and 4) uninsured. Patients were stratified further to consider age, gender, initial staging, pre-existing comorbidities, and social history. Data were analyzed with χ(2) test, 1-way analysis of variance, odds ratios, and binary logistic regression. RESULTS: This study consisted of 89 surgically treated patients. The uninsured and Medicaid groups had the highest incidence of postoperative complications. Uninsured patients, followed by the Medicare cohort, were the most likely to have an extended length of stay. CONCLUSION: Uninsured and Medicaid patients are at increased probability for major and minor complications after head and neck cancer surgery. Uninsured patients also showed the greatest tendency for a prolonged length of hospital stay. This could reflect their lack of preventive care, increased use of tobacco and alcohol, presentation with more advanced disease, and delays in initiating treatment.