An Analysis of Global Surgery Opportunities in American Otolaryngology Residency Programs.

OBJECTIVES: To depict the current state of global surgery opportunities in United States ACGME-approved Otolaryngology residency programs and compare the characteristics of programs with and without these opportunities. METHODS: In this cross-sectional analysis, websites of ACGME-accredited Otolaryngology residency programs were analyzed for information on program size, rank, age, and geographic region as obtained through the Doximity platform in 2023. Additional parameters were obtained for programs listing global surgery opportunities such as funding, faculty oversight, location/region, focus, and relationship to the community served. Data were tabulated and analyzed in Microsoft Excel and Stata. RESULTS: Of the 131 ACGME-accredited Otolaryngology residency programs, 26 (20%) of programs advertised a global surgery opportunity. Nine (35%) of these promoted funding, 15 (58%) offered a clinical focus, one (4%) offered a research focus, and 10 (38%) offered a combined approach. The Midwest region had the most programs with global surgery opportunities (n = 8, 31%). Less than half (42%) of programs had an established partnership with local partners within low and middle-income countries (LMICs). When comparing programs, the average Doximity rank, average program age, and average program size of programs that offered global surgery opportunities was significantly higher than those that did not (37.2 vs. 71.5, 54 vs. 41, 19.5 vs. 13.7; all p < 0.05). CONCLUSIONS: Approximately one-fifth of Otolaryngology training programs have a global surgery opportunity. Programs that offer these opportunities had a higher Doximity ranking, older program age, and a larger trainee cohort. These results highlight potential areas for expanding global surgery opportunities in academic institutions. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Perceptions and Understanding of Transgender Patient Care: A Survey of Practicing Facial Plastic Surgeons.

Transgender individuals face significant health disparities including deficiencies in physician education, knowledge, and comfort with care. The objective of this study was to determine the perceptions, practice patterns, and familiarity of facial plastic surgeons with transgender health care. An anonymous questionnaire was sent to facial plastic surgeons within the American Academy of Facial Plastic and Reconstructive Surgery list-serve. Primary datapoints included participant characteristics, transgender-related experience, and educational goals. Of the 66 facial plastic surgeons surveyed, 49% had treated 1 to 10 transgender patients during their career, and 70% were actively treating at least 1 transgender patient. The number of patients treated and surgeries performed was significantly associated with self-perceived competence, comfort counseling on gender-affirming surgeries, discussing gender identity, asking preferred pronouns, and a desire to learn more about transgender care. Most participants (61%) obtained transgender care training through real-world experience, with only 18% receiving formal training in residency or fellowship. In total, 50% of respondents believe transgender care training among facial plastic surgeons is inadequate and 60% support its incorporation into residency/fellowship curricula. Increased awareness is needed to address the disparities experienced by transgender patients. Many facial plastic surgeons desire to learn more and support incorporating transgender care into training. Understanding the current state of transgender care can assist the facial plastic community in promoting education that strengthens physicians' ability to deliver competent care that addresses the inequities faced by this diverse group.

Multidisciplinary Management of Total Anterior Skull Base Osteoradionecrosis.

Cases of delayed osteoradionecrosis (ORN) of the anterior skull base have unique management considerations. A 59-year-old woman with a history of basaloid squamous cell carcinoma of the sinonasal cavity with intracranial extension through the anterior skull base developed delayed radiation sequelae of anterior skull base ORN. She underwent an initial endoscopic resection in 2011 with persistent disease that required an anterior craniofacial resection with left medial maxillectomy in 2012. She had a radiologic gross total resection with microscopic residual disease at the histologic margins prompting adjuvant chemoradiotherapy to target volume doses of 66 to 70 Gy with concurrent cisplatin chemotherapy. She subsequently developed an intracranial abscess in 2021 along the anterior skull base that required a craniotomy and endoscopic debridement. Despite aggressive surgical and medical therapy, she had persistent intracranial infections and evidence of skull base ORN. She ultimately underwent a combined open bifrontal craniotomy and endoscopic resection of the necrotic frontal bone and dura followed by an anterolateral thigh free flap reconstruction with titanium mesh cranioplasty. The patient recovered well from a microvascular free-tissue reconstruction without concern for cerebrospinal fluid leak. Anterior skull base reconstruction with free tissue transfer is a commonly utilized method for oncologic resections. Here, an anterolateral free flap was effectively used to treat an anterior skull base defect secondary to a rare indication of skull base ORN.

