Postoperative analysis of osseous midface reconstructions: The value of imaging and a novel scoring system for complexity and operative success.

BACKGROUND: Few standardized methods exist for evaluating the postoperative outcomes of osteocutaneous free flaps. We propose an anatomic-based scoring system for midface free flap reconstruction. METHODS: One hundred and twelve patients across four institutions underwent osteocutaneous reconstruction of the midface. Postoperative scans were scored based on the number of independent osseous subunits reconstructed (Subunit Score), the number of different bony appositions with bony contact (Contact Score), and the number of osseous segments in anatomic position (Position Score). These were added together to create a Total Score. RESULTS: Osteocutaneous radial forearm flaps had the lowest Subunit Score (p = 0.001). Fibula flaps had the highest Contact Score (p = 0.0008) and Position Score (p = 0.001). Virtual surgical planning was associated with an increased Subunit Score (p = 0.02) and Total Score (p = 0.04). CONCLUSIONS: We propose a novel scoring system for osseous midface reconstruction based on postoperative imaging scans. This can help guide management decisions and create a common language to compare outcomes.

The underappreciated role of auriculotemporal nerve involvement in local failure following parotidectomy for cancer.

BACKGROUND: Locoregional recurrence rates following parotidectomy for cancer remain as high as 20-30%. The auriculotemporal nerve (ATN) may allow parotid cancers to spread from the facial nerve (FN) toward the skull base, causing local recurrence. METHODS: Retrospective review of 173 parotidectomies for malignancy. Preoperative and post-recurrence imaging were reviewed by a neuroradiologist for signs of tumor adjacent to the ATN. RESULTS: Clinical and imaging signs of possible ATN involvement correlated with FN weakness and sacrifice. Eight patients had pathologically confirmed tumor from the ATN or V3. Forty-four percent of local recurrences had post-recurrence imaging showing tumor along the course of the ATN. Locoregional failure along the ATN was also associated with preoperative FN weakness, intraoperative FN sacrifice, and failure to complete recommended adjuvant therapy. CONCLUSIONS: Parotid cancers may invade the FN and spread to the skull base via the ATN. If not appropriately managed, this may lead to local recurrence.

Diagnostic accuracy and confidence for otoscopy: Are medical students receiving sufficient training?

OBJECTIVES/HYPOTHESIS: To assess the confidence and abilities of medical students to diagnose specific types of otologic pathology, and to determine how different training experiences in medical school impact these outcomes. STUDY DESIGN: Survey analysis. METHODS: Sixty third- and fourth-year medical students completed a computerized online survey. Participants answered questions about their otoscopic training experience and confidence, and provided diagnoses for 72 digital images taken with a high-definition video otoscope that showed common otologic pathologies of the tympanic membrane and middle ear space. RESULTS: Most participants (65%) had received less exposure to otoscopic training in medical school than they expected. Confidence in diagnostic ability was low. For diagnostic ability, the mean percent correct across pathologies was 54% ± 7.7%. Medical school year (P = .006), intended specialty (P = .022), and total number of otolaryngology rotations (P = .048) were predictive of diagnostic accuracy on univariable logistic regression analyses, but medical school year (P = .039) was the only significant independent predictor in multivariable analysis. Intended specialty (P = .047) and total number of otolaryngology rotations (P = .035) were predictive of prequiz diagnostic confidence on univariable logistic regression analyses. CONCLUSIONS: Medical students were not satisfied with their exposure to otoscopic training. Intended specialty, total number of otolaryngology rotations, and year in medical school predicted diagnostic accuracy. Intended specialty and total number of otolaryngology rotations predicted diagnostic confidence. Additional studies are needed to investigate how training experiences can be improved to optimize otoscopy training during medical school. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1891-1897, 2019.

Developing a synchronous otolaryngology telemedicine Clinic: Prospective study to assess fidelity and diagnostic concordance.

OBJECTIVE: To evaluate diagnostic concordance of a synchronous telemedicine otolaryngology clinic with use of currently available technology. STUDY DESIGN: Prospective. METHODS: Patients in a rural otolaryngology clinic were enrolled in a pilot telemedicine clinic. To assess system fidelity, an on-site and remote (consulting) otolaryngologist conducted simultaneous patient evaluations using streaming telecommunication technology for all aspects of the clinical encounter, including high-definition examination and endoscopic images. Both physicians and patients were blinded and diagnoses recorded. Post-encounter physician surveys and an original patient-centered TeleENT Satisfaction Questionnaire (TESQ) were used to assess overall satisfaction. RESULTS: Twenty-one patients were enrolled consecutively. Visual technology was found acceptable in all cases, and audio technology was acceptable in 20 of 21 encounters. Patient satisfaction was 96%, and patients felt comfortable using a telemedicine system in the future. Encounters were not significantly longer than traditional encounters. Physician diagnostic agreement was found in 95% of cases, and the consulting physician indicated that all encounters provided sufficient history, examination, and high-quality images to generate an accurate diagnosis, order additional workup, and/or make an appropriate referral. CONCLUSION: A synchronous otolaryngology telemedicine clinic is comparable to a standard clinic in terms of diagnostic concordance and patient satisfaction when using streaming technology and high-definition images. Using telemedical technology may be a viable way to increase otolaryngology access in remote or underserved areas. With system validity now established, future studies will assess the feasibility of using trained on-site physician extenders (nurse practitioners or physician assistants) to conduct in-person patient encounters with remote otolaryngologist support. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:1068-1074, 2018.

NUT Midline Carcinoma of the Sublingual Gland: Clinical Presentation and Review.

NUT midline carcinoma (NMC) is a rare and aggressive disease encountered in the midline of the head and neck or mediastinum. Due to its sparse incidence and subtle pathologic features, we aim to increase knowledge and awareness for this pathologic entity. We present an exemplary case of a young, healthy male presenting with oral cavity pain and cervical lymphadenopathy. This patient was initially diagnosed with an unspecified, highly aggressive sublingual gland malignancy and underwent locoregional resection with free flap reconstruction however suffered a rapid local recurrence and widely extensive metastasis within just 1 month. After rigorous analysis, final pathologic diagnosis revealed a poorly differentiated carcinoma with evidence of squamous differentiation that eventually, post-mortem tested positive for NMC. Only one prior case of sublingual gland NMC has been previously reported as we discuss the literature regarding all sublingual gland malignancies as well as the pathologic features and treatment options for NMC. We recommend consideration of testing for the NUT proto-oncogene at the time of biopsy in the clinical setting of a poorly differentiated midline carcinoma, especially with squamous differentiation, of the head or neck in order to identify patients for clinical trial enrollment and appropriately counsel on the poor clinical prognosis. Improving clinician awareness is critical to increase diagnostic accuracy and need to study prospective treatment outcomes as the first step toward improving management of this difficult disease.