Recurrent Zenker's Traction Diverticulum After Cervical Spine Surgery: Lessons Learned.

This is a report of our institutional experience regarding pharyngoesophageal diverticula formation following anterior cervical spine surgery (ACSS). It is a retrospective chart review of institutional patients from January 2008 to May 2020. Patients at our institution were identified by our two senior authors. Inclusion criteria included patients > 18 years old, a history of prior ACSS, and a confirmed diagnosis of pharyngoesophageal diverticulum with radiographic imaging. Three patients were identified to have an ACSS-related diverticulum. The case presentations describe surgical management and the subsequent postoperative course. One patient had a particularly complicated course with recurrent diverticulum formation despite prior excision. The patient continued to have dense scar tissue adhering the posterior esophageal wall to the nearby cervical spine plates, despite prior excision and rotation of nearby tissue. This difficult case demonstrated the need for an open and aggressive approach. ACSS-related diverticula that form in patients with a history of prior anterior cervical spine surgery appear to be a form of traction diverticulum due to dense scar tissue that adheres the pharyngoesophageal mucosa to the adjacent cervical spinal plate. This type of diverticulum differs from Zenker's diverticulum. Surgical management is recommended to resolve patients' symptoms.

Institutional experience with total pharyngectomy reconstruction: Exploring the role of the salivary bypass tube.

BACKGROUND: There is a lack of consensus regarding the effectiveness of salivary bypass tubes during total pharyngectomy reconstruction to prevent pharyngocutaneous fistula or pharyngoesophageal stricture. METHODS: Our study examined tubed free flap reconstruction outcomes for total pharyngectomy defects over 11 years at a single tertiary referral center. We compared postoperative fistula and stricture rates between two groups: those with salivary bypass tubes inserted during reconstruction and those without. RESULTS: Among 36 patients, 26 had radial forearm, and 10 had anterolateral thigh free flap reconstruction. 53% received salivary bypass tubes. However, the tubes did not significantly reduce the relative risks of fistula or stricture. Notably, neck dissection during total pharyngectomy was associated with increased fistula incidence. Minor salivary bypass tube-related complications affected 21% of subjects. CONCLUSION: The role of salivary bypass tubes in total pharyngectomy reconstruction remains uncertain.

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.

Risk Factors for Recurrence and the Role of Radiotherapy in Low-grade Myofibroblastic Sarcoma: A Systematic Review.

Low-grade myofibroblastic sarcoma (LGMS) is a rare malignancy that commonly occurs in the head and neck region. The role of radiotherapy has been unclear in treating LGMS and the risk factors for recurrence have remained undefined. The objective of this study is to determine risk factors for the recurrence of LGMS in the head and neck as well as the role of radiotherapy in the treatment of LGMS. A comprehensive review of the literature was performed through Pubmed leading to the inclusion of 36 articles after our inclusion and exclusion criteria were applied. Continuous variables were analyzed with a 2-tail unpaired t test. Categorical variables were assessed with the χ 2 test or Fisher exact test. Logistic regression and multivariable logistic regression analysis with 95% CIs were used to obtain odds ratios. LGMS most commonly occurred in the oral cavity (49.2%). Half of all recurrences occurred in the paranasal sinuses/skull base. LGMS occurring at the paranasal sinuses/skull base had a significantly increased risk of recurrence compared with other subsites within the head and neck (odds ratio: -40; 95% CI: 2.190, 762.005; P = 0.013). The average time to recurrence of LGMS was 19.2 months. Adjuvant treatment with radiation did not improve recurrence rates. Sex, tumor size, or bony involvement were not found as risk factors for recurrence. Patients with LGMS of the paranasal sinuses and skull base are at high risk for recurrence and should be monitored closely. The role of adjuvant radiation treatment in these patients remains unclear.

Relationship Between Worst Pattern of Invasion and Extranodal Extension in Oral Tongue Squamous Cell Carcinomas.

