Mandibular Osteoradionecrosis: Defining the Microbial Milieu and Antimicrobial Resistance at the Time of Rescue Flap Surgery.

OBJECTIVE: To report the microorganisms and their antibiotic sensitivity profile from tissue cultures and stains at the time of anterolateral thigh fascia lata (ALTFL) rescue flap for management of mandibular osteoradionecrosis (ORN). METHODS: Retrospective chart review of patients who underwent ALTFL rescue flap for native mandibular ORN between 2011 and 2022. RESULTS: Twenty-six cases comprising 24 patients (mean age 65.4 years, 65.4% male) with mandibular ORN from whom tissue cultures and gram stain were obtained at the time of ALTFL rescue flap. 57.7% grew bacterial species, while 34.6% grew fungal species. Multibacterial speciation was noted in 26.9% of cultures. A combination of bacterial and fungal growth was also seen in 15.4% of cases. All gram-positive cocci (GPC) were pansensitive to antibiotics except for one case of Staphylococcus aureus, which was resistant to levofloxacin. Gram-negative bacilli (GNB) species were isolated in 50.0% of cases. All fungal growth was due to Candida species. No growth was noted in 23.1% of cases. Multidrug resistance was noted in 53.8% of cases when GNB was isolated. CONCLUSION: We report 76.9% of our cases of mandibular ORN had microbial growth from tissue cultures obtained at the time of the ALTFL rescue flap. Fungal growth was noted in a substantial number of cases and should be obtained as a specimen when pursuing culture-driven antibiotic therapy. Most GPCs were pansensitive to antibiotics, while GNBs were often the harbinger of multidrug resistant mandibular ORN. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:166-169, 2024.

Clinical features, evaluation, and management of ophthalmic complications of facial paralysis: A review.

The purpose of this review was to study the evaluation, diagnosis, and management of ophthalmic complications associated with facial nerve palsy and to discuss the current and future interventions. The ophthalmic complications of facial paralysis include lagophthalmos, ectropion, exposure keratopathy, ocular synkinesis, and crocodile tears. Evaluation by an ophthalmologist skilled in recognizing and managing complications of facial paralysis shortly after its initial diagnosis can help identify and prevent long-term complications. Several types of grading scales are used to evaluate, measure the severity, and track surgical and patient-reported treatment outcomes. Lagophthalmos or ectropion are managed using temporary measures aimed at lubricating and covering the eye, including scleral lenses; however, these measures can be expensive and challenging to acquire and maintain. Temporary surgical interventions include lateral tarsorrhaphy, weighted eyelid implants, lateral canthoplasty, and other procedures that tighten or lift the eyelid or surrounding tissues. Management of flaccid facial paralysis due to iatrogenic injury or neoplasm requires neurorrhaphy or graft repair. The most common techniques for dynamic reconstruction in chronic facial paralysis are regional and free muscle flap transfer. Future directions for the management of ophthalmic complications aim to induce blinking and eye closure by developing systems that can detect blinking in the normal eye and transmit the signal to the paralyzed eye using mechanisms that would stimulate the muscles to induce eyelid closure. Blink detection technology has been developed, and a study demonstrated that blinking can be stimulated using electrodes on the zygomatic branch of the facial nerve. Further studies are needed to develop a system that will automate blinking and synchronize it with that of the normal eye.

Minimally Invasive Approach to Access Vessels for Microvascular Anastomosis in Head and Neck Reconstruction.

OBJECTIVES: To describe our technique, review indications, and evaluate the outcomes of the minimal access approach for recipient vessel identification in microvascular tissue transfer. METHODS: Retrospective chart review of all patients who underwent microvascular reconstruction using the minimal access technique between 2015 and 2021. RESULTS: We report 236 cases, comprising 214 patients with a mean age of 60.2 years (3-88). The most common primary defect sites were the mandible (22.6%), cranium (14%), maxilla (13.2%), skull base (12.8%), and nose/nasal cavity (10.6%). Indications for free flap reconstruction included head and neck cancer extirpation (32.2%), osteoradionecrosis (29.7%), acquired deformity (14.0%), chronic wound (11.9%) and oral motor dysfunction (7.2%). Free flap donor sites used were the anterolateral thigh (84.3%), fibula (7.2%), and radial forearm (6.4%). Vessels utilized include superficial temporal (49.8%), facial (38.3%), angular (11.1%), and transverse cervical (0.4%). The overall complication rate was 14% (n = 33), with surgical complications at the recipient site accounting for 67.6% (n = 25). Flap failure occurred in 3.4% of procedures. Prior head and neck surgery and free flaps were associated with an increased risk of major recipient site complications (n = 20, p = 0.0257 and n = 14, p = 0.0117, respectively). CONCLUSION: Minimal access techniques allow consistent recipient vessel identification for microvascular-free tissue transfer. These approaches may be utilized in reconstructing a broad range of head and neck defects, are low morbidity, and contribute to an overall shorter length of stay. LEVEL OF EVIDENCE: 2 Laryngoscope, 2023.

