Practice Trends and Evidence-Based Practice in Microvascular Reconstruction.

Microvascular and free flap reconstruction are important to the otolaryngology-head and neck surgery practice. Herein, the reader will find an up-to-date discussion of various evidence-based practice trends related to microvascular surgery, including surgical techniques, anesthetic and airway considerations, free flap monitoring and troubleshooting, surgical efficiency, and both patient-related and surgeon-related risk factors that may affect outcomes.

Osteotomized folded scapular tip free flap for complex midfacial reconstruction.

Aim: To describe a novel technique for the reconstruction of geometrically complex defects of the midface using an osteotomized folded scapular tip-free flap. Methods: Five patients underwent maxillectomy with defects disrupting two or more of the following facial axes: orbital, nasofacial, and palatal axes. Patients underwent primary reconstruction using an angular artery-based scapular tip-free flap with an osteotomy to fold the flap. Harvest techniques, including placement of osteotomies, folding and plating, surgical esthetic, and functional outcomes, are presented. Results: Osteotomies placed in the scapular tip-free flap allowed folding of the osseous flap and improved restoration of all three facial axes with a single flap. In one patient, the tip of the scapula was used to reconstruct the nasofacial axis, while the body and lateral border were used to reconstruct the palate. In four patients, the tip of the scapula was used to reconstruct the orbital axis, while the body and lateral border were used to reconstruct the nasofacial axis. Patients had successful oronasal separation, healed wounds withstanding adjuvant therapy, satisfactory orbital positioning and facial projection, preserved masticatory surfaces and opportunity for dental implants. Conclusion: The midface is geometrically complex and is one of the most challenging head and neck sites to reconstruct. Ablative defects in this area can disrupt facial axes resulting in poor esthetic and functional outcomes. This study demonstrates the reconstructive advantages of a novel osteotomized folded scapular tip-free flap.

Three-dimensional modeling of the scapular tip for anterolateral and lateral mandibular defects.

OBJECTIVE: Three-dimensional (3D) computational modeling represents an invaluable surgical tool for complex reconstructive cases. There exists limited data on 3D imaging to evaluate the use of the scapular tip free flap in complex, anterolateral mandibular reconstructions. The purpose of this study is to radiographically assess the scapular tip free flap in anterolateral defects of the mandible. METHODS: A retrospective case series of 50 patients was performed on head and neck cancer patients treated at Michigan Medicine from 2013 to 2018. Patients who had pre-operative computed tomography neck and thorax for review were included. RESULTS: The scapular tip was able to cover defects from the ipsilateral mandibular angle to the symphysis in all cases. On average, the bone extended to cover defects from the mandibular angle to 17 mm (SD ± 3.6 mm) beyond the mandibular symphysis, which equates to 70% (95% CI 0.66-0.74) of the distance from the symphysis to the contralateral mental foramen. CONCLUSION: Use of the scapular tip as a donor site for reconstruction of the mandibular body can be evaluated pre-operatively utilizing 3D imaging. All patients were able to achieve posterior coverage to the vertical plane of the mandibular condyle and contralateral extension across the symphysis on average extends almost three-fourths of the distance to the mandibular foramen. The extent of contralateral coverage can be more accurately delineated utilizing the patient's pre-operative imaging.

Mandated wrapping of airway cart instruments: Limited access without the intended safety benefits.

OBJECTIVES/HYPOTHESIS: Isolated case studies have shown improper sterilization or contamination of equipment from anesthesia carts can lead to transmission of disease and even death. Citing this literature, national accrediting agencies mandated all instruments in the otolaryngology airway carts at San Antonio Military Medical Center be packaged to prevent contamination. This study sought to determine the infection and safety implications of packaged airway cart instruments. STUDY DESIGN: Retrospective chart review. METHODS: A review of upper aerodigestive tract procedures, some of which penetrated mucosa, was performed by analyzing 100 patient records during the unpackaged period and 100 during the packaged period. A comparison of infections, deaths, and length of stay in the hospital was included in the analysis. Additionally, a timed simulation to setup a simple group of instruments for an emergency airway situation from both the unpackaged and packaged airway carts was performed using a total of 11 surgical technologists and nurses. RESULTS: Each group had a total of four airway infections and neither had any deaths. The average length of hospital stay was 0.36 days for the unpackaged period and 0.44 days from the packaged period. None of these variables reached statistical significance. The average time to find and set out the correct instruments for the two groups was 46.6 and 95.5 seconds for the unpackaged and packaged airway carts, respectively (P = .004). CONCLUSIONS: This study suggests individually packaging of instruments used for emergency airway cases may put lives at risk when time matters and fails to decrease the risk of infection. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:715-719, 2019.

Current practices in microvascular reconstruction in otolaryngology-head and neck surgery.