BACKGROUND: Oral tongue squamous cell carcinoma (OTSCC) is a common malignancy of the oral cavity with poor survival rates. The aim of this project is to investigate the relationship between certain histopathological factors such as Worst Pattern of Invasion (WPOI) and Extranodal Extension (ENE) in patients with oral tongue squamous cell carcinoma (OTSCC) who underwent surgical resection at Loyola University Medical Center. METHODS: This was a retrospective cohort study at a tertiary care academic medical center. All patients that underwent primary surgical resection of OTSCC between 1/1/2015 and 1/1/2022 were reviewed. Patients were identified using the Cerner CoPath Laboratory Information System. RESULTS: A total of 82 patients met inclusion criteria and were included in the study. Higher grades of WPOI (WPOI 5) were not significantly associated with the presence of ENE in our study (P = 0.82), regardless of the presence of major or minor ENE. WPOI 5 was associated with a higher incidence of local recurrence (P = 0.011). CONCLUSIONS: Higher grades of WPOI were not found to correlate with the presence of ENE, a common histopathological factor that is used as an important prognostic indicator in OTSCC. It is important for clinicians to consider these factors separately when determining whether a patient is high-risk and would benefit from aggressive multimodal treatment.

The Dynamic Tracheoesophageal Prosthesis Length.

OBJECTIVE: In a postlaryngectomy patient, tracheoesophageal (TE) speech is considered to be the most effective and preferred method of communication. Previous research has demonstrated that despite an appropriately sized TE prosthesis placement at the time of puncture, there are a portion of patients that require resizing postoperatively. The purpose of this study was to report on the variability of the tracheoesophageal prosthesis length. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic medical center. METHODS: This was a retrospective chart review of 62 patients who underwent secondary tracheoesophageal puncture (TEP) at a tertiary care academic medical center from January 2008 to November 2019. Patient demographic information, average changes in prosthesis length, number of prosthesis adjustments, and timing of prosthesis exchanges were collected. RESULTS: 62 patients met criteria for study inclusion. Mean age was 61.96 years old with 49 being male (79%) and 13 (21%) females. Overall change in prosthesis length was - 3.85 mm ± 3.58 with time to first prosthesis change at 2.29 months ± 2.73. There was an average of 4.37 changes ± 3.43 before reaching a stable length. Twenty-six patients (41.9%) had increases in their prosthesis length resulting in closure of the tracheoesophageal fistula requiring seven patients (11.3%) to return to the operating room for repuncturing. History of smoking (P = 0.02), Blom-Singer prosthesis type (P = 0.03), and larger diameter (P = 0.01) appeared to be predisposing factors for a fluctuating prosthesis length. CONCLUSION: Tracheoesophageal prosthesis length decreases over time for secondary punctures, requiring adjustments with a speech language pathologist. There are a clinically significant portion that have fluctuations in prosthesis length resulting in an increased risk for requiring re-puncturing.

A Case of Panophthalmitis Secondary to Odontogenic Maxillary Sinusitis.

Endogenous endophthalmitis is a bacterial or fungal infection within the eye that includes the vitreous and aqueous humors. Panophthalmitis is a subtype of endogenous endophthalmitis that also includes infection of the adjacent soft tissue of the orbit. We present a case of a 91-year-old female who initially presented with left eye pain and decreased vision. She was found to have panophthalmitis secondary to odontogenic maxillary sinusitis. To our knowledge, there has not been a case reported in the literature before that has established this association between panophthalmitis and odontogenic maxillary sinusitis.

The role of perineural invasion in parotid malignancy outcomes: A systematic review and meta-analysis.