Clinical application of physical therapy in facial paralysis treatment: A review.

This review aims to summarize recent studies regarding the specific modalities of physical therapy as a form of treatment for patients with facial paralysis, analyze the different components of physical therapy, and provide healthcare providers with guidance for their best practice in treating patients with facial paralysis. This paper will discuss the mechanism, indications, and impact factors for facial retraining, evaluate the standards for facial retraining, the creation of a treatment plan, and analyze the combined use of facial retraining with botulinum toxin injections and the application of facial retraining in post facial reanimation patients. Other modes of physical therapy, including electrical stimulation, dry needling, and acupuncture, will be addressed. Lastly, the application of new digital technology will be discussed.

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis.

Importance: Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed. Objective: To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN. Design, Settings, and Participants: This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023. Main Outcomes and Measures: Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals. Results: The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months. Conclusions and Relevance: The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

The psychological and psychosocial effects of facial paralysis: A review.

Facial nerve function is essential for a multitude of processes in the face, including facial movement; expression; and functions, such as eating, smiling, and blinking. When facial nerve function is disrupted, facial paralysis may occur and various complications for the patient may result. Much research has been conducted on the physical diagnosis, management, and treatment of facial paralysis. However, there is a lack of knowledge of the psychological and social effects of the condition. Patients may be at an increased risk for anxiety and depression, as well as negative self and social perceptions. This review analyzes the current literature on the various adverse psychological and psychosocial effects of facial paralysis, factors that may play a role, and treatment options that may help improve patients' quality of life.

Advances in Facial Reanimation.

Facial nerve paralysis is a debilitating clinical entity that presents as a complete or incomplete loss of facial nerve function. The etiology of facial nerve palsy and sequelae varies tremendously. The most common cause of facial paralysis is Bell's palsy, followed by malignant or benign tumors, iatrogenic insults, trauma, virus-associated paralysis, and congenital etiologies.

Trilayer temporalis fascia interposition graft: A reliable technique for nasal septal perforation repair.

PURPOSE: Nasal septal perforation (NSP) repair is a complex procedure with variable techniques and success rates. In this study we describe NSP repair using a trilayer interposition graft of temporalis fascia and thin polydioxanone (PDS) plate without intranasal flaps and report outcomes in our patient population. MATERIALS AND METHODS: IRB-approved retrospective review of 20 consecutive patients presenting to a tertiary medical center with NSP from September 2018 to December 2020 and who underwent NSP repair via our trilayer temporalis fascia interposition graft. De-identified patient data was obtained from the medical record and stored on an encrypted secure server. Descriptive statistics were examined for each variable. RESULTS: All 20 NSP repairs demonstrated durable repair with complete mucosal coverage at last follow-up (average 7 months). Complete resolution of preoperative symptoms was achieved in 85 % of patients, with partial resolution in the remaining 15 %. Of the 20 perforations 25 % were small (<1 cm), 50 % medium (1-2 cm), and 25 % large (>2 cm). The only surgical complication was a single intranasal synechiae. No graft harvest site complications were noted. CONCLUSION: The application of a trilayer temporalis fascia - PDS plate interposition graft without intranasal flaps is highly effective for repair of NSP.

Management, Referral Patterns, and Outcomes in Bell's Palsy: A Single-Institution 903 Patient Series.

OBJECTIVE: In 2013, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published guidelines for Bell's palsy (BP), including recommendations for workup, management, and specialist referral. Patients with BP often present to primary care; however, adherence to guidelines may vary by setting. This study sought to evaluate the management of patients with BP presenting to primary care, emergency department (ED), and urgent care settings. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care center. METHODS: Retrospective chart review of patients identified by diagnosis code for BP. RESULTS: A total of 903 patients were included; 687 (76.1%) presented to ED, 87 (9.6%) to internal medicine, 77 (8.5%) to family medicine, and 52 (5.8%) to urgent care. On presentation, 804 (89.0%) patients were prescribed corticosteroids and 592 (65.6%) antiviral therapy. Steroid therapy ranged from 1 dose to greater than a 14-day course, with 177 (19.6%) receiving an adequate duration of 10 days or greater. Referrals were provided to facial plastics and/or otolaryngology for 51 patients (5.6%). For all comers, 283 (31.3%) had complete resolution, 197 (21.8%) had an incomplete resolution, 62 (6.9%) had persistent palsy, and 361 (40.0%) lost to follow-up. In assessing the association between clinic setting and management, appropriate corticosteroid therapy (p < .01), imaging (p < .01), and eye care (p < .01) were statistically significant. CONCLUSION: Adherence to guidelines for BP management varies amongst providers. In our study cohort, 15.5% of patients received medical therapy in accordance with AAO-HNS guidelines, and only 5.6% were referred to facial plastics. To facilitate more appropriate care, tertiary care institutions may benefit from system-wide care pathways to manage acute BP.

The profunda artery perforator flap for head and neck reconstruction.

INTRODUCTION: The profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity. METHODS: Cadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy. RESULTS: 22 PAP flaps were studied. Each contained 1-6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3-15 cm), 11.4 cm (range 5-17 cm), and 17.5 cm (range 12.5-22 cm). Average pedicle length was 11.07 cm (range 7-16 cm), 11.78 cm (range 9-16 cm), and 11.23 cm (range 9-15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27-4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27-3.82 mm). Range of maximal primary closure was 6-11 cm. CONCLUSION: PAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.

Association between hypertension requiring medication and 30-day outcomes in head and neck microvascular surgery.

BACKGROUND: Hypertension has been shown to be both a protective factor and a risk factor for complications in head and neck reconstructive surgery. METHODS: Retrospective analysis of microvascular free tissue transfer patients using the National Surgical Quality Improvement Program database. RESULTS: Hypertensive patients (n = 1598; 46.9%) had a significantly higher rate of complications, including pneumonia (p < 0.001), myocardial infarction (p = 0.003), and intra/post-operative transfusion (p < 0.001). In a multivariable model, hypertension was associated with returning to the operating room (OR = 1.45 [95% CI 1.20, 1.76], p < 0.001), post-operative medical complications (OR = 1.53 [95% CI 1.24, 1.90], p < 0.001), and surgical complications (OR = 1.17 [95% CI 1.00, 1.37], p = 0.047). However, no difference in 30-day readmission was found (p > 0.05). CONCLUSIONS: Hypertension is a modifiable risk factor for post-operative complications in head and neck free tissue transfer, in which prospective studies are required to establish causation. This study may serve as an impetus for proactive recommendations to manage hypertension before undergoing head and neck microvascular surgery.

Predictive value of the ACS NSQIP calculator for head and neck reconstruction free tissue transfer.

BACKGROUND: Predictive models to forecast the likelihood of specific outcomes after surgical intervention allow informed shared decision-making by surgeons and patients. Previous studies have suggested that existing general surgical risk calculators poorly forecast head and neck surgical outcomes. However, no large study has addressed this question while subdividing subjects by surgery performed. OBJECTIVES: To determine the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator in estimating length of hospital stay and risk of postoperative complications after free tissue transfer surgery. STUDY DESIGN: A retrospective chart review of patients at one institution was performed using Current Procedural Terminology codes for anterolateral thigh (ALT) flap, fibula free flap (FFF), and radial forearm free flap (RFFF) reconstruction. Output data from the ACS NSQIP surgical risk calculator were compared with the observed rates in our patients. METHODS: Incidences of cardiac complications, pneumonia, venous thromboembolism, return to the operating room, and discharge to skilled nursing facility (SNF) were compared to predicted incidences. Length of stay was also compared to the predicted length of stay. RESULTS: Three hundred thirty-six free flap reconstructions with 197 ALT flaps, 85 RFFFs, and 54 FFFFs were included. Brier scores were calculated using ACS NSQIP forecast and actual incidences. No Brier score was <0.01 for the entire sample or any subgroup, which indicates that the NSQIP risk calculator does not accurately forecast outcomes after free tissue reconstruction. CONCLUSION: The ACS NSQIP failed to accurately forecast postoperative outcomes after head and neck free flap reconstruction for the entire sample or subgroup analyses. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:679-684, 2020.