Use of an open partial laryngectomy technique for a massive laryngeal leiomyosarcoma in a 40-year-old man with functional preservation postoperatively.

Laryngeal cancers are one of the most common head and neck malignancies and can lead to significant morbidity and mortality. Although they most commonly originate from squamous cell carcinoma, there are multiple different pathologies that can arise. We present a patient with an atypical presentation of a glottic mass for which final pathology revealed a leiomyosarcoma (LMS). We report the first case in the English literature of a large bulky LMS that was removed entirely through a partial vertical laryngectomy and pharyngectomy, with maintained swallow and speech function postoperatively.

Single-port transoral robotic surgery for a rare tonsil mass.

Squamous cell carcinoma predominates as the most common malignant lesion of the oropharynx with human papilloma virus-associated disease now predominant over tobacco-related oropharynx cancer. Other rare malignant pathologies can manifest as visible neoplasms in these anatomic sites with varying degrees of symptoms such as dysphagia, odynophagia, otalgia, aspiration, hemorrhage, weight loss and dyspnea. We present a case of a rarely encountered primary oropharyngeal sarcoma managed by single-port transoral robotic resection and a selective cervical lymph node dissection followed by adjuvant radiotherapy.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review of 2021.

Objective: To evaluate new medical devices and drugs pertinent to otolaryngology-head and neck surgery that were approved by the Food and Drug Administration (FDA) in 2021. Data Sources: Publicly available FDA device and drug approvals from ENT (ear, nose, and throat), anesthesia, neurosurgery, plastic surgery, and general surgery FDA committees. Review Methods: FDA device and therapeutic approvals were identified and reviewed by members of the American Academy of Otolaryngology-Head and Neck Surgery's Medical Devices and Drugs Committee. Two independent reviewers assessed the relevance of devices and drugs to otolaryngologists. Medical devices and drugs were then allocated to their respective subspecialty fields for critical review based on available scientific literature. Conclusions: The Medical Devices and Drugs Committee reviewed 1153 devices and 52 novel drugs that received FDA approval in 2021 (67 ENT, 106 anesthesia, 618 general surgery and plastic surgery, 362 neurosurgery). Twenty-three devices and 1 therapeutic agent relevant to otolaryngology were included in the state of the art review. Advances spanned all subspecialties, including over-the-counter hearing aid options in otology, expanding treatment options for rhinitis in rhinology, innovative laser-safe endotracheal tubes in laryngology, novel facial rejuvenation and implant technology in facial plastic surgery, and advances in noninvasive and surgical treatment options for obstructive sleep apnea. Implications for Practice: FDA approvals for new technology and pharmaceuticals present new opportunities across subspecialties in otolaryngology. Clinicians' nuanced understanding of the safety, advantages, and limitations of these innovations ensures ongoing progress in patient care.

Impact of preoperative and intraoperative management on outcomes in osteoradionecrosis requiring free flap reconstruction.

BACKGROUND: Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and outcomes. METHODS: Multi-institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n = 260). RESULTS: Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p = 0.03) and 30-day readmission (p = 0.04). Patients with FF compromise had higher TSH (p = 0.04) and lower albumin levels (p = 0.005). Prealbumin levels were lower in patients who required neck washouts (p = 0.02) or a second FF (p = 0.03). TSH levels were higher in patients undergoing postoperative debridement (p = 0.03) or local flap procedures (p = 0.04). CONCLUSION: Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.

Head and neck free-flap salvage.

PURPOSE OF REVIEW: To highlight three clinical arenas in which head and neck free-flap compromise is encountered and acted upon: nonoperative, operative and postoperative realms. RECENT FINDINGS: Time to identification and intervention is paramount to successful free-flap salvage. Surgical microvascular revision remains chief amongst strategies to revert vascular compromise of a free-flap. Adjuncts, such as thrombolytics and systemic anticoagulation have an important role in the complex work of microvascular free tissue care. Venous congestion of free flaps holds favorable for salvage when compared with arterial insufficiency. SUMMARY: Vascular compromise of head and neck free flaps is a rare and feared event for microvascular surgeons, with successful transfers rates approaching above 95%. Success in salvage is dependent on prompt identification of tissue compromise and timely, directed interventions to re-establish tissue perfusion.

