Tracheostomy protocols during COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has resulted in the implementation of rapidly changing protocols and guidelines related to the indications and perioperative precautions and protocols for tracheostomy. The purpose of this study was to evaluate current guidelines for tracheostomy during the COVID-19 pandemic to provide a framework for health systems to prepare as the science evolves over the upcoming months and years. METHODS: Literature review was performed. Articles reporting clinical practice guidelines for tracheostomy in the context of COVID-19 were included. RESULTS: A total of 13 tracheotomy guidelines were identified. Two were available via PubMed, five in society or organization websites, and six identified via health system websites or other sources. Five were from Otolaryngology-Head and Neck Surgery specialties, six from Anesthesiology and one from Pulmonary/Critical Care. All (100%) studies recommended postponing elective OR cases in COVID-19 positive patients, while seven recommended reducing team members to only essential staff and three recommended forming a designated tracheostomy team. Recommendations with supporting references are summarized in the article. CONCLUSIONS: Tracheostomy guidelines during the COVID-19 pandemic vary by physician groups and specialty, hospital systems, and supply-chain/resource availability. This summary is provided as a point-in-time current state of the guidelines for tracheotomy management in April 2020 and is expected to change in coming weeks and months as the COVID-19 pandemic, virus testing and antibody testing evolves.

Complications, Mortality, and Functional Decline in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction.

Importance: Data regarding outcomes after major head and neck ablation and reconstruction in the growing geriatric population (specifically ≥80 years of age) are limited. Such information would be extremely valuable in preoperative discussions with elderly patients about their surgical risks and expected functional outcomes. Objectives: To identify patient and surgical factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline; to explore whether an association exists between the type of reconstructive procedure and outcome; and to create a preoperative risk stratification system for these outcomes. Design, Setting, and Participants: This retrospective, multi-institutional cohort study included patients 80 years or older undergoing pedicle or free-flap reconstruction after an ablative head and neck surgery from January 1, 2015, to December 31, 2017, at 17 academic centers. Data were analyzed from February 1 through April 20, 2019. Main Outcomes and Measures: Thirty-day serious complication rate, 90-day mortality, and 90-day decline in functional status. Preoperative comorbidity and frailty were assessed using the American Society of Anesthesiologists classification, Adult Comorbidity Evaluation-27 score, and Modified Frailty Index. Multivariable clustered logistic regressions were performed. Conjunctive consolidation was used to create a risk stratification system. Results: Among 376 patients included in the analysis (253 [67.3%] men), 281 (74.7%) underwent free-flap reconstruction. The median age was 83 years (range, 80-98 years). A total of 193 patients (51.3%) had 30-day serious complications, 30 (8.0%) died within 90 days, and 36 of those not dependent at baseline declined to dependent status (11.0%). Type of flap (free vs pedicle, bone vs no bone) was not associated with these outcomes. Variables associated with worse outcomes were age of at least 85 years (odds ratio [OR] for 90-day mortality, 1.19 [95% CI 1.14-1.26]), moderate or severe comorbidities (OR for 30-day complications, 1.80 [95% CI, 1.34-2.41]; OR for 90-day mortality, 3.33 [95% CI, 1.29-8.60]), body mass index (BMI) of less than 25 (OR for 30-day complications, 0.95 [95% CI, 0.91-0.99]), high frailty (OR for 30-day complications, 1.72 [95% CI, 1.10-2.67]), duration of surgery (OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), flap failure (OR for 90-day mortality, 3.56 [95% CI, 1.47-8.62]), additional operations (OR for 30-day complications, 5.40 [95% CI, 3.09-9.43]; OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), and surgery of the maxilla, oral cavity, or oropharynx (OR for 90-day functional decline, 2.51 [95% CI, 1.30-4.85]). Age, BMI, comorbidity, and frailty were consolidated into a novel 3-tier risk classification system. Conclusions and Relevance: Important demographic, clinical, and surgical characteristics were found to be associated with postoperative complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck surgery. Free flap and bony reconstruction were not independently associated with worse outcomes. A novel risk stratification system is presented.

Age-related differences in olfactory cleft volume in adults: A computational volumetric study.

