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.

Fibrin sealant and parotidectomy wound complications in 100 patients.

PURPOSE: To determine whether the use of fibrin sealant impacted the rate of postoperative wound complications following parotidectomy. METHODS: We retrospectively reviewed 100 consecutive parotidectomies with and without fibrin sealant. Primary outcomes were development of seroma, sialocele, abscess, or hematoma within the first 30 days as well as length of hospital stay for drain output if one was placed. Secondary outcomes analyzed wound complications based on several patient and surgical factors. RESULTS: In our cohort, there were 82 superficial parotidectomies (82%), and the most common pathology was pleomorphic adenoma (39%) followed by Warthin's tumor (27%). Fibrin sealant was used in 46 patients (46%). Postoperative wound complications occurred in 20 patients, and were not statistically different with or without fibrin sealant placement (23.9% vs. 16.7%, p = 0.454). Fibrin sealant did not significantly reduce wound complications regardless of tissue volume removed, use of acellular dermis, history of smoking, diagnosis of diabetes, or active anticoagulant/antiplatelet use. Only four patients without fibrin sealant (7.4%) required hospitalization beyond 24 h for high drain output. CONCLUSIONS: In our retrospective cohort, the development of postoperative wound complications following parotidectomy did not appear to be significantly impacted by the use of a fibrin sealant.

Dorsal scapular artery as a recipient vessel in the vessel-depleted neck during free tissue transfer in head and neck reconstruction.

BACKGROUND: The vessel-depleted neck poses a unique challenge to the microvascular surgeon. Using 3D modeling and cadaveric dissection, we describe the approach and advantages of a known but less frequently used recipient vessel, the dorsal scapular artery, during free tissue transfer. METHODS: Three patients with vessel-depleted necks required reconstruction with free tissue transfer. The dorsal scapular artery was used as a recipient vessel. Three-dimensional anatomic models were created and cadaveric dissections were performed to characterize the anatomy. RESULTS: The dorsal scapular artery was successfully used in 3 patients as the recipient pedicle for free tissue transfer. The vessel was identified deep in the posterior triangle after emerging through the brachial plexus. In all cases, the artery was in a previously undissected field, and had a large caliber and favorable geometry for microvascular anastomosis. CONCLUSION: The dorsal scapular artery is a viable recipient vessel during head and neck reconstruction in the vessel-depleted neck.

Otolaryngology Residency Program Research Resources and Scholarly Productivity.

Objective To delineate research resources available to otolaryngology residents and their impact on scholarly productivity. Study Design Survey of current otolaryngology program directors. Setting Otolaryngology residency programs. Subjects and Methods An anonymous web-based survey was sent to 98 allopathic otolaryngology training program directors. Fisher exact tests and nonparametric correlations were used to determine statistically significant differences among various strata of programs. Results Thirty-nine percent (n = 38) of queried programs responded. Fourteen (37%) programs had 11 to 15 full-time, academic faculty associated with the residency program. Twenty (53%) programs have a dedicated research coordinator. Basic science lab space and financial resources for statistical work were present at 22 programs (58%). Funding is uniformly provided for presentation of research at conferences; a minority of programs (13%) only funded podium presentations. Twenty-four (63%) have resident research requirements beyond the Accreditation Council for Graduate Medical Education (ACGME) mandate of preparing a "manuscript suitable for publication" prior to graduation. Twenty-five (67%) programs have residents with 2 to 3 active research projects at any given time. None of the investigated resources were significantly associated with increased scholarly output. There was no uniformity to research curricula. Conclusions Otolaryngology residency programs value research, evidenced by financial support provided and requirements beyond the ACGME minimum. Additional resources were not statistically related to an increase in resident research productivity, although they may contribute positively to the overall research experience during training. Potential future areas to examine include research curricula best practices, how to develop meaningful mentorship and resource allocation that inspires continued research interest, and intellectual stimulation.

The Role of the Away Rotation in Otolaryngology Residency.

