The Use of Patient-Specific Orbital Reconstruction Implants During Maxillectomy Reconstruction.

Background: Reconstruction of the orbital floor after maxillectomy can result in significant functional and aesthetic morbidity. Study Objective: To measure eyelid position, self-reported visual outcomes, and complications in patients undergoing concurrent maxillectomy and reconstruction with a patient-specific orbital reconstruction implant (PSORI). Design Type: Case series. Materials and Methods: Case series including 12 patients who received PSORI for orbital floor reconstruction after tumor extirpation. Primary outcomes gathered were diplopia, ectropion, and wound healing complications. Results: The majority of patients were men (75%) and the mean age was 53.3 years. Ten patients underwent free flap reconstruction with the majority receiving fibula free flaps (n = 6). Median follow-up was 415.5 days. Three patients (25%) experienced long-term complications, including diplopia (n = 1) and hardware extrusion (n = 3). Each of these occurred in the context of total maxillectomy and radiation. This prompted subsequent use of a modified implant design for the final six patients and the preferential use of a midface-degloving approach. These interventions eliminated extrusions in subsequent patients. Conclusion: PSORIs can be used for orbital floor reconstruction following maxillectomy in combination with free tissue transfer. Implant design is critical to reduce complications. The use of a midface degloving approach and a modified low-profile design was associated with a low rate of complications.

Factors Associated with Lymph Node Count in Mucosal Squamous Cell Carcinoma Neck Dissection.

OBJECTIVE/HYPOTHESIS: Decreased lymph node count (LNC) from neck dissection (ND) for mucosal head and neck squamous cell carcinoma (HNSCC) patients is correlated with decreased survival. Advanced age and low BMI due to undernutrition from dysphagia from advanced T-stage tumors are common in patients with HNSCC. We studied the relationship between these two well-described causes for immune dysfunction and LNC in patients undergoing neck dissection. STUDY DESIGN: We conducted a retrospective review at a single tertiary care institution of patients with HNSCC that underwent neck dissection from 2006 to 2017. METHODS: Stepwise linear and logistic regression analyses were performed on 247 subjects to identify independent significant factors associated with 1) the LNC per neck level dissected; 2) advanced T-stage. One-way ANOVA was utilized to demonstrate differences between the p16 positive and negative subgroups. RESULTS: Low BMI (<23 vs. ≥23) (P = .03), extra nodal extension (ENE) (P = .0178), and advanced age (P = .005) were associated with decreased LNC per neck level dissected on multivariable analysis. Higher T-stage (P = .0005) was correlated with low BMI (<23) after controlling for the effects of tobacco, smoking, sex, ECE, and p16 status. p16+ patients, on average had higher BMI, were younger and produced a higher nodal yield (P < .0001, .007, and .035). CONCLUSIONS: Patient intrinsic factors known to correlate with decreased immune function and worse outcomes, including p16 negative status, advanced age, and low BMI from undernutrition and ENE are associated with low nodal yield in neck dissections. LNC may be a metric for anti-tumor immune function that correlates with prognosis and T-stage. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1516-1521, 2021.

Care in the time of coronavirus: Ethical considerations in head and neck oncology.

As COVID-19 continues to challenge the practice of head and neck oncology, clinicians are forced to make new decisions in the setting of the pandemic that impact the safety of their patients, their institutions, and themselves. The difficulty inherent in these decisions is compounded by potentially serious ramifications to the welfare of patients and health-care staff, amid a scarcity of data on which to base informed choices. This paper explores the risks of COVID-19 incurred while striving to uphold the standard of care in head and neck oncology. The ethical problems are assessed from the perspective of the patient with cancer, health-care provider, and other patients within the health-care system. While no single management algorithm for head and neck cancer can be universally implemented, a detailed examination of these issues is necessary to formulate ethically sound treatment strategies.

Head and neck oncology during the COVID-19 pandemic: Reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks.