Microvascular Reconstruction of Osteonecrosis: Assessment of Long-term Quality of Life.

OBJECTIVE: Review long-term clinical and quality-of-life outcomes following free flap reconstruction for osteonecrosis. STUDY DESIGN: Retrospective multi-institutional review. SETTING: Tertiary care centers. METHODS: Patients included those undergoing free flap reconstructions for osteonecrosis of the head and neck (N = 232). Data included demographics, defect, donor site, radiation history, perioperative management, diet status, recurrence rates, and long-term quality-of-life outcomes. Quality-of-life outcomes were measured using the University of Washington Quality of Life (UW-QOL) survey. RESULTS: Overall flap success rate was 91% (n = 212). Relative to preoperative diet, 15% reported improved diet function at 3 months following reconstruction and 26% at 5 years. Osteonecrosis recurred in 14% of patients (32/232); median time to onset was 11 months. Cancer recurrence occurred in 13% of patients (29/232); median time to onset was 34 months. Results from the UW-QOL questionnaire were as follows: no pain (45%), minor or no change in appearance (69%), return to baseline endurance level (37%), no limitations in recreation (40%), no changes in swallowing following reconstruction (28%), minor or no limitations in mastication (29%), minor or no speech difficulties (93%), no changes in shoulder function (84%), normal taste function (19%), normal saliva production (27%), generally excellent mood (44%), and no or minimal anxiety about cancer (94%). CONCLUSION: The majority of patients maintained or had advancement in diet following reconstruction, with low rates of osteonecrosis or cancer recurrence and above-average scores on UW-QOL survey suggesting good return of function and quality of life.

Improving Head and Neck Microvascular Reconstructive Care with a Novel Perioperative Checklist.

OBJECTIVE/HYPOTHESIS: To appraise the utility of a novel EMR-based checklist for complex head and neck microvascular free-tissue reconstruction. STUDY DESIGN: A prospectively collected retrospective matched cohort study from a single tertiary care academic institution. METHODS: A retrospective matched cohort study from an academic tertiary care center with 76 total patients analyzed for disease-specific and quality outcomes before and after implementation of an EMR-based checklist tailored to complex head and neck care. The intervention group consisted of 38 consecutive patients undergoing microvascular free tissue reconstruction after implementation of the EMR-based checklist strategy. A historic cohort of 38 patients was derived by matching patients meticulously for disease-specific and surgical characteristics. Primary outcomes included post-operative medical and surgical complications, intensive care requirements, 30-day reoperation rates, hospital length of stay, and completion of preoperative metastatic evaluations. Secondary outcomes included patterns of antibiotic administration, ultimate discharge dispositions, flap survival, and recognition of preoperative hypothyroidism in previously radiated patients. RESULTS: Implementation of the perioperative checklist yielded an overall reduction in major medical complications (10.5% vs. 29.0%, P < .05*), post-operative antibiotic administration (17.4% vs. 44.7%, P < .05*), hospital length of stay (median (IQR) days 6 (1) versus 7 (3.25), P < .05*), and improved metastatic evaluation completion (92.1% vs. 63.2%, P < .05*). There was an improved discharge disposition (92.1% vs. 73.7%, P < .05*). No difference was observed in major wound complications (50.0% vs. 57.9%, P = .49), 30-day re-operation rates (31.5% vs. 34.2%, P = .81), 30-day readmission rates (21.1% vs. 21.1%, P > .99), escalations to intensive-care (13.2% vs. 21.1%, P = .36), or flap survival (97.4% vs. 89.5%, P = .17). CONCLUSIONS: Use of our EMR-based perioperative checklist reduced major medical complications, post-operative antibiotic administration, hospital length of stay, and improved discharge outcomes for patients undergoing microvascular free-tissue reconstruction. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2251-E2256, 2021.

Non-HPV-Related Head and Neck Squamous Cell Carcinoma in a Young Patient Cohort.