OBJECTIVES/HYPOTHESIS: There is a growing need to understand the underlying mechanisms of age-related olfactory dysfunction with the increasing proportion of older adults over the next 20 years. Despite the importance of olfactory cleft (OC) volumes on odorant deposition and olfactory function, little is known about age-related changes to OC volume. The goal of this study was to use automated techniques in a cross-sectional design to investigate the extent to which OC volumes vary with age and determine the spatial specificity of any age-related effects. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Deformation-based morphometry was utilized to measure OC and sinus volumes in two independent samples of 101 (Medical University of South Carolina [MUSC] sample) and 95 (Hammersmith sample) healthy adults who underwent T1-weighted magnetic resonance imaging, with the Hammersmith sample serving as a replication sample. RESULTS: The mean age of the MUSC and Hammersmith samples were 54.9 ± 17.0 years and 52.1 years ± 15.7 years, respectively. In both samples, there was a significant positive association between age and OC volume that occurred at a constant rate across the lifespan (Cohen's f2 of 0.065 in the MUSC sample and 0.110 in the Hammersmith sample). Age-associated OC volume increases occurred in conjunction with decreases in sinus volumes as well as increases in non-OC nasal cavity volumes. CONCLUSIONS: In this cross-sectional study, there is an increase in OC volume with increasing age that occurs in the context of broad age-associated differences in sinonasal anatomy. Future studies should investigate the impact of age-associated differences in intranasal anatomy on nasal airflow, odorant deposition, and olfactory function. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:E55-E60, 2019.

Radiologic changes in the aging nasal cavity.

BACKGROUND: With an aging population, it is important to understand age-related anatomic changes in the nasal cavity and cribriform plate (CP) that may have clinical implications. METHODOLOGY: Computed tomography (CT) scans obtained for non-rhinologic conditions were divided into a young cohort (N=35, 18-34 years old) and an older adult cohort (N=32, 80-99 years old). Intranasal airspace volumes and bony anatomy of the CP were manually segmented using OsiriX software. The CP was assessed for mean Hounsfield Units (HU) and percentage of olfactory foramina. Deformation based morphometry (DBM) was then performed on the same cohort and correlated with manual measurements. RESULTS: Individual nasal cavity volumes increased 17-75% with age. Regression analysis of all scans revealed age to be the predominant variable influencing intranasal volume differences when controlling for sex and head size. Mean HU of the CP negatively correlated with age. No age-related differences in bone stenosis of olfactory foramina were identified. Automated DBM measurements of intranasal volumes, as well as CP and zygoma mean HU correlated with manual measurements. CONCLUSION: Older subjects have a global increase in intranasal volumes and diffuse bone density loss in the CP. The clinical impact of age-related anatomic changes in the nasal cavity and CP requires further investigation.

Factors associated with gastrostomy tube dependence following salvage total laryngectomy with microvascular free tissue transfer.

BACKGROUND: Following salvage total laryngectomy (STL) with microvascular-free tissue transfer (MFTT), patients are at high risk for swallowing dysfunction, but risk factors for persistent gastrostomy tube (G-tube) dependence are unknown. METHODS: Retrospective review of 33 patients who underwent STL with MFTT. RESULTS: A total oral diet was achieved by 81% of patients with ≥6 months of postoperative follow-up. Approximately 27% of patients were G-tube dependent preoperatively with 67% achieving a total oral diet postoperatively. Factors associated with persistent G-tube dependence included pT4 tumor, pN2+ status, more extensive pharyngectomy, and re-irradiation. Strictures occurred in 30% of patients and were associated with more extensive pharyngectomy and tubed reconstruction. CONCLUSIONS: For patients undergoing STL with MFTT, the majority of patients achieve a total oral diet regardless of their preoperative swallowing function. Advanced-stage recurrent tumors and increased extent of pharyngectomy contribute to poorer swallowing outcomes.

Cleft Lip and Palate.

Orofacial clefts are common congenital malformations with genetic and environmental risk factors. In the perinatal period, feeding and nutrition can be a challenge and the need for specialized feeders is common. Lip taping and nasoalveolar molding are early interventions that can be used to preoperatively modify cleft defects to enhance surgical outcomes. Multiple techniques are available for repair of orofacial clefts and choice of technique depends on cleft extent and surgeon preference. After definitive repair, children remain at increased risk for middle ear disease, velopharyngeal dysfunction, and malocclusion and require ongoing follow-up with a multidisciplinary team.

Association of the Anterolateral Thigh Osteomyocutaneous Flap With Femur Structural Integrity and Assessment of Prophylactic Fixation.