PURPOSE: At present, perineural invasion is used as a histologic indicator of aggressive salivary gland disease. In other head and neck malignancies, perineural invasion impacts staging of cancer lesions and therefore affects treatment options. OBJECTIVE: To compare survival outcomes in primary parotid malignancies with and without perineural invasion.A systematic review pooled data from the scientific literature in patients with any primary parotid malignancy to investigate the prognosis of those with perineural invasion. DATA SOURCES: PubMed (Medline), Scopus and Cochrane databases were queried from inception to July 2020 without any initial search constraints. Additional publications were included from review of pertinent articles. STUDY SELECTION: Our inclusion criteria included primary parotid cancers with reported perineural invasion on survival outcomes. Exclusion criteria were non-English language text, non-human studies, reviews, textbooks, abstracts, case reports and case series. Two authors independently reviewed articles for inclusion. Of the initial 465 records, 83 articles were reviewed in full to yield a final collection of 14 studies. DATA EXTRACTION AND SYNTHESIS: PRISMA-p guidelines were used in the reporting of our studies. A MOOSE Checklist was also used. MINORS criteria were applied to assess risk of bias. Random-effects models were used to estimate pooled effect sizes. No institutional review board review was needed for our study. MAIN OUTCOMES AND MEASURES: Primary study outcomes were set prior to data collection and included overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS) and distant-metastasis-free survival (DMFS) in patients with and without perineural invasion. RESULTS: Fourteen studies contributed to this meta-analysis. Compared to patients without perineural invasion, the pooled rate of mortality (HR = 3.64), time to recurrence (HR = 3.56), disease-specific mortality (HR = 2.77) and distant metastasis (HR = 3.84) was significantly higher for patients with PNI (all p <.001). Controlling for perineural invasion status, no moderator was associated with these survival outcomes (all p >.05). Given the clinical severity of perineural invasion, few studies were null as shown in a panel of publication bias plots. CONCLUSION: Perineural invasion portends a poor survival outcome in patients with parotid malignancies.

An institutional review of recurrent pleomorphic adenoma of the parotid gland.

OBJECTIVE: Surgical resection is standard treatment for pleomorphic adenoma (PA) of the parotid gland. A small number (2-5%) of these tumors recur. Recurrence usually necessitates reoperation, which is technically challenging and puts the facial nerve (FN) at risk. The aim of this study is to characterize the recurrent parotid PA population and compare outcomes after surgery for singly recurrent and multiply recurrent tumors. METHODS: This study was a retrospective chart review of patients at a single tertiary care academic medical center who underwent operations for recurrent PA of the parotid gland between 2007 and 2020. Demographic data, details of surgical interventions, pre- and postoperative FN function, and recurrence rates were studied. These factors were compared between patients with singly and multiply recurrent tumors. RESULTS: Thirty-eight patients met criteria: 4 patients presented for primary PA and subsequently recurred, 26 with a first recurrence, 7 with a second recurrence, and 1 with a fourth recurrence. Multiply recurrent PAs were more likely to require at least partial nerve sacrifice at the time of reoperation (P = 0.0092). Significantly worse long-term FN outcomes were seen following surgery for multiply recurrent PA (P = 0.008). There was no significant difference between the rate of re-recurrence following first revision surgery vs second-fourth revision surgery. Time to reoperation was significantly shorter between the first and second revision surgery than between the primary surgery and first revision (P = 0.0017). CONCLUSION: Surgery for recurrent PA incurs high risk to the FN, and this risk appears to increase in the setting of multiple recurrences.

Aneurysmal Bone Cysts of the Craniofacial Origin: A Systematic Review.

OBJECTIVE: Aneurysmal bone cysts (ABCs) are blood-filled, locally destructive, benign bone tumors. Our objective was to conduct a systematic review outlining patient demographics, clinical characteristics, management, and outcomes of those with ABCs of the craniofacial bones. DATA SOURCES: Using PubMed, Cochrane, and Embase databases, 116 studies were included. REVIEW METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted. Data including patient demographics, clinical characteristics, treatment strategies, and patient outcomes were collected. RESULTS: A total of 127 patients from 116 studies were identified. Age ranged from 8 months to 90 years, with a mean age of 19.0 years. The most commonly affected craniofacial locations were the mandible (n = 31, 24.4%), temporal bone (n = 21, 16.5%), and occipital bone (n = 14, 11.0%). The most common presenting symptoms included a nontender mass (n = 51, 40.2%), a tender mass (n = 31, 24.4%), and generalized headache (n = 30, 23.6%). Imaging modalities included computed tomography (CT) and magnetic resonance imaging (MRI) (n = 77, 60.6%), CT alone (n = 31, 24.4%), and MRI alone (n = 8, 6.2%). All patients underwent surgical resection, with 1 patient requiring adjuvant radiation in addition to surgery. In total, 121 patients were disease-free and symptom-free without evidence of recurrence (17.4-month mean follow-up, 5.4 months average time to first recurrence). CONCLUSION: The current literature's characterization of ABCs in craniofacial bones is limited to case reports and case series. Given the rarity of these tumors, head and neck surgeons may rely on systematic reviews such as the present analysis to guide management.

