Structural Support for Large to Total Nasal Reconstruction.

When large defects of the nose are present, it is imperative to address all 3 layers: the external skin envelope, the osteocartilaginous support, and the inner mucosal lining. The middle structural framework is the primary factor in determining the overall shape of the nose, in addition to facilitating a functional and patent airway. As such, its reconstruction must be robust enough to provide lasting osteocartilaginous support while minimizing disfiguring bulk. The goal is replacement of missing tissue with grafts of similar strength, size, and shape. This article will review approaches to the reconstruction of structural support in large nasal defects.

Speech Intelligibility in Patients with Facial Paralysis.

Background: Patients with facial paralysis often report frustration with communication; however, there are limited data regarding intelligibility deficiencies. Objective: To compare speech intelligibility in patients with severe and non-severe facial paralysis, and in patients with or without synkinesis. Methods: Video and audio data were reviewed retrospectively. Groups were stratified as follows: Group A - severe paralysis (Sunnybrook 0-20) without synkinesis; Group B - non-severe (Sunnybrook >20) paralysis without synkinesis; and Group C - non-severe paralysis with synkinesis. Intelligibility was assessed by lay-people and a speech and language pathologist (SLP) using the Frenchay Dysarthria Assessment Version 2 (FDA-2). A receiver operating characteristic (ROC) curve was used to determine a Sunnybrook cutoff for intelligibility. Results: Eighty cases were reviewed with mean age 55.6, 53.8% female. 25.0% were in Group A, 30.0% Group B, and 45.0% in Group C. Lay-people rated 15.0% and the SLP rated 28.7% as having intelligibility deficiency. An ROC curve demonstrated that patients with Sunnybrook ≤18.5 were more likely to have intelligibility abnormality. Conclusion: Patients with Sunnybrook ≤18.5 are more likely to demonstrate intelligibility deficiency. Clinicians with a more trained ear are more likely to identify intelligibility abnormality compared with lay-people. Those with synkinesis are more intelligible compared with those without it.

Latissimus dorsi myocutaneous free flap for the laryngopharyngectomy defect.

BACKGROUND: Partial or total laryngopharyngectomy defects have traditionally been reconstructed using the radial forearm, anterolateral thigh, or jejunal free flaps. The latissimus dorsi myocutaneous free flap (LDMFF) is an option for high-risk patients with complex laryngopharyngeal ± cutaneous neck defects. METHODS: Retrospective single-surgeon case series from 2017 to 2022. Outcomes were assessed at both the back donor site and head and neck. RESULTS: Twenty-four patients were identified. Flap survival was 100%. There was 1 (4.2%) pharyngocutaneous fistula and 2 (8.3%) tracheo-esophageal peristomal fistulas. At last follow-up, 17 (71%) were sustaining weight on oral intake, and 7 (29%) were G-tube dependent with 4 of these able to do some type of oral intake. Seven (29.2%) had post-operative stricture/stenosis requiring dilation. There were only minor donor site complications, all managed conservatively. CONCLUSIONS: The LDMFF can be a robust reconstructive option, particularly for radiated high-risk patients with complex pharyngeal defects, including skin.

Treatment Options in Mal de Débarquement Syndrome: A Scoping Review.

OBJECTIVE: The purpose of this study was to review current treatment options available for mal de debarquement syndrome (MdDS). DATA SOURCES: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review guidelines, we performed systematic search queries for MdDS-related texts. Documents must have been in the English language, and the time frame was all documents up until May 23, 2022. METHODS: Studies were selected if they were published in a peer-reviewed journal and if one of the primary objectives was the assessment of treatment for MdDS. The quality and validity of all documents were assessed by two independent co-investigators. Conflicts were resolved by a third investigator. RESULTS: One hundred ninety-four unique references were identified and underwent review. Ninety-seven were selected for full-text review, and 32 studies were ultimately included. Data were stratified by treatment methodology for MdDS. The categories used were pharmacologic, physical therapy, and neuromodulating stimulation. CONCLUSIONS: Improvement in patient-reported outcomes is reported with several treatment modalities including specific protocols of vestibular rehabilitation, neuromodulating stimulation, and pharmacologic management with several types of neurotropic drugs.