Importance: The chimeric anterolateral thigh osteomyocutaneous (ALTO) free flap is a recently described microvascular option for head and neck osseous defects associated with complex soft-tissue requirements. To date, the association of ALTO flap harvest with femur structural integrity and the need for routine prophylactic fixation following harvest has been incompletely described. Objective: To investigate the association of ALTO flap harvest, with and without prophylactic fixation, on femur structural integrity as measured by 4-point bend and torsional biomechanical testing. Design and Setting: At a research laboratory, 24 synthetic fourth-generation composite femurs with validated biomechanical properties underwent 10-cm-long, 30% circumferential osteotomies at the proximal middle third of the femur; 6 femurs served as controls. Osteotomized femurs with and without fixation underwent torsional and 4-point bend biomechanical testing. Femur fixation consisted of intramedullary nail and distal interlock screw placement. Main Outcomes and Measures: Force and torque to fracture (expressed in kilonewtons [kN] and Newton meters [N∙m], respectively) were compared between controls, osteotomized femurs without fixation, and osteotomized femurs with fixation. Additional outcome measures included femur stiffness and fracture patterns. Results: On posterior to anterior (PA) 4-point bend testing, force to fracture of osteotomized femurs was 22% of controls (mean difference, 8.3 kN; 95% CI, 6.6-10.0 kN). On torsional testing the torque to fracture of osteotomized femurs was 12% of controls (mean difference, 351.1 N∙m; 95% CI, 307.1-395.1 N∙m). Following fixation there was a 67% improvement in PA force to fracture and a 37% improvement in torque to fracture. However, osteotomized femurs with fixation continued to have a reduced PA force to fracture at 37% of controls (mean difference, 6.8 kN; 95% CI, 4.5-9.2 kN) and torque to fracture at 16% of controls (mean difference, 333.7 N∙m; 95% CI, 306.8-360.6 N∙m). On torsional testing, all osteotomized femurs developed similar spiral fractures through a corner of the distal osteotomy site. This fracture pattern changed after prophylactic fixation with femurs developing nondisplaced fractures through the proximal osteotomy site. There were no underlying hardware failures during testing of osteotomized femurs with fixation. Conclusions and Relevance: Anterolateral thigh osteomyocutaneous flap harvest results in significant changes in the structural integrity of the femur. Postoperative stabilization should be strongly considered, with future research directed at investigating the clinical significance of residual biomechanical changes following femur fixation.

Novel Radiographic Assessment of the Cribriform Plate.

Background The cribriform plate (CP) is a common site of spontaneous cerebrospinal fluid (SCSF) leaks. Radiographic assessment of the anterior and lateral skull base has shown thinner bone in patients with SCSFs; however, prior assessment of the CP has required postmortem cadaver dissection. Objective To develop novel radiographic techniques to assess the anatomy of the CP. Methods Computed tomography (CT) scans were performed on cadaveric specimens. Bone density and anatomy of a predefined volume of interest of the posterior CP were assessed by two independent reviewers. CT assessment of olfactory foramina was also performed and validated using anatomic dissection of cadaver specimens. Results Interclass correlation coefficients (ICCs) for measuring the same volume of each CP was 0.96, confirming reproducible anatomic localization. Cadaver CPs had a mean Hounsfield units of 263, indicating a mix of bone and soft tissue, and ICC was 0.98, confirming reproducible radiographic measurements. Optimal CT estimates of bone composition of CPs averaged 85% (range 76% to 96%) compared to actual anatomic dissection which averaged 84% bone (range 74% to 91%, r = .690, P = .026). Conclusion Our novel, noninvasive CT method for assessing CP anatomy is reproducible and correlates with anatomic dissection assessing bone composition. The clinical implications of anatomic changes in the CP are an area for further study.

Swallowing Outcomes in Elderly Patients following Microvascular Reconstruction of the Head and Neck.

Objective To describe swallowing outcomes in elderly patients undergoing microvascular reconstruction of the upper aerodigestive tract and identify risk factors for poor postoperative swallowing function. Study Design Case series with chart review. Setting Academic medical center. Subjects and Methods Sixty-six patients aged ≥70 years underwent microvascular reconstruction of the upper aerodigestive tract. The primary outcome measure was the Functional Oral Intake Scale (FOIS); preoperative and postoperative scores were dichotomized to define "good swallowing" and "poor swallowing." Logistic regression was performed to identify risk factors for poor postoperative swallowing function. Results In total, 91% of reconstructions were performed for oncologic defects. The most common defect site was the oral cavity (67%), and the anterolateral thigh (29%) was the most frequently used donor site. At 3-year follow up, 75% of patients had good swallowing function with 95% of patients who achieved good swallowing function doing so within 6 months of surgery. On multivariable analysis, patients with pT4 tumors (odds ratio [OR], 5.2; 95% confidence interval [CI], 1.0-25.6) and those undergoing at least partial glossectomy (OR, 4.7; 95% CI, 1.1-20.7) were more likely to experience poor swallowing function at 6-month follow-up. Conclusion Approximately half of elderly patients achieve good swallowing function within 6 months following microvascular reconstruction of the upper aerodigestive tract. Elderly patients with pT4 tumors and those requiring glossectomy are at highest risk for poor swallowing outcomes. These data can be used to inform preoperative patient counseling and design interventions aimed at improving swallowing function in those at high risk for poor outcomes.

Thirty-day readmission in patients undergoing head and neck microvascular reconstruction.