Salvage Total Laryngectomy Swallowing Outcomes Based on Flap Reconstruction: Onlay vs Incorporated Technique.

After a salvage total laryngectomy, one of patients' primary goals is to resume oral intake. This retrospective chart review included all patients who underwent a salvage total laryngectomy with free or pedicled flap reconstruction to compare swallowing outcomes in those with an incorporated flap or primary pharyngeal closure with an onlay flap. There was no significant difference in the ability to achieve complete feeding tube independence or the time that it took to achieve independence. Patients with an onlay flap had significantly lower rates of subjective dysphagia and stricture as compared with patients with incorporated flaps. Incorporated fasciocutaneous flaps showed no significant difference from onlay flaps in terms of outcomes. However, incorporated musculocutaneous flaps showed higher rates of subjective dysphagia and stricture when compared with onlay flaps. Patients undergoing a salvage total laryngectomy and reconstruction with an onlay flap had significantly less postoperative dysphagia and stricture than patients with a musculocutaneous incorporated flap.

HPV vaccination practices and attitudes among primary care physicians since FDA approval to age 45.

PURPOSE: The aim of this study was to examine HPV vaccine administration practices since FDA approval to age 45 and assess knowledge regarding HPV and its association with oropharyngeal cancer. METHODS: A survey was distributed to 86 primary care physicians at Loyola University Medical Center. The survey contained 11 questions designed to capture HPV vaccination practices, knowledge of FDA approval, and barriers to vaccination. RESULTS: 46 (53%) physicians completed the survey and 45 responses were included. Among respondents who treat males ages 9-21 and females ages 9-26, the vaccination is widely recommended with >95% always or almost always recommending the vaccination. Among those treating males >21, and females >26, 52% and 35% of physicians recommend vaccination to these cohorts, respectively. Only 17% and 26% of respondents would recommend the vaccine to men and women respectively up to age 45. 100% of respondents recognize an association between HPV and cervical cancer, and 90% of respondents recognize HPV's association with oropharyngeal cancer. However, respondents also associate HPV with oral cavity and laryngeal cancer. 28% of respondents said parents are barriers to vaccination, while 7% said that insurance is a barrier. CONCLUSIONS: HPV vaccination is widely recommended by physicians at our institution; however, for men older than 21 and women older than 26, vaccination recommendation rates decrease, and relatively few physicians would offer the vaccination up to age 45. Primary care physicians at our institution recognize HPV's close association to oropharyngeal cancer. Barriers to vaccination are primarily negative perception of the vaccine by patients and parents.

Comparing postoperative outcomes after free flap surgery in a specialty step-down unit vs nonspecialty intensive care unit.

BACKGROUND: To determine if there was a difference in postoperative outcomes of head and neck free flap reconstruction patients treated in a specialty step-down unit compared to a nonspecialty intensive care unit (ICU). METHODS: A retrospective review was performed of all patients who underwent free flap reconstruction for head and neck defects from 2014 to 2017 at Loyola University Medical Center. Patients managed postoperatively in the ICU were compared to patients managed in a specialty step-down unit. Postoperative outcomes, length of stay, and readmission were compared. RESULTS: Three hundred and five patients were included in the study. Patients managed postoperatively in the specialty step-down unit had comparable rates of postoperative complications and flap failure as ICU patients. Step-down patients had significantly shorter lengths of stay (Mdn = 5 days, IQR = 5-7 days) than patients in the ICU (Mdn = 6 days, IQR = 5-6 days; P < .001).

Oral tongue cancer in a patient with hereditary nonpolyposis colorectal cancer: A case report and review of the literature.

Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant disorder characterized by mutations of mismatch repair genes leading to the early development of multiple malignancies. The most common malignancy is colorectal cancer but there is a strong association with malignancies of the ovary, endometrium, small intestine, stomach, skin, brain, and pancreas. We report a case of a 35-year-old female with a history of known HNPCC who presented with adenocarcinoma of the small intestine as well as a synchronous oral tongue squamous cell carcinoma. The patient underwent a combined oncologic surgery involving a hemiglossectomy, selective neck dissection, and partial small bowel resection. Despite the wide range of malignancies seen in patients with HNPCC, no cases of oral cavity cancer have previously been reported. This represents the first case in the literature of oral cavity cancer in a patient with HNPCC.