The COVID-19 pandemic demands reassessment of head and neck oncology treatment paradigms. Head and neck cancer (HNC) patients are generally at high-risk for COVID-19 infection and severe adverse outcomes. Further, there are new, multilevel COVID-19-specific risks to patients, surgeons, health care workers (HCWs), institutions and society. Urgent guidance in the delivery of safe, quality head and neck oncologic care is needed. Novel barriers to safe HNC surgery include: (1) imperfect presurgical screening for COVID-19; (2) prolonged SARS-CoV-2 aerosolization; (3) occurrence of multiple, potentially lengthy, aerosol generating procedures (AGPs) within a single surgery; (4) potential incompatibility of enhanced personal protective equipment (PPE) with routine operative equipment; (5) existential or anticipated PPE shortages. Additionally, novel, COVID-19-specific multilevel risks to HNC patients, HCWs and institutions, and society include: use of immunosuppressive therapy, nosocomial COVID-19 transmission, institutional COVID-19 outbreaks, and, at some locations, societal resource deficiencies requiring health care rationing. Traditional head and neck oncology doctrines require reassessment given the extraordinary COVID-19-specific risks of surgery. Emergent, comprehensive management of these novel, multilevel surgical risks are needed. Until these risks are managed, we temporarily favor nonsurgical therapy over surgery for most mucosal squamous cell carcinomas, wherein surgery and nonsurgical therapy are both first-line options. Where surgery is traditionally preferred, we recommend multidisciplinary evaluation of multilevel surgical-risks, discussion of possible alternative nonsurgical therapies and shared-decision-making with the patient. Where surgery remains indicated, we recommend judicious preoperative planning and development of COVID-19-specific perioperative protocols to maximize the safety and quality of surgical and oncologic care.

Submental flap practice patterns and perceived outcomes: A survey of 212 AHNS surgeons.

OBJECTIVES: To describe American Head and Neck Society (AHNS) surgeon submental flap (SMF) practice patterns and to evaluate variables associated with SMF complications. METHODS: The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between 11/11/16 and 12/31/16. Surgeon demographics, training, practice patterns and techniques were characterized and evaluated for associations with frequency of SMF complications. RESULTS: Among 212 AHNS surgeons, 108 (50.9%) reported performing SMFs, of whom 86 provided complete responses. Most surgeons who performed the SMF routinely reconstructed oral cavity defects with the flap (86.1%, n = 74). Thirty-seven surgeons (43.0%) experienced "very few" complications with the SMF. Surgeons who practiced in the United States versus internationally (p = 0.003), performed more total career SMFs (p = 0.02), and routinely reconstructed parotid and oropharyngeal defects (p = 0.04 and p < 0.001) with SMFs were more frequently perceived to have "very few" complications. SMF surgeons reported more perceived complications with the SMF compared to pectoralis major (p = 0.001) and radial forearm free flaps (p = 0.01). However, similar perceived complications were reported between all three flaps when surgeons performed >30 SMF. Among 94 surgeons not performing SMFs, 71.3% had interest in a SMF training course. CONCLUSIONS: Practice patterns of surgeons performing SMFs are diverse, although most use the flap for oral cavity reconstruction. While 43% of surgeons performing the SMF reported "very few" complications, overall complication rates with the SMF were higher compared to other flaps, potentially due to limited experience with the SMF. Increased training opportunities in SMF harvest and inset are indicated.

Management of Skull Fractures and Calvarial Defects.

Scalp and calvarial defects can result from a myriad of causes including but not limited to trauma, infection, congenital malformations, neoplasm, and surgical management of tumors or other pathologies. While some small, nondisplaced fractures with minimal overlying skin injury can be managed conservatively, more extensive wounds will need surgical repair and closure. There are many autologous and alloplastic materials to aid in dural and calvarial reconstruction, but no ideal reconstructive method has yet emerged. Different reconstructive materials and methods are associated with different advantages, disadvantages, and complications that reconstructive surgeons should be aware of. Herein, we discuss different methods and materials for the surgical reconstruction of calvarial defects.

Systematic Review of Supraclavicular Artery Island Flap vs Free Flap in Head and Neck Reconstruction.

OBJECTIVE: The aim of this systematic review is to compare the surgical outcomes of supraclavicular artery island flap (SCAIF) and free tissue transfer (FTT) in head and neck reconstruction. DATA SOURCES: PubMed, Web of Science, and EMBASE databases. REVIEW METHODS: Independent screening and data extraction were performed by 2 authors. Only studies that directly compared SCAIF and FTT were included. Data were pooled with random-effects meta-analysis to determine the standardized mean differences (SMDs), risk differences, and 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistics. The Methodological Index for Non-Randomized Studies tool was used to evaluate extent of bias in studies. RESULTS: The initial query yielded 661 results, of which 4 comparative studies remained for final analysis. The pooled sample sizes for the SCAIF and FTT cohorts were 100 and 84, respectively. SCAIF was associated with reduction of operative time by a large effect size (SMD, 1.65; 95% confidence interval, 0.78-2.52). The harvested flap areas and perioperative complications, including rates of total flap loss, partial flap necrosis, and recipient/donor site dehiscences, were comparable between the 2 procedures with low to high heterogeneity among studies. CONCLUSION: SCAIF requires less operative time and has comparable short-term perioperative results to FTT. The findings of this study support the viability of SCAIF as an alternative to FTT and provide evidence for its inclusion in the reconstructive armamentarium of major head and neck ablation and trauma.

Holmium Laser for Endoscopic Treatment of Benign Tracheal Stenosis.

Introduction Laryngotracheal stenosis is a difficult problem with varied etiology and various treatment options. The holmium laser represents another tool for the treatment of benign tracheal stenosis. Objectives To determine the utility of holmium laser treatment for benign tracheal stenosis with regards to safety and efficacy. Methods This was a retrospective case study examining patients with benign tracheal stenosis from 1998-2016 who underwent holmium laser treatment. Determining the safety of this procedure was the primary goal, and complications were monitored as a surrogate of safety. Results A total of 123 patients who underwent holmium laser treatment for benign tracheal stenosis were identified. In total, 123 patients underwent 476 procedures, with follow-up ranging from 1 month to 14 years. No intraoperative or post-operative complications were identified as a direct result of the use of this particular laser. Conclusions The holmium laser is an effective and safe laser to use for tracheal stenosis treatment. It is a contact laser with a short acting distance, which reduces the risk of injury to distal airway structures. Given the favorable experience reported here, the holmium laser should be considered when tracheal surgery is attempted.

Holmium Laser for Endoscopic Treatment of Benign Tracheal Stenosis

Abstract Introduction Laryngotracheal stenosis is a difficult problem with varied etiology and various treatment options. The holmium laser represents another tool for the treatment of benign tracheal stenosis. Objectives To determine the utility of holmium laser treatment for benign tracheal stenosis with regards to safety and efficacy. Methods This was a retrospective case study examining patients with benign tracheal stenosis from 1998-2016 who underwent holmium laser treatment. Determining the safety of this procedure was the primary goal, and complications were monitored as a surrogate of safety. Results A total of 123 patients who underwent holmium laser treatment for benign tracheal stenosis were identified. In total, 123 patients underwent 476 procedures, with follow-up ranging from 1 month to 14 years. No intraoperative or post-operative complications were identified as a direct result of the use of this particular laser. Conclusions The holmium laser is an effective and safe laser to use for tracheal stenosis treatment. It is a contact laser with a short acting distance, which reduces the risk of injury to distal airway structures. Given the favorable experience reported here, the holmium laser should be considered when tracheal surgery is attempted.

Intraoperative nerve monitoring during parathyroid surgery: The Fort Worth experience.

BACKGROUND: Avoidance of recurrent laryngeal nerve (RLN) injury during parathyroid surgery is of paramount important. The purpose of this study was to determine if intraoperative nerve monitoring allowed for decreased rates of RLN injury during parathyroid surgery. METHOD: Between 1997 and 2016, 213 patients undergoing parathyroidectomy were retrospectively analyzed to determine postoperative recurrent nerve injury. Eighty-seven patients did not have intraoperative nerve monitoring, whereas 126 patients did. RESULTS: Based on the number of patients presenting with nerve injury during the postoperative period operated on with and without nerve monitoring, it was found that the difference in the 2 modalities was not statistically significant (P > .05). CONCLUSION: Routine use of intraoperative nerve monitoring during parathyroid surgery may not yield any additional benefit in preventing injury to the RLN.

Systematic Review and Meta-analysis of Studies Evaluating Functional Rhinoplasty Outcomes with the NOSE Score.