BACKGROUND: Characteristics of 30-day unplanned readmissions after head and neck microvascular reconstruction remain poorly understood. METHODS: We conducted a retrospective cohort of patients who underwent head and neck microvascular reconstruction between 2010 and 2015. RESULTS: The 30-day unplanned readmission rate was 13.0% (64/493). The most common readmission diagnoses were dehiscence, surgical site infection, or fistula (45.3%; n = 29). Of the readmissions, 46.9% (30/64) occurred within 7 days of discharge from the hospital. Risk factors for readmission on multivariable analysis included body mass index (BMI) < 21 kg/m (odds ratio [OR] 2.47; 95% confidence interval [CI] 1.36-4.47), primary site of oropharynx (OR 1.66; 95% CI 1.17-6.06), hypopharynx/larynx (OR 3.66; 95% CI 1.70-7.88), or sinonasal/skull base (OR 4.07; 95% CI 1.43-11.55), and fistula during the index hospitalization (OR 2.98; 95% CI 1.22-7.24). CONCLUSION: More than 1 in 10 patients undergoing head and neck microvascular reconstruction has a 30-day unplanned readmission, most commonly related to wound complications. Further efforts are needed to determine optimal 30-day unplanned readmission reduction strategies.

The Validity of Self-reported Recent Smoking in Head and Neck Cancer Surgical Patients.

OBJECTIVE: In cancer patients, cigarette smoking causes poorer response to treatment, treatment toxicity, increased risk of recurrence, higher surgical complication rates, and poorer overall survival. As such a significant determinant of patient prognosis, accurate classification of current smoking status is important. Self-reported smoking status may lead to misclassification if patients conceal their true status. The purpose of this study was to assess the validity of self-reported tobacco use during the previous 48 hours in head and neck cancer patients on the day of surgery. STUDY DESIGN: Cross-sectional. SETTING: Two academic medical centers in the southeastern United States. SUBJECTS AND METHODS: On the day of surgery, 108 head and neck cancer patients completed a survey asking about tobacco use during the past 48 hours and had semi-quantitative levels of urinary cotinine measured to biochemically validate self-reported recent smoking. RESULTS: Self-reported smoking yielded a sensitivity of 60.9% (95% CI, 45.4%-74.9%) and a specificity of 98.4% (95% CI, 91.3%-100.0%). The sensitivity increased to 76.1% (95% CI, 61.2%-87.4%) when allowing for the possibility that exposure to secondhand smoke or use of nicotine-containing products could have caused a positive cotinine test. CONCLUSION: In this patient population, self-reported recent smoking yielded a high (39%) proportion of false-negatives, and even 24% remained false-negatives after allowing for other sources of nicotine exposure. This magnitude of underreporting combined with the importance of tobacco use to patient prognosis supports the need for routinely biochemically verifying recent tobacco use in self-reported nonsmokers within the clinical setting.

Suppurative cervical lymphadenitis in infancy: microbiology and sociology.

OBJECTIVE: To investigate the associations between patient age, sociological factors, and the microbiology of pediatric neck infections. METHODS: Retrospective chart review of children up to 5 years old who underwent surgical management of suppurative cervical lymphadenitis. RESULTS: A total of 76 individuals met inclusion criteria; 93% of culture-positive infections were caused by Staphylococcus aureus in infants, compared with 59% in children between 13 months and 5 years of age (P = .002). Of the S aureus isolates, 51% were methicillin-resistant S aureus (MRSA) and 49% were methicillin-sensitive S aureus. Methicillin resistance was associated with African American race (P = .004); 67% of participants received empirical antibiotics prior to admission. Of these, 73% received antibiotics in the ß-lactam class, and 25% received treatment with clindamycin. CONCLUSIONS: Incidence of MRSA is high in infants with cervical lymphadenitis who fail empirical antibiotic therapy and require surgical management. Empirical coverage for cervical lymphadenitis with ß-lactam antibiotics may provide inadequate coverage for early infection in this population.

Revealing a signaling role of phytosphingosine-1-phosphate in yeast.

Sphingolipids including sphingosine-1-phosphate and ceramide participate in numerous cell programs through signaling mechanisms. This class of lipids has important functions in stress responses; however, determining which sphingolipid mediates specific events has remained encumbered by the numerous metabolic interconnections of sphingolipids, such that modulating a specific lipid of interest through manipulating metabolic enzymes causes 'ripple effects', which change levels of many other lipids. Here, we develop a method of integrative analysis for genomic, transcriptomic, and lipidomic data to address this previously intractable problem. This method revealed a specific signaling role for phytosphingosine-1-phosphate, a lipid with no previously defined specific function in yeast, in regulating genes required for mitochondrial respiration through the HAP complex transcription factor. This approach could be applied to extract meaningful biological information from a similar experimental design that produces multiple sets of high-throughput data.