OBJECTIVES/HYPOTHESIS: Despite major advances in the field of head and neck microvascular free tissue transfer (MFTT) over the past several decades, there are no standardized perioperative regimens for the care of patients undergoing free flap reconstructive surgery, and continued variation in practice exists. This study aimed to report current trends in the field of MFTT performed by otolaryngologists, including surgeon training, institutional operative practices, and perioperative management. STUDY DESIGN: Cross-sectional survey. METHODS: A survey of Accreditation Council for Graduate Medical Education-accredited residency programs and American Head and Neck Society fellowship sites was conducted. RESULTS: Seventy-one (62.8%) programs responded, with 67 (94.4%) routinely performing MFTT and 23 (32.4%) having a dedicated microvascular fellowship program. Of institutions performing MFTT, 66 (98.5%) reported the use of a two-surgeon team, most commonly both otolaryngologists (76.3%). Institutional MFTT volumes and donor site frequency are reported. Postoperative care includes routine admission to the intensive care unit (75.2%), step-down unit (15.0%), or general care floor (8.1%). Postoperative flap monitoring practices, including modalities, personnel, and timing/frequency show institutional variation. Despite differences in postoperative monitoring regimen and management (sedation, anticoagulation, antibiotic use), surgeon-reported measures of flap success rate (95.7%, standard deviation [SD] 4.7%) and complication rate (6.8%, SD 2.4%) show little difference across institutions. CONCLUSIONS: Many elements of MFTT perioperative care show continued variation at an institutional level. There is a notable shift toward the two-team approach within otolaryngology. Self-reported flap complication and success rates showed no significant differences based on perioperative care and monitoring regimen. Further study of perioperative practices should focus on standardization of care to improve overall outcomes in this complex patient population. LEVEL OF EVIDENCE: NA Laryngoscope, 129:138-145, 2019.

The Spider Limb Positioner in subscapular system free flaps.

BACKGROUND: The subscapular system is a versatile vascular network that can provide multiple flaps for reconstruction of the head and neck. A significant drawback of using the subscapular system is that patient positioning can preclude the use of simultaneous two-team ablative and reconstructive surgery. Herein, we describe a novel use of an upper extremity limb positioner (Spider Limb Positioner) used primarily in orthopedic surgery to facilitate concurrent two-team technique in head and neck surgery. METHODS: Using a bean bag and the Spider Limb Positioner for the upper extremity, a semidecubitus position was used for subscapular donor site dissection. Ablative and reconstructive teams worked concurrently in all cases. RESULTS: This technique was utilized 78 times on 73 patients, with chimeric flaps used in 38% of cases. The average operative time was 466 min. Only one patient required repositioning intraoperatively due to a change in the subscapular donor site side. There were no nerve compression injuries or positioning related complications. CONCLUSION: Scapular and parascapular free flaps are useful tools for reconstruction of the head and neck. In a two-team approach, the use of a semidecubitus position in conjunction with the Spider Limb Positioner facilitates exposure for the reconstructive team without compromising access for the ablative team.

Management of Battlefield Injuries to the Skull Base.

High velocity skull base injuries on the battlefield are unique in comparison to most civilian sector trauma. With more than 43,000 United States military personnel injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), the most recent conflicts in Iraq and Afghanistan have significantly expanded the understanding of the physiology of modern battlefield trauma and how to appropriately address these injuries. The acute care principles of effective triage, airway management, and hemorrhage control in these injuries can be life saving and are reviewed here. Specific injury patterns and battlefield examples are reviewed as well, with a review of some of the lessons learned while providing care in a deployed setting. Utilization of the knowledge learned in Iraq and Afghanistan, which have improved casualty care of deployed service members, can be used both in future military conflicts and in civilian trauma care.

Management and reconstruction of blast wounds of the head and neck.

PURPOSE OF REVIEW: The purpose of this review is to highlight recent literature related to the initial management and reconstruction of blast injuries to the head and neck. RECENT FINDINGS: An increasing percentage of combat-related injuries are caused by blast trauma. Management of blast trauma over the last 10 years has improved understanding of the unique nature of these injuries and the importance of thoughtful management and reconstruction. Blast trauma is associated with an increased need for definitive airway management. As a result, initial triage principles of airway management and hemorrhage control are extremely important in the acute setting. Blast trauma results in high-velocity injuries that can lead to extensive soft tissue damage, which has important implications for reconstruction. Staging reconstruction is an important consideration for more extensive injuries. SUMMARY: Experience on the battlefield with blast injuries over the last decade has led to efficient triage with focus on hemorrhage and airway control. The lessons learned in Iraq and Afghanistan with the unique physiology of blast trauma have improved the casualty care of service members and can be used both in future military conflicts and in civilian trauma care.

Dyspnea, Dysphonia, and Cough: Varied Presentations of Tracheobronchopathia Osteochondroplastica.

OBJECTIVES: Tracheobronchopathia osteochondroplastica (TPO) is an uncommon, benign disease consisting of submucosal, osteocartilaginous nodules that project into the tracheal lumen. Far less commonly, these nodules can occur outside the tracheal cartilage. This case series discusses the wide range of symptoms and treatments of the disease. METHODS: Three patients presented to the laryngology clinic with 3 varied presentations of TPO, including dyspnea, dysphonia, and cough. These patients were evaluated, subsequently diagnosed with TPO, and treated accordingly. RESULTS: Two of the 3 patients presented with extratracheal lesions presenting in the cricoid and thyroid cartilages. The patient presenting with symptoms of dysphonia was found to have bilateral TPO exclusively within the thyroid cartilage, which has never been reported previously. After undergoing a partial thyroid cartilage resection removing the bulk of the lesion, the patient's symptoms drastically improved. CONCLUSION: While TPO may be a rare diagnosis in the general otolaryngologist practice, symptoms frequently bring patients into the otolaryngologist's clinic, and an awareness of the disease can help minimize unnecessary interventions and allow the surgeon to appropriately counsel patients.

The otologist's tuning fork examination--are you striking it correctly?

OBJECTIVE: To determine if the manner in which a tuning fork is activated affects its vibrational response. STUDY DESIGN: Diagