Morbidity and Survival in Elderly Patients Undergoing Free Flap Reconstruction: A Retrospective Cohort Study.

Objective To review a single institution's outcomes of free flap reconstruction of the head and neck in patients aged ≥80 years as compared with those <80 years. Study Design Retrospective cohort study. Setting Tertiary academic hospital. Subjects and Methods Patients aged ≥ 80 years who underwent free flap reconstruction of the head and neck between 2007 and 2013 were identified and matched by type of reconstruction with a cohort of younger patients. Outcome measures included flap success, length of stay, discharge disposition, complications, and 2-year mortality. Associations between complications and comorbidities were also evaluated. Results Sixty-six patients aged ≥80 years were identified, and a paired sample <80 years old was selected. There were 3 flap failures per group and 1 perioperative mortality in the elderly group. There was no significant difference in length of stay or major complications between groups. Significantly more elderly patients were discharged to a nursing facility. There was no significant difference in mortality rates at 2 years postoperatively. No associations were seen between level of comorbidity and complications among the elderly group. Conclusion Free flap reconstruction of the head and neck remains a viable option in patients of advanced age. Similar outcomes in terms of flap success, complications, and length of hospitalization can be achieved as compared with younger patients undergoing similar reconstructions. The role of comorbid disease as a predictor of complications remains unclear. There is no significant difference in 2-year mortality for elderly free flap patients versus younger controls.

Post-operative budesonide irrigations for patients with polyposis: a blinded, randomized controlled trial.

OBJECTIVE: To compare normal saline (NS) vs. NS+budesonide irrigations in post- functional endoscopic sinus surgery (FESS) patients with chronic rhinosinusitis with polyposis (CRSwNP). Currently, no evidence exists for NS+budesonide irrigation over NS irrigation alone. STUDY DESIGN: Prospective, single-blind, randomized controlled trial. METHODS: Subjects were prospectively enrolled to NS or NS+budesonide arms. Patients were evaluated at pre-operative and three post-operative visits (POV): POV1 (1-2 weeks post-op), POV2 (3-8 weeks post-op), and POV3 (3-6 months post-op). Patients were evaluated by three quality of life (QOL) questionnaires (SNOT-22, RSOM-31, and RSDI) and two olfaction scores (UPSIT and the PEA test). RESULTS: Fifty patients were randomized, with 25 patients in the NS arm and 25 patients in the NS+budesonide arm. Two patients had unexpected pathology and were excluded from the study. By POV2 and POV3, patients experienced a significant improvement in all three QOL surveys, although the degree of improvement between arms was not significant up through POV3. Neither arm experienced significant olfactory improvement up through POV3. CONCLUSIONS: While both NS and NS+budesonide treatments improve QOL for post-FESS patients, neither intervention significantly increases QOL as compared to the other. Olfaction was not significantly improved in either treatment group.

Pediatric foreign body aspiration: A nidus for Aspergillus colonization.

We describe an immunocompetent child with bronchial fungus following foreign body aspiration. A two-year-old male presented with cough. Workup revealed air trapping and bronchoscopy showed aspirated foreign material in the right mainstem bronchus. Histopathology revealed fungal organisms suggestive of Aspergillus within an ulcer of the adjacent bronchial mucosa. Foreign body aspiration has been posited as a nidus for aspergilloma formation but is not yet described in the available English-language pediatric literature. Here, the foreign body provided a site for fungal growth in the bronchus of an otherwise healthy child. This case suggests that bronchial foreign body may pose risk of fungal colonization even in immunocompetent children.

Pedicled extranasal flaps in skull base reconstruction.

Cerebrospinal fluid (CSF) leaks most commonly arise during or after skull base surgery, although they occasionally present spontaneously. Recent advances in the repair of CSF leaks have enabled endoscopic endonasal surgery to become the preferred option for management of skull base pathology. Small defects (<1 cm) can be repaired by multilayered free grafts. For large defects (>3 cm), pedicled vascular flaps are the repair method of choice, resulting in much lower rates of postoperative CSF leaks. The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for the vast majority of skull base defects. It has a large area of potential coverage and high rates of success. However, preoperative planning is required to avoid sacrificing the NSF during resection. In cases where the NSF is unavailable, often due to tumor involvement of the septum or previous resection removing or compromising the flap, other flaps may be considered. These flaps include intranasal options - inferior turbinate or middle turbinate flaps - as well as regional pedicled flaps: pericranial flap, temporoparietal fascial flap, or palatal flap. More recently, novel alternatives such as the pedicled facial buccinator flap and the pedicled occipital galeopericranial flap have been added to the arsenal of options for skull base reconstruction. Characteristics of and appropriate uses for each flap are described.

Endoscopic skull base techniques for juvenile nasopharyngeal angiofibroma.

This review focuses on the anatomy and techniques for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA), as well as adjunctive and potential alternative treatments. JNA is a benign but locally aggressive vascular tumor that primarily affects adolescent boys. Traditionally, these tumors have been removed via open surgical approaches. Recent advances in endoscopic equipment and techniques have enabled the endoscopic surgical excision of these tumors with favorable outcomes and decreased morbidity. At our institution as at others, we have achieved successful outcomes with transnasal endoscopic resection of JNA, including tumors with significant extension into adjacent compartments.