Objective To provide aggregate data regarding the ability of functional rhinoplasty to improve nasal obstruction as measured by the Nasal Obstruction Symptom Evaluation (NOSE) score. Data Sources PubMed, EMBASE, Cochrane databases. Review Methods A search was performed with the terms "nasal obstruction" and "rhinoplasty." Studies were included if they evaluated the effect of functional rhinoplasty on nasal obstruction with the NOSE score. Case reports, narratives, and articles that did not use the NOSE score were excluded. Functional rhinoplasty was defined as surgery on the nasal valve. This search resulted in 665 articles. After dual-investigator independent screening, 16 articles remained. Study results were pooled with a random effects model of meta-analysis. Change in NOSE score after surgery was assessed via the mean difference between baseline and postoperative results and the standardized mean difference. Heterogeneity was assessed and reported through the I2 statistic. Results Patients in the included studies had moderate to severe nasal obstructive symptoms at baseline. The NOSE scores were substantially improved at 3-6, 6-12, and ≥12 months, with absolute reductions of 50 points (95% CI, 45-54), 43 points (95% CI, 36-51), and 49 points (95% CI, 39-58), respectively. All of these analyses showed high heterogeneity. Conclusions Nasal obstruction as measured by the NOSE survey is reduced by 43 to 50 points (out of 100 points) for 12 months after rhinoplasty. Our confidence in these results is limited by heterogeneity among studies, large variability in outcomes beyond 12 months, and the inherent potential for bias in observational studies.

The role of parotidectomy in the treatment of auricular squamous cell carcinoma.

OBJECTIVE: We analyze parotid specimens in patients treated with prophylactic parotidectomy for squamous cell carcinoma of the auricle greater than or equal to 2 cm to determine rates of metastasis and the efficacy of elective resection. STUDY DESIGN: Case series with chart review. SETTING: Cancer treatment center in Fort Worth, Texas, from 1998 to 2013. SUBJECTS AND METHODS: The study included 104 patients between ages 36 and 97 years with primary auricular squamous cell carcinoma greater than or equal to 2 cm, with no evidence of adenopathy or parotid involvement on imaging. Patients underwent local excision and ipsilateral parotidectomy. The primary cancer was analyzed for vascular involvement, perineural invasion, and cartilage involvement, while the parotid specimen was analyzed for cancer positivity. RESULTS: Thirty-nine parotid (37.5%) samples were positive for carcinoma. Of these, 16 patients had primary auricular carcinomas with vascular involvement, 17 had perineural invasion, and 4 had cartilage involvement. Thirty-two of 77 affected men and 7 of 27 affected women had positive parotid specimen. Vascular involvement (P = .0006) and perineural invasion (P = .0027) of the primary lesion were significantly higher in patients with a positive parotid specimen. Cartilage involvement and sex were not statistically significant. CONCLUSIONS: Elective parotidectomy is beneficial in patients with squamous cell carcinoma of the auricle at least 2 cm in size, especially in lesions having perineural invasion and vascular involvement. For patients with positive parotid specimens, we recommend postoperative external beam radiation therapy and close surveillance.

Facial nerve trauma: evaluation and considerations in management.

The management of facial paralysis continues to evolve. Understanding the facial nerve anatomy and the different methods of evaluating the degree of facial nerve injury are crucial for successful management. When the facial nerve is transected, direct coaptation leads to the best outcome, followed by interpositional nerve grafting. In cases where motor end plates are still intact but a primary repair or graft is not feasible, a nerve transfer should be employed. When complete muscle atrophy has occurred, regional muscle transfer or free flap reconstruction is an option. When dynamic reanimation cannot be undertaken, static procedures offer some benefit. Adjunctive tools such as botulinum toxin injection and biofeedback can be helpful. Several new treatment modalities lie on the horizon which hold potential to alter the current treatment algorithm.

Management of carotid artery trauma.

With increased awareness and liberal screening of trauma patients with identified risk factors, recent case series demonstrate improved early diagnosis of carotid artery trauma before they become problematio. There remains a need for unified screening criteria for both intracranial and extracranial carotid trauma. In the absence of contraindications, antithrombotic agents should be considered in blunt carotid artery injuries, as there is a significant risk of progression of vessel injury with observation alone. Despite CTA being used as a common screening modality, it appears to lack sufficient sensitivity. DSA remains to be the gold standard in screening. Endovascular techniques are becoming more widely accepted as the primary surgical modality in the treatment of blunt extracranial carotid injuries and penetrating/blunt intracranial carotid lessions. Nonetheless, open surgical approaches are still needed for the treatment of penetrating extracranial carotid injuries and in patients with unfavorable lesions for endovascular intervention.