Objective To determine the availability and purpose of away rotations during otolaryngology residency. Study Design Cross-sectional survey. Setting Otolaryngology residency programs. Subjects and Methods An anonymous web-based survey was sent to 98 allopathic otolaryngology training program directors, of which 38 programs responded. Fisher exact tests and nonparametric correlations were used to determine statistically significant differences among various strata of programs. A P value of <.05 was considered statistically significant. Results Thirty-nine percent (n = 38) of queried programs responded. Mandatory away rotations and elective away rotations were both present in 6 of 38 programs (16%). Neither number of faculty ( P = .119) nor residents ( P = .88) was predictive of away rotation. Away rotations were typically >151 miles from the home institution and typically used to address deficiencies in clinical exposure (67%) or case volume (50%). Participants of mandatory away rotations were universally provided housing, with other consideration such as stipend (33%), relocation allowance (33%), or food allowance (16%) sometimes offered. In contrast to mandatory rotations, half of elective rotations were to obtain a unique international mission trip experience. Nearly one-third of surveyed program directors (29%) would consider adding an away rotation to their curriculum in the next 3 years. Conclusions Mandatory and elective away rotations play a role in a small, but not insignificant, number of training programs. The rationale for these rotations is variable. Given that nearly one-third of program directors would consider adding an away rotation in the near future, further research into components of a meaningful away rotation and how to optimize the away rotation experience is warranted.

Otogenic lateral sinus thrombosis in children: A review of 7 cases.

Otogenic lateral sinus thrombosis (LST) is a rare but serious intracranial complication of acute or chronic otitis media. Reported mortality rates have ranged from 8 to 25%; the pediatric mortality rate might be as low as 5%. Controversy still exists over the medical and surgical management of this condition. We conducted a retrospective chart review of 7 cases of pediatric otogenic LST that were treated at our institution over a period of 8 years. We hypothesized that good outcomes in very sick patients can be achieved by aggressively managing the mastoid cavity and without the need for a thrombectomy. Our study group was made up of 4 boys and 3 girls, aged 6 to 15 years (mean: 11.1). All patients received intravenous antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus and placement of a tympanostomy tube. Sinus exploration with thrombectomy was not performed in any patient. Anticoagulation was used perioperatively in 5 patients (71%) without complication. All patients recovered well without major sequelae, which supports our hypothesis. We also describe the case of a patient with multiple concomitant intracranial comorbidities associated with this rare condition.

Primacy of surgery in the management of mucoepidermoid carcinoma in children.

BACKGROUND: Epithelial salivary gland neoplasms are rare in children. Malignant tumors account for 30% to 50% of cases in the pediatric age group, with mucoepidermoid carcinoma as the most common histology. METHODS: A retrospective medical record review was conducted from 1953 to 2007 to identify patients with mucoepidermoid carcinoma at the age of 18 years or younger at the time of diagnosis. Forty-nine patients were identified. Their medical records were examined for presentation, treatment, pathologic features, and outcomes. RESULTS: Forty-nine pediatric patients with mucoepidermoid carcinoma were identified. The parotid gland (49%) and oral cavity (35%) were the most common subsites. Nodal metastasis was seen in 24% of patients. All patients underwent surgery, and 11 patients (22%) were treated with radiation therapy. The 5-year overall survival was 98%, the 10-year overall survival was 94%, and 10% of patients developed recurrence. CONCLUSION: Mucoepidermoid carcinoma in children carries a favorable prognosis and can be successfully treated with surgery alone in most cases.

Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess.

OBJECTIVE: Controversies remain regarding the management of orbital cellulitis (OC). The objective of this study was to examine the outcomes of patients admitted to our institution for orbital cellulitis during a 7-year period. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral pediatric hospital. SUBJECTS AND METHODS: Charts of 465 consecutive OC admissions were reviewed for presentation, imaging, medical and surgical treatment, and outcome. RESULTS: Of these patients, 189 were treated in the emergency room and 276 were admitted. CT scan was performed on 240 patients. Subperiosteal abscess (SPA) was noted in 68 patients. Of these, 47 were treated medically and 21 had surgery. Surgical patients were older (8.3 vs 6.2 years, P = 0.039), had larger abscesses (>10 mm, P < 0.001), required a longer admission (10.2 vs 6.6 days, P < 0.001), and had higher temperatures on admission (38.0 degrees C vs 37.3 degrees C, P = 0.03). CONCLUSION: The majority of small SPAs as diagnosed on CT scans in younger children can be successfully treated medically. Surgery, however, should be considered for a worsening clinical examination. Our findings confirm those of previous reports on this clinical entity.