Osseocartilaginous Rib Graft L-Strut for Nasal Framework Reconstruction.

BACKGROUND: In the setting of major nasal framework reconstruction, it is critical to create a stable, warp-resistant L-strut to resist the contractile forces of healing to achieve a durable outcome. OBJECTIVES: The authors sought to demonstrate the effectiveness of the osseocartilaginous rib graft for nasal framework reconstruction. METHODS: Retrospective analysis was performed of all patients who underwent osseocartilaginous rib graft for L-strut reconstruction from 2007 to 2017 at a tertiary care hospital. Only patients with severe framework-only defects (Type IV, Daniel Classification) or total/subtotal nasal defects (Type V, Daniel Classification) were included. Primary outcome measures were: (1) maintenance of projection; (2) graft warping; and (3) graft resorption. RESULTS: Twenty-six patients aged an average of 54.6 years underwent nasal framework reconstruction with an osseocartilaginous rib graft L-strut. Eighteen patients had framework-only deformities (Daniel Type IV) and 8 had total or subtotal nasal deformities (Daniel Type V). Twelve patients underwent reconstruction for autoimmune mediated deformity, 10 for malignancy, 3 for traumatic injury, and 1 for an iatrogenic deformity. Average follow-up was 21 months. There was no observed warping of the L-strut construct, and all but 2 patients demonstrated total maintenance of projection. Resorption of the caudal cartilage graft was identified as the etiology of partial loss of projection in 2 patients. CONCLUSIONS: The osseocartilaginous rib graft L-strut provides a stable, warp-resistant construct for patients lacking major dorsal and caudal support, which may be applied to reconstruction of defects due to malignancy, autoimmune, traumatic, or iatrogenic etiologies.

Pediatric vestibular testing: Tolerability of test components in children.

INTRODUCTION: Objective of the study is to define rates of successful completion of components of pediatric vestibular testing (VT). METHODS: Retrospective review of VT performed on patients less than 18 years of age from 2004 to 2015. RESULTS: 188 pediatric patients (mean age: 13.9 ±â€¯3.56 years old, range 2-17 years) underwent testing. Thirty-five (18.6%) had abnormal test results. Pediatric patients unable to complete all aspects of VT could still complete an average of 7.9 ±â€¯4.0 of 12 test components. The optokinetic tracking test was the most commonly omitted component of the vestibular tests. In a multivariate analysis, failure to perform Nylen-Barany positional testing (χ2 27.5, p < 0.0001) or Dix-Hallpike (5.66, p = 0.0174) testing was associated with inability to obtain final diagnosis on VT. CONCLUSIONS: Interpretable VT may be obtained in most children, even in those that do not tolerate the full testing protocol. Spontaneous and gaze-evoked nystagmus testing maybe considered as part of initial testing protocol before attempting less well-tolerated components such as bithermal calorics or components that require VNG goggles.

Comprehensive approach to reestablishing form and function after radical parotidectomy.

INTRODUCTION: The reconstructive goals following radical parotidectomy include restoration of symmetry, reanimation of the face, and reestablishment of oral competence. We present our experience utilizing the anterolateral thigh (ALT) free flap, orthodromic temporalis tendon transfer (OTTT), and facial nerve cable grafting to reestablish form and function. MATERIAL AND METHODS: From 2010 to 2016, 17 patients underwent radical parotidectomy followed by immediate reconstruction. An ALT was harvested to accommodate the volume and skin defect. Additional fascia lata and motor nerve to vastus lateralis (MNVL) were obtained. Anastomosis of the ALT to recipient vessels was performed, most commonly using the facial artery and internal jugular vein. OTTT was performed by securing the medial tendon of the temporalis to orbicularis oris through a nasolabial incision. Fascia lata was tunneled through the lower lip, then secured laterally to the temporalis tendon. The MNVL was cable grafted from either the proximal facial nerve or masseteric nerve to the distal facial nerve branches. ALT fascia was suspended to the superficial muscular aponeurotic system. RESULTS: Average follow up was 19 months. Only one patient failed to achieve symmetry attributed to dehiscence of OTTT. All patients achieved oral competence and dynamic smile with OTTT activation. Facial nerve recovery was seen in 8 patients. 5 reached a House Brackman Score of 3. Two donor site seromas and two wound infections occurred. CONCLUSION: Simultaneous ALT, OTTT, and facial nerve cable grafting provides early reestablishment of facial symmetry, facial reanimation, and oral competence with minimal morbidity.