Postoperative Tachycardia in Head and Neck Microvascular Free Flap Patients.

OBJECTIVE: The goal of this study was to determine the incidence of postoperative tachycardia and its predictive value of complications in patients following microvascular free flap surgery in the head and neck. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care academic medical center. SUBJECTS AND METHODS: All patients who underwent a microvascular free flap of the head and neck by surgeons in the department of otolaryngology from 2013 to 2017 were included in this study. RESULTS: Of the 344 who patients met inclusion criteria, 40.4% had a maximum heart rate (HR) of the hospitalization over 110 beats per minute (bpm). Patients with a maximum HR greater than 110 bpm were 19 times more likely to experience a composite vascular complication (myocardial infarction, myocardial necrosis, or pulmonary embolism) than patients with a maximum HR <110 bpm ( P = .0063). Patients with a history of chronic kidney disease were also noted to have an increased risk of experiencing a postoperative composite vascular event. CONCLUSION: Postoperative tachycardia is significantly associated with adverse outcomes and should not be dismissed as a normal variant. Identifying patients at an increased risk of having an underlying complication can help guide interpretation, workup, and management of postoperative patients in the head and neck population.

Body Mass Index and Parotidectomy Outcomes.

Multiple specialties have demonstrated increased risk of certain postoperative complications in patients with an increased body mass index (BMI). The goal of this study was to understand the outcomes of patients undergoing parotidectomy with an increased BMI and to identify any other patient risk factors for postoperative complications. This study was a retrospective chart review of 432 patients. Patient variables collected included BMI, age, gender, history of diabetes mellitus, type of parotidectomy, and pathology. Outcomes reviewed included facial nerve weakness, hematoma or seroma formation, and wound infection. The results showed that BMI had no statistically significant effect on complications. However, patients undergoing a total parotidectomy, malignant pathology, and patients with a history of diabetes mellitus had significantly more postoperative facial weakness. In conclusion, BMI does not influence postoperative complications in patients undergoing parotidectomy. Patients with diabetes, those undergoing total parotidectomies, and patients with malignant pathology have significantly more facial weakness and should be counseled accordingly.

Safety and Efficacy of Outpatient Parotidectomy.

PURPOSE: Given the increasing costs of medical care, there has been a shift to outpatient elective surgeries in certain patient populations among all surgical specialties. The goal of this study was to compare the safety and efficacy of outpatient parotidectomy with traditional inpatient parotidectomy. MATERIALS AND METHODS: This is a retrospective chart review of all patients who underwent a parotidectomy at a single tertiary academic center from 2007 through 2017. RESULTS: There were 568 patients who met the inclusion criteria. There was no difference in demographics or patient comorbidities between the inpatient and outpatient groups. There was no increased incidence of postoperative complications or extent of postoperative care in patients who underwent outpatient parotidectomy. On average at the authors' institution, the direct outpatient parotidectomy cost was $1,200 less than the inpatient equivalent. CONCLUSION: Outpatient parotidectomy can be performed safely and cost effectively with no increased risk of complications.

Treatment of locally advanced parotid malignancies with parotidectomy and temporal bone resection.

PURPOSE: In this study we review our institution's experience and outcomes with temporal bone resection and parotidectomy in the treatment of advanced parotid malignancies. METHODS: Patients undergoing lateral temporal bone resection and parotidectomy from 2007-2013 were identified in the EPIC electronic medical record. Primary tumor location, staging, surgical procedure, and patient demographic and outcome data were collected retrospectively. RESULTS: Fifteen patients underwent combined temporal bone resection and parotidectomy for parotid malignancy. Carcinoma ex-pleomorphic and squamous cell carcinoma were the most common pathologies. Two year disease free survival was 40%. Distant metastases were the most common site of disease recurrence. Only nodal disease was predictive of reduced disease free survival, though pre-operative facial paralysis showed a trend towards significance. Margin status and operating for recurrent tumor did not influence outcome in our series. CONCLUSION: Local and regional tumor controls are attainable with combined skull base approaches to advanced parotid malignancies. Unfortunately these cases have a high rate of distant recurrence despite negative margins and local control.