OBJECTIVES: Head and neck squamous cell carcinoma (HNSCC) is rare in patients younger than 40 years. Many practitioners suspect HNSCC is a more aggressive disease in this age group, and perhaps increasing in incidence; however, there are scant and conflicting data to support this assertion. We sought to compare outcomes for young patients with non-human papillomavirus (HPV)-related HNSCC to those of older patients. METHODS: A retrospective chart review of patients with HNSCC treated from 2004 to 2016 at 2 tertiary referral centers. Patients aged 18 to 40 with p16-negative HNSCC were included in the young patient cohort (n = 59). A randomly selected stage- and subsite-matched cohort aged 55 to 65 was analyzed for comparison (n = 114). RESULTS: When considering all patients with HNSCC, patients younger than 40 were more likely to have oral tongue cancer (62.7%) compared to patients age 55 to 65 (16.9%). When an older patient cohort was stage- and subsite-matched to the young patient cohort, there were more never smokers (49.2% vs 17.5% of older patients, P < .01) and females (40.7% vs 24.6% of older patients, P = .028) in the young patient group. The young patient cohort had better average overall survival than the older group (14.4 vs 8.1 years, respectively, P = .02), but similar average disease-free survival (6.2 years vs 6.6 years, respectively, P = .67); 50.9% of young patients had tumors with adverse histologic features versus 42.0% of older patients (P = .28). The young patients demonstrated a superior average conditional survival after recurrence (9.8 years vs 3.2 years for older patients, P < .01). CONCLUSIONS: Despite the limitations of study design, these data suggest that young patients who develop non-HPV-related HNSCC tend to have similarly aggressive disease, but longer overall survival and better survival after recurrence. These findings may be attributable to better overall health as evidenced by fewer comorbidities.

Surgical margins in oral cavity squamous cell carcinoma: Current practices and future directions.

OBJECTIVE: To discuss the current available techniques for intraoperative margin assessment in the surgical treatment of oral squamous cell carcinoma (OSCC) through a review of the available literature. METHODS: A systematic review was undertaken of the available English literature between 2008 through 2018 regarding surgical margins in OCSS. A total of 893 relevant articles were returned; 144 met criteria for review; and 64 articles were included. RESULTS: In this review, we discuss the data surrounding the use of frozen section in OCSS. Additionally, alternative techniques for margin assessment are discussed, including Mohs, molecular analysis, nonfluorescent dyes, fluorescent dyes, autofluorescent imaging, narrow-band imaging, optical coherence tomography, confocal microscopy, high-resolution microendoscopy, and spectroscopy. For each technique, particular emphasis is placed on the local recurrence, disease-free survival, and overall survival rates when available. CONCLUSION: This review provides support for the practice of specimen-driven margin assessment when using frozen section analysis to improve the utility of the results. Finally, several alternatives for intraoperative margin assessment currently under investigation, including pathologic, wide-field imaging and narrow-field imaging techniques, are presented. We aim to fuel further investigation into methods for margin assessment that will improve survival for patients with OSCC through a critical analysis of the available techniques. LEVEL OF EVIDENCE: NA Laryngoscope, 130:128-138, 2020.

Lateral nasal wall extension of the nasoseptal flap for skull-base and medial orbital wall defects.

BACKGROUND: Sinonasal and skull-base tumors that previously required open resection can often be completely resected via an endonasal approach. The nasoseptal flap (NSF) is the workhorse vascularized tissue flap for the endoscopic reconstruction of large skull-base defects from tumor resections. The objective of the current article is to describe a novel modification of the NSF for simultaneous reconstruction of skull-base and medial orbital wall defects. METHODS: An extension of the standard NSF to include mucosa of the lateral nasal wall was developed for closure of simultaneous skull-base and medial orbital wall defects. Outcomes including successful cerebrospinal fluid (CSF) leak closure, orbital edema, and postoperative cosmesis are reported. Eyelid edema was characterized according to the Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) scale. RESULTS: Three patients underwent reconstruction using the modified NSF (average age 75 years). The average defect size of the skull base was 3.6 ± 0.1 cm by 2.3 ± 0.2 cm. The average defect size of the medial orbit was 2.7 ± 0.1 cm by 2.6 ± 0.1 cm. All defects were successfully covered intraoperatively using the lateral nasal wall extension of the NSF. Two patients developed mild eyelid edema, whereas 1 individual had no noticeable swelling (SPREE classification 2, 2, and 1). All patients were successfully sealed at last clinical follow up (average 28 weeks). CONCLUSION: The modification of the NSF described here provides excellent coverage for reconstruction of large anterior skull-base defects and simultaneous medial orbital wall defects.

Fluorescence Imaging of Nerves During Surgery.