Perioperative cardiac complications in patients undergoing head and neck free flap reconstruction.

BACKGROUND: Limited data exists on cardiac complications following head and neck free flaps. DESIGN: A retrospective review was performed on patients that underwent free flap reconstruction from 2012 to 2015. RESULTS: 368 flaps were performed. 12.5% of patients experienced a cardiac event. Hypertension, coronary artery disease, heart failure, venous thromboembolism, and anticoagulation were associated with cardiac complications. ASA class was not predictive of cardiac events. 7.6% of patients required anticoagulation, which exhibited a strong association with surgical site hematoma. Cardiac complications led to a significantly increased length of stay. CONCLUSIONS: There is a significant rate of cardiac events in this cohort. When estimating risk, a patient's total burden of comorbidities is more important than any one factor. ASA Class fails to demonstrate utility in this setting. Cardiac events have implications for quality-related metrics including length of stay and hematoma rate.

Role of adenoidectomy in chronic nasal obstruction after nasal steroid therapy failure.

OBJECTIVE: To identify clinical characteristics of pediatric patients that failed nasal steroid therapy for management of chronic nasal obstruction and to evaluate the efficacy of adenoidectomy in this subset of patients. DESIGN: Retrospective chart review. SETTING: Tertiary care academic center. SUBJECTS: Analysis was performed on children that underwent adenoidectomy between 2011 and 2015 for chronic nasal obstruction refractory to nasal steroids. RESULTS: Seventy-four cases were identified. Average age of presentation was 3.6years. Pre-operatively, 25.7% of patients had known asthma, 16.2% reported respiratory allergies, and 20.3% reported use of systemic antihistamines. The most common pre-operative symptoms included mouth breathing (82.4%), nasal congestion (81.1%), snoring (71.6%), and rhinorrhea (37.8%). Average adenoid size was 68% pre-operatively. Ninety-eight percent of patients experienced improvement or resolution of their symptoms following adenoidectomy. CONCLUSIONS: This study demonstrates average rates of respiratory allergies, but high rates of asthma among patients that fail nasal steroid therapy for chronic nasal obstruction. Adenoidectomy is a highly efficacious intervention in this subset of patients.

Generation and analysis of a barcode-tagged insertion mutant library in the fission yeast Schizosaccharomyces pombe.

BACKGROUND: Barcodes are unique DNA sequence tags that can be used to specifically label individual mutants. The barcode-tagged open reading frame (ORF) haploid deletion mutant collections in the budding yeast Saccharomyces cerevisiae and the fission yeast Schizosaccharomyces pombe allow for high-throughput mutant phenotyping because the relative growth of mutants in a population can be determined by monitoring the proportions of their associated barcodes. While these mutant collections have greatly facilitated genome-wide studies, mutations in essential genes are not present, and the roles of these genes are not as easily studied. To further support genome-scale research in S. pombe, we generated a barcode-tagged fission yeast insertion mutant library that has the potential of generating viable mutations in both essential and non-essential genes and can be easily analyzed using standard molecular biological techniques. RESULTS: An insertion vector containing a selectable ura4+ marker and a random barcode was used to generate a collection of 10,000 fission yeast insertion mutants stored individually in 384-well plates and as six pools of mixed mutants. Individual barcodes are flanked by Sfi I recognition sites and can be oligomerized in a unique orientation to facilitate barcode sequencing. Independent genetic screens on a subset of mutants suggest that this library contains a diverse collection of single insertion mutations. We present several approaches to determine insertion sites. CONCLUSIONS: This collection of S. pombe barcode-tagged insertion mutants is well-suited for genome-wide studies. Because insertion mutations may eliminate, reduce or alter the function of essential and non-essential genes, this library will contain strains with a wide range of phenotypes that can be assayed by their associated barcodes. The design of the barcodes in this library allows for barcode sequencing using next generation or standard benchtop cloning approaches.