Lymph Node Yield in Therapeutic Neck Dissection: Impact of Dissection Levels and Prior Radiotherapy.

OBJECTIVE: Lymph node yield in therapeutic neck dissection is clinically significant and incompletely studied. We quantified node yield based on extent of neck dissection and presence of preoperative radiation. We also evaluated factors affecting incidence of extracapsular spread (ECS). METHODS: Retrospective review of 499 patients undergoing therapeutic neck dissection; 414 patients met inclusion criteria and were divided into 2 groups: neck dissection alone or before radiation (surgery first: 280 patients; 385 dissections) and primary radiation before surgery (radiation first: 134 patients; 157 dissections). Node yield relative to levels dissected and incidence of ECS were examined. RESULTS: Dissection-specific node yield was greater in the surgery first group for dissection of levels I-V (31.1 ± 16.7 vs 24.0 ± 14.7, P < .001) and levels II-V (26.7 ± 14.4 vs 21.1 ± 10.7). Extracapsular spread incidence was 32.1% (98/305) in the surgery first group and 15.4% (23/149) in the radiation first group ( P < .001). CONCLUSION: This study clarifies anticipated node yield based on number of levels dissected and presence of preoperative radiation. Node yield and incidence of ECS are lower in patients undergoing preoperative radiation.

Preliminary Evaluation of Functional Swallow After Total Laryngectomy Using High-Resolution Manometry.

INTRODUCTION: Understanding of swallowing pressures after total laryngectomy (TL) and what constitutes a "functional" swallow are limited. Mobile structures are altered or removed after TL, with consequent effects on pressure profiles. High-resolution manometry (HRM) can characterize these pressures. METHODS: Six TL subjects without dysphagia and 6 controls underwent pharyngeal HRM. Timing and pressure variables for the velopharynx, mesopharynx, and upper esophageal sphincter (UES) were compared. Changes in variables due to bolus volume were evaluated in TL subjects. RESULTS: The TL subjects had increased duration of velopharyngeal pressure (P = .012). Maximum mesopharyngeal pressure was lower versus controls (P = .003). Maximal and total pre-opening (P = .002, P = .002) and post-closure (P = .001, P = .002) UES pressures were lower. Maximum mesopharyngeal pressure (P = .032) decreased with increasing bolus volume. CONCLUSIONS: Increased velopharyngeal pressure duration and total swallow duration reflect separation of the pharynx into distinct conduits for air and food, thus ensuring successful bolus passage without the need for respiration. Decreased UES pressure highlights the effects of disrupting the cricopharyngeal and rostral esophageal muscle fibers from their attachments to the larynx and performing a cricopharyngeal myotomy. Additional studies including subjects with dysphagia could further characterize the functional TL swallow and identify aspects susceptible to dysfunction.

Metastatic synovial sarcoma of the scalp: Case report.

BACKGROUND: Synovial sarcoma is a malignant tumor of soft tissue that is rarely found in the head and neck. Even less common are metastasis within the head and neck. METHODS: We describe a case of a delayed metastatic synovial sarcoma to the scalp. A man who had been diagnosed and treated 16 years previously for monophasic synovial sarcoma of the groin, presented with a new scalp lesion confirmed to be metastatic monophasic synovial sarcoma. Wide local excision and sentinel lymph node biopsy (SLNB) were performed and adjuvant radiation therapy was deferred. RESULTS: A positron emission tomography (PET)/CT was obtained 3 months after surgery and showed no evidence of local recurrence or metastatic disease. CONCLUSION: This case report describes a rare case of synovial sarcoma metastasizing to the scalp. The genetic, histopathologic, and clinical features of synovial sarcoma are reviewed with a focus on their manifestation and management within the head and neck.

In-office biopsy of upper airway lesions: safety, tolerance, and effect on time to treatment.

OBJECTIVES/HYPOTHESIS: Definitive tissue diagnosis for lesions warranting biopsy is shifting from the operating room to the office. Safety, tolerance, factors related to successful biopsy, and time to treatment are not well-defined. METHODS: Retrospective review of 116 patients undergoing in-office biopsy of oropharynx, larynx, or hypopharynx were included. Logistic regression determined if demographics, site, T-stage, or approach (transoral/transnasal) were related to success. Time to definitive treatment was also analyzed. RESULTS: Ninety-two transnasal and 24 transoral biopsies were performed on 73 laryngeal, 35 oropharyngeal, and 8 hypopharyngeal lesions. Of those, 97 of 116 diagnoses were made in-office. There were no complications; two patients did not tolerate the procedure. Success was not related to age (P = 0.374), site (P = 0.527), T-stage (P = 0.587), or approach (P = 0.566). Time to treatment was 24.2 ± 13.9 days with successful office biopsy and 48.8 ± 49.4 days without. CONCLUSIONS: High procedural completion rate was observed across patients, sites, and approaches. All patients should be considered for in-office biopsy, a more time- and cost-effective option leading to earlier treatment.

Care of pediatric tracheostomy in the immediate postoperative period and timing of first tube change.

OBJECTIVE: To analyze the safety of a standardized pediatric tracheostomy care protocol in the immediate postoperative period and its impact on tracheostomy related complications. STUDY DESIGN: Retrospective case series. SUBJECTS: Pediatric patients undergoing tracheotomy from February 2010-February 2014. METHODS: In 2012, a standardized protocol was established regarding postoperative pediatric tracheostomy care. This protocol included securing newly placed tracheostomy tubes using a foam strap with hook and loop fastener rather than twill ties, placing a fresh drain sponge around the tracheostomy tube daily, and performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome measures included rate of skin breakdown and presence of a mature stoma allowing for a safe first tracheostomy tube change. Two types of tracheotomy were performed based on patient age: standard pediatric tracheotomy and adult-style tracheotomy with a Bjork flap. Patients were analyzed separately based on age and the type of tracheotomy performed. RESULTS: Thirty-seven patients in the pre-protocol group and 35 in the post-protocol group were analyzed. The rate of skin breakdown was significantly lower in the post-protocol group (standard: p=0.0048; Bjork flap: p=0.0003). In the post-protocol group, all tube changes were safely accomplished on postoperative day three or four, and the stomas were deemed to be adequately matured to do so in all cases. CONCLUSION: A standardized postoperative pediatric tracheostomy care protocol resulted in decreased rates of skin breakdown and demonstrated that pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively.

Secondary tracheoesophageal puncture in-office using Seldinger technique.

OBJECTIVE: Evaluate the safety and efficacy of in-office secondary tracheoesophageal puncture (TEP) technique using transnasal esophagoscopy (TNE) and the Seldinger technique in conjunction with a cricothyroidotomy kit for placement. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECT AND METHODS: A retrospective chart review was performed on 83 subjects who underwent in-office secondary TEP. Variables that were examined included disease site, staging, histologic diagnosis, extent of resection and reconstruction, chemoradiation, functional voice status (as assessed by speech pathologist in most recent note), and complications directly related to the procedure. RESULTS: Eighty-three individuals from our institution met our criteria for in-office secondary TEP from 2005 to August 2012. Of these, 97.6% (81/83) had no complications of TEP. The overall complication rate was 2.4% (2/83). Complications included bleeding from puncture site and closure of puncture site after dislodgement of prosthesis at the time of puncture. Fluent conversational speech was achieved in 69.9% of all patients (58/83), and an additional 19.3% (16/83) achieved functional/intelligible speech; of those, 3.6% (3/83) were unable to achieve fluent conversational speech due to anatomic defects from previous surgery. CONCLUSION: An in-office TEP can be safely performed using the Seldinger technique with direct visualization using TNE, despite the extent of resection or reconstruction, with functional speech outcomes comparable to other studies available in the literature.

Glove and gown effects on intraoperative bacterial contamination.

OBJECTIVE: Experiments were performed to determine the risk of bacterial contamination associated with changing outer gloves and using disposable spunlace paper versus reusable cloth gowns. BACKGROUND: Despite decades of research, there remains a lack of consensus regarding certain aspects of optimal aseptic technique including outer glove exchange while double-gloving and surgical gown type selection. METHODS: In an initial glove study, 102 surgical team members were randomized to exchange or retain outer gloves 1 hour into clean orthopedic procedures; cultures were obtained 15 minutes later from the palm of the surgeon's dominant gloved hand and from the surgical gown sleeve. Surgical gown type selection was recorded. A laboratory strike-through study investigating bacterial transmission through cloth and paper gowns was performed with coagulase-negative staphylococci. In a follow-up glove study, 251 surgical team members, all wearing paper gowns, were randomized as in the first glove study. RESULTS: Glove study 1 revealed 4-fold higher levels of baseline bacterial contamination (31% vs 7%) on the sleeve of surgical team members wearing cloth gowns than those using paper gowns [odds ratio (95% confidence interval): 4.64 (1.72-12.53); P = 0.0016]. The bacterial strike-through study revealed that 26 of 27 cloth gowns allowed bacterial transmission through the material compared with 0 of 27 paper gowns (P < 0.001). In glove study 2, surgeons retaining outer gloves 1 hour into the case had a subsequent positive glove contamination rate of 23% compared with 13% among surgeons exchanging their original outer glove [odds ratio (95% confidence interval): 1.97 (1.02-3.80); P = 0.0419]. CONCLUSIONS: Paper gowns demonstrated less bacterial transmission in the laboratory and lower rates of contamination in the operating room. Disposable paper gowns are recommended for all surgical cases, especially those involving implants, because of the heightened risk of infection. Outer glove exchange just before handling implant materials is also recommended to minimize intraoperative contamination.

Adverse effects of long-term proton pump inhibitor use: a review for the otolaryngologist.

OBJECTIVE: Proton pump inhibitors (PPIs) are the mainstay of current medical management for laryngopharyngeal reflux, and treatment often involves long-term use of this class of medications. The long-term adverse effects of PPI use have not been studied extensively, but several analyses have demonstrated epidemiological links between PPI use and adverse outcomes. These include altered mineral and vitamin absorption, orthopedic injury, acute coronary syndromes (ACS), and infectious risks. STUDY DESIGN: A PubMed search was performed for subject headings, including PPIs and adverse outcomes. Relevant studies were included in this review. Studies were compiled, reviewed, and compared in a narrative form. RESULTS: Several epidemiological links between PPI use and metabolic, infectious, cardiac, and orthopedic adverse outcomes were found. No definite causal effects were identified. CONCLUSION: Given these epidemiological patterns, we recommend that the clinician be aware of these possible unintended consequences. In addition, we recommend consideration of dual-energy X-ray absorptiometry (DEXA) bone density scans in at-risk patients who have not been previously tested. We recommend consideration of vitamin B12 and iron levels in selected patients who are at high risk. We also recommend close communication with our cardiology colleagues, as we attempt to ascertain the relationship between clopidogrel and PPI use. We recommend caution in the use of omeprazole in patients undergoing active treatment for ACS. Finally, we recommend consideration of Helicobacter pylori or serum gastrin level testing in patients with known risk factors for gastric carcinoma.

Clinical, histopathologic, and radiographic indicators of malignancy in head and neck paragangliomas.

OBJECTIVE: The goal of this study is to review our series of head and neck paragangliomas to identify factors that may help in predicting malignancy. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Subjects with head and neck paragangliomas at our institution from 1976 to current were reviewed. In addition to statistical comparisons of epidemiologic factors, pathologic and radiographic characteristics were reviewed. RESULTS: Of the 84 subjects, there were seven malignant paragangliomas (8%). Age was found to be significantly different between the benign and malignant subgroups, with an average age of 54 ± 16 and 40 ± 12 years, respectively (P = 0.02). Pain was a presenting complaint in five patients with benign disease (6%), and five of the seven malignant patients (71%) presented with pain, showing a significant association between pain and disease type (P < 0.0001). The odds ratio for a patient with pain having a malignant tumor was 36 (95% CI: 5.5-234). Enlarging neck mass was noted in all cases of malignant disease, but only in 31 percent of cases of benign disease (P < 0.0001). In a secondary analysis of carotid body tumors alone, enlarging neck mass was not found to be significant between benign and malignant disease (P = 0.14). However, pain continued to be significantly different, with 67 percent of malignant lesions demonstrating pain, compared with only 11 percent of benign lesions (P = 0.01). CONCLUSION: This study suggests that pain, a rapidly enlarging neck mass, and younger age are predictive factors of underlying malignancy, which should prompt one to consider an aggressive diagnostic and management approach.

HLA sensitization and allograft bone graft incorporation.

UNLABELLED: Achieving union between host bone and massive structural allografts can be difficult. Donor and recipient human leukocyte antigen (HLA) mismatches and recipient antibody response to donor HLA antigens might affect union. In a prospective multiinstitutional study, we enrolled a consecutive series of patients receiving cortex-replacing, massive structural bone allografts to determine the rate of donor-specific HLA antibody sensitization and to investigate the potential effect of such HLA alloantibody sensitization on allograft incorporation. HLA typing of patients and donors was determined by molecular typing methods. Donor-specific HLA sensitization occurred in 57% of the patients but had no demonstrable effect on graft incorporation or union. The type of host-allograft junction did have a major effect on graft incorporation. Cortical-to-cortical allograft-to-host junctions healed more slowly (mean, 542 days) than corticocancellous to corticocancellous allograft-to-host junctions (mean, 243 days). Although HLA sensitization does not appear to delay structural allograft bone incorporation, further followup is required to determine if there is an association between HLA sensitization and long-term graft survival. Based on these preliminary data, measures to further minimize or modulate HLA sensitization or response are not indicated at present for the purposes of improving structural bone allograft union. LEVEL OF EVIDENCE: Level II, prognostic study.

Characterization of the temporo-spatial effects of chronic bilateral intrahippocampal cannulae on interleukin-1beta.

The implantation of a foreign object in the brain produces an acute neuroinflammatory state in which glia (astrocytes and microglia) may remain chronically activated in response to the inert foreign object. Activated glia can exhibit a sensitized pro-inflammatory response to immunogenic stimuli. This may be relevant to intracranial cannula implantation, which is commonly used to administer substances directly into the brain. If intracranial cannulation activates glia, a subsequent neuroinflammatory stimulus might induce a potentiated pro-inflammatory response, thereby introducing a potential experimental confound. We tested the temporal and spatial responses of interleukin-1beta (IL-1beta) to an acute immune challenge produced by lipopolysaccharide (LPS) in animals with chronic bilateral intrahippocampal cannulae implants (stainless steel). Cannulation increased the gene expression of the microglia activation antigens MHC II and CD11b, but not the astrocyte antigen GFAP. Moreover, this activation was temporally and spatially dependent. In addition, IL-1beta mRNA, but not IL-1beta protein, was significantly elevated in cannulated animals. Administration of LPS, however, significantly potentiated the brain IL-1beta response in cannulated animals, but not in stab wounded or naïve animals. This IL-1beta response was also temporo-spatially dependent. Thus, the pro-inflammatory sequelae of intracranial cannulation should be considered when designing studies of neuroinflammatory processes.