Patient-Related Factors Do Not Predict Use of Computer-Based Auditory Training by New Adult Cochlear Implant Recipients.

OBJECTIVE: The use of computer-based auditory training (CBAT) after cochlear implantation is associated with improved speech recognition and real-world functional abilities. However, patient-related factors associated with CBAT use remain unknown. This study seeks to identify such factors and recognize those at risk for not implementing CBAT. STUDY DESIGN: Prospective natural experiment. SETTING: Tertiary academic center. PATIENTS: A total of 117 new adult cochlear implant (CI) recipients with bilateral moderate-to-profound hearing loss. INTERVENTIONS/MAIN OUTCOME MEASURES: Patient demographic and lifestyle information, preimplantation aided speech recognition scores, Cochlear Implant Quality of Life (CIQOL) domain and global scores, CIQOL-Expectations scores, and CBAT use in the first 3 months after activation. Patient-related variables included age, sex, race, duration of hearing loss before implantation, hours of CI use per day, hearing-aid use before implantation, living arrangements/marital status, annual household income, employment, technology use, and education. RESULTS: Overall, 33 new CI users (28.2%) used CBAT in the first 3 months after activation. On bivariate analysis of the pre-CI CIQOL scores, CIQOL-Expectations score, aided speech recognition scores, and demographic/lifestyle factors examined, regular use of smartphone, tablet, or computer technology was significantly associated with an increased likelihood of CBAT use (odds ratio, 9.354 [1.198-73.020]), whereas higher CIQOL-Expectations emotional domain scores were associated with a lower likelihood of CBAT use (d = -0.69 [-1.34 to -0.05]). However, using multivariable analysis to control for potential confounding factors revealed no significant associations between CBAT use in the first 3 months after cochlear implantation and any examined factor. CONCLUSIONS: No associations between patient demographic, lifestyle, or pre-CI speech recognition and patient-reported outcome measures and CBAT use were identified. Therefore, discussions with all patients after implantation on the availability of CBAT and its potential benefits are warranted. In addition, given the limited overall use of CBAT and its association with improved CI outcomes, future studies are needed to investigate facilitators and barriers to CBAT use.

Tracheotomy Outcomes in 64 Ventilated COVID-19 Patients at a High-Volume Center in Bronx, NY.

OBJECTIVES/HYPOTHESIS: The COVID-19 pandemic has resulted in a dramatic increase in the number of patients requiring prolonged mechanical ventilation. Few studies have reported COVID-19 specific tracheotomy outcomes, and the optimal timing and patient selection criteria for tracheotomy remains undetermined. We delineate our outcomes for tracheotomies performed on COVID-19 patients during the peak of the pandemic at a major epicenter in the United States. METHODS: This is a retrospective observational cohort study. Mortality, ventilation liberation rate, complication rate, and decannulation rate were analyzed. RESULTS: Sixty-four patients with COVID-19 underwent tracheotomy between April 1, 2020 and May 19, 2020 at two tertiary care hospitals in Bronx, New York. The average duration of intubation prior to tracheotomy was 20 days ((interquartile range [IQR] 16.5-26.0). The mortality rate was 33% (n = 21), the ventilation liberation rate was 47% (n = 30), the decannulation rate was 28% (n = 18), and the complication rate was 19% (n = 12). Tracheotomies performed by Otolaryngology were associated with significantly improved survival (P < .05) with 60% of patients alive at the conclusion of the study compared to 9%, 12%, and 19% of patients undergoing tracheotomy performed by Critical Care, General Surgery, and Pulmonology, respectively. CONCLUSIONS: So far, this is the second largest study describing tracheotomy outcomes in COVID-19 patients in the United States. Our early outcomes demonstrate successful ventilation liberation and decannulation in COVID-19 patients. Further inquiry is necessary to determine the optimal timing and identification of patient risk factors predictive of improved survival in COVID-19 patients undergoing tracheotomy. LEVEL OF EVIDENCE: 4-retrospective cohort study Laryngoscope, 131:E1797-E1804, 2021.

Early Surgical Management of Medical Tourism Complications Improves Patient Outcomes.

BACKGROUND: Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs. METHODS: A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors' primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis. RESULTS: Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003). CONCLUSIONS: Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The safety and efficacy of open bedside tracheotomy: A retrospective analysis of 1000 patients.

OBJECTIVES: To evaluate the safety/efficacy of performing open bedside tracheotomy (OBT) in intensive care unit (ICU) patients and identify predictive factors for outcomes. METHODS: This is a retrospective cohort study. We identified 1000 consecutive patients undergoing OBT at a single university hospital starting from August 1, 2007. Complication rate, 30-day mortality, decannulation rate, time to surgery (TTS) from initial consult, and ICU length of stay were analyzed. Multivariate analysis was performed to identify predictors of complication rate, 30-day mortality, and decannulation rate. RESULTS: Mean TTS was 1.80 days. Major complication rate was 1%. No intraoperative deaths were caused by tracheotomy although two deaths resulted from late tracheotomy-related complications. Thirty-day mortality was 26.6%. The only significant predictor for overall complications was mild chronic hepatitis (OR = 2.355). Predictors for 30-day mortality included platelet count <50,000 (OR = 2.125) and vasopressor use (OR = 3.51). Each additional year of age was associated with decreased decannulation rate (OR = 0.972). CONCLUSIONS: This study demonstrates the safety and efficacy of starting an OBT program in a highly comorbid population without strict selection criteria. Safety of OBT was supported by minimal major complication rates and no intraoperative tracheotomy-related deaths in our cohort. These complication rates were comparable to, or lower than, published studies of open and percutaneous techniques. Predictive factors for decannulation, complication, and mortality were identified to help determine which patients would benefit from OBT. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1263-1269, 2020.

Bariatric surgery in the elderly: outcomes analysis of patients over 70 using the ACS-NSQIP database.

BACKGROUND: Bariatric surgery offers patients with morbid obesity and related diseases short- and long-term benefits to their health and quality of life. Evidence-based medicine is integral in the evaluation of risk versus benefit; however, data are lacking for several high-risk patient populations, including the elderly. OBJECTIVES: This study assessed morbidity and mortality data for patients age ≥70 undergoing laparoscopic sleeve gastrectomy (SG) or laparoscopic Roux-en-Y gastric bypass (RYGB). SETTING: University Hospital, Bronx, New York, United States using national database. METHODS: We used the American College of Surgeons-National Surgical Quality Improvement Project database for years 2005-2016 and identified patients who underwent primary SG or RYGB. Patients age ≥70 were assigned to the over age 70 (AGE70+) cohort and younger patients were assigned to the under age 70 (U70) cohort. Postoperative length of stay and 30-day morbidity and mortality were assessed. RESULTS: A total of 1498 patients age ≥70 underwent nonrevisional bariatric surgery, including 751 (50.1%) SG and 747 (49.9%) RYGB. AGE70+ was associated with increased mortality and increased rates of cardiac, pulmonary, renal, and cerebrovascular morbidity. AGE70+ patients had longer mean length of stay, and were more likely to require transfusion and return to operative room. When stratified by procedure, rates of organ-space surgical site infection, acute renal failure, urinary tract infection, myocardial infarction, deep vein thrombosis/thrombophlebitis, and septic shock were significantly increased in AGE70+ patients undergoing RYGB but not SG. Impaired functional status was associated with increased rates of morbidity and mortality for AGE70+ patients and for U70 patients, although the small number of patients within each category limited statistical analysis. CONCLUSIONS: Evaluation of risk versus benefit is performed on a case-by-case basis, but evidence-based medicine is critical in empowering surgeons and patients to make informed decisions. The overall rate of morbidity and mortality for AGE70+ patients undergoing bariatric surgery was increased relative to U70 patients. Rates of several adverse events, including acute renal failure and myocardial infarction, were increased in AGE70+ patients undergoing RYGB but not SG, suggesting that SG may be the preferred procedure for elderly patients with organ-specific risk factors. The increased rates of morbidity and mortality observed for patients with impaired functional status supports consideration of functional status when evaluating preoperative risk.

Association of Delayed Time to Treatment Initiation With Overall Survival and Recurrence Among Patients With Head and Neck Squamous Cell Carcinoma in an Underserved Urban Population.

IMPORTANCE: Delay in time to treatment initiation (TTI) can alter survival and oncologic outcomes. There is a need to characterize these consequences and identify risk factors and reasons for treatment delay, particularly in underserved urban populations. OBJECTIVES: To investigate the association of delayed treatment initiation with outcomes of overall survival and recurrence among patients with head and neck squamous cell carcinoma (HNSCC), to analyze factors that are predictive of delayed treatment initiation, and to identify specific reasons for delayed treatment initiation. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study at an urban community-based academic center. Participants were 956 patients with primary HNSCC treated between February 8, 2005, and July 17, 2017, identified through the Montefiore Medical Center Cancer Registry. EXPOSURES: The primary exposure was TTI, defined as the duration between histopathological diagnosis and initial treatment. The threshold for delayed treatment initiation was determined by recursive partitioning analysis. MAIN OUTCOMES AND MEASURES: Overall survival, recurrence, and reasons for treatment delay. RESULTS: Among 956 patients with HNSCC (mean [SD] age, 60.8 [18.2] years; 72.6% male), the median TTI was 40 days (interquartile range, 28-56 days). The optimal TTI threshold to differentiate overall survival was greater than 60 days (20.8% [199 of 956] of patients in our cohort). Independent of other relevant factors, patients with HNSCC with TTI exceeding 60 days had poorer survival (hazard ratio, 1.69; 95% CI, 1.32-2.18). Similarly, TTI exceeding 60 days was associated with greater risk of recurrence (odds ratio, 1.77; 95% CI, 1.07-2.93). Predictors of delayed TTI included African American race/ethnicity, Medicaid insurance, body mass index less than 18.5, and initial diagnosis at a different institution. Commonly identified individual reasons for treatment delay were missed appointments (21.2% [14 of 66]), extensive pretreatment evaluation (21.2% [14 of 66]), and treatment refusal (13.6% [9 of 66]). CONCLUSIONS AND RELEVANCE: Delaying TTI beyond 60 days was associated with decreased overall survival and increased HNSCC recurrence. Identification of predictive factors and reasons for treatment delay will help target at-risk patients and facilitate intervention in hospitals with underserved urban populations.

Analysis of Immediate versus Delayed Sternal Reconstruction with Pectoralis Major Advancement Versus Turnover Muscle Flaps.

BACKGROUND: The pectoralis major muscle flap is a versatile reconstructive option for deep sternal wound infections (DSWI). The timing and surgical technique of bilateral pectoralis major muscle advancement flaps versus unilateral pectoralis major muscle turnover and unilateral pectoralis major muscle advancement flap on patient outcomes remain to be elucidated. The purpose of this investigation was to compare timing, immediate versus delayed reconstruction, and the surgical technique in patients with deep sternal wounds infections on patient outcomes. METHODS: A retrospective review of patients who underwent sternal reconstruction with pectoralis major muscle was conducted. Patients diagnosed with DSWI after undergoing cardiac surgery were included for analysis. Patients were divided by flap timing and flap type for analyses. Bivariate tests were performed to compare patient clinical characteristics. Outcomes of interest were rates of postoperative complications, same admission mortality, reoperation, readmission, operating room time, and length of stay. RESULTS: A total of 88 patients were included for analyses (n = 57 bilateral advancement, n = 31 unilateral advancement with unilateral turnover; n = 62 immediate, and n = 26 delayed). Baseline characteristics did not differ between groups of flap type or timing. When postoperative complication rates were compared, the rate of tissue necrosis was significantly greater in patients with unilateral advancement with unilateral turnover flaps (n = 6 [19.4%]) compared with bilateral advancement flaps (n = 2 [3.5%]; p = 0.021). Mortality during admission did not differ with respect to flap type but differed significantly with respect to flap timing (immediate n = 7 [11.3%], delayed n = 9 [34.6%]; p = 0.015). Length of stay differed significantly by both type and timing (type: bilateral advancement = 26.9 ± 22.6 days, unilateral turnover = 38.0 ± 26.7 days, p = 0.042; timing: immediate = 26.8 ± 22.1 days, delayed = 40.2 ± 27.8, p = 0.019). CONCLUSION: Patients who underwent pectoralis major muscle advancement flaps had lower incidence of tissue necrosis. Furthermore, the timing of immediate sternal reconstruction was associated with a decreased hospital length of stay.