OBJECTIVE: This review details the agents for fluorescence-guided nerve imaging in both preclinical and clinical use to identify factors important in selecting nerve-specific fluorescent agents for surgical procedures. BACKGROUND: Iatrogenic nerve injury remains a significant cause of morbidity in patients undergoing surgical procedures. Current real-time identification of nerves during surgery involves neurophysiologic nerve stimulation, which has practical limitations. Intraoperative fluorescence-guided imaging provides a complimentary means of differentiating tissue types and pathology. Recent advances in fluorescence-guided nerve imaging have shown promise, but the ideal agent remains elusive. METHODS: In February 2018, PubMed was searched for articles investigating peripheral nerve fluorescence. Key terms used in this search include: "intraoperative, nerve, fluorescence, peripheral nerve, visualization, near infrared, and myelin." Limits were set to exclude articles exclusively dealing with central nervous system targets or written in languages other than English. References were cross-checked for articles not otherwise identified. RESULTS: Of the nonspecific agents, tracers that rely on axonal transport showed the greatest tissue specificity; however, neurovascular dyes already enjoy wide clinical use. Fluorophores specific to nerve moieties result in excellent nerve to background ratios. Although noteworthy findings on tissue specificity, toxicity, and route of administration specific to each fluorescent agent were reported, significant data objectively quantifying nerve-specific fluorescence and toxicity are lacking. CONCLUSIONS: Fluorescence-based nerve enhancement has advanced rapidly over the past 10 years with potential for continued utilization and progression in translational research. An ideal agent would be easily administered perioperatively, would not cross the blood-brain barrier, and would fluoresce in the near-infrared spectrum. Agents administered systemically that target nerve-specific moieties have shown the greatest promise. Based on the heterogeneity of published studies and methods for reporting outcomes, it appears that the development of an optimal nerve imaging agent remains challenging.

Analgesic Effects of Intravenous Acetaminophen vs Placebo for Endoscopic Sinus Surgery and Postoperative Pain: A Randomized Clinical Trial.

Importance: Intravenous acetaminophen is a commonly prescribed analgesic for the prevention and treatment of postsurgical pain. Its efficacy in the context of endoscopic sinus surgery (ESS) has yielded mixed results. Objective: To compare the efficacy of perioperative intravenous acetaminophen (IVAPAP) with that of placebo in improving early postoperative pain after endoscopic sinus surgery (ESS). Design, Setting, and Participants: A prospective, randomized clinical trial including 62 patients undergoing ESS for chronic rhinosinusitis in a single tertiary referral hospital. Interventions: Participants were randomized to receive 1 g of IVAPAP or 100 mL of placebo consisting of saline infusions immediately before the start of surgery and 4 hours after the initial dose. Main Outcomes and Measures: The primary outcome was postoperative pain measured by visual analog scale (VAS) scores up to 24 hours after surgery by blinded observers. Secondary endpoints included postoperative opioid (intravenous and oral) use and adverse events in the 24-hour postoperative period. Results: Of the 62 enrolled adult participants, 60 were randomized (31 to IVAPAP intervention and 29 to placebo). The mean (SD) age of participants was 53.7 (14.7) years and 35 (58%) of the participants were men and 25 (42%) were women. Within the first hour, mean pain scores were reduced in the IVAPAP group compared with the control group, reaching a maximum difference of 7.7 mm on a VAS scale favoring the treatment group with a true difference possibly as high as 22 mm, and the data are compatible with a clinically meaningful difference. At 12- and 24-hours, average pain scores were less in the placebo group and the data are compatible with a clinically meaningful difference of 5.8 (-5.2 to 16.8) and 8.2 (-1.9 to 18.4), respectively, favoring the placebo group. However, at all time points the CIs included the null value and were wide, thus preventing definitive conclusions. Inspection of the secondary outcomes favored IVAPAP, but the wide range of the CIs and inclusion of the null value prevent definitive conclusions. Conclusions and Relevance: The results of this study are inconclusive. The data suggest that perioperative intravenous acetaminophen may reduce immediate postoperative pain and opioid requirements compared with placebo and these differences could be clinically meaningful. Unfortunately, the imprecision of the estimates prevents definitive conclusion. Use of IVAPAP does not seem to increase adverse events. Trial Registration: clinicaltrials.gov Identifier: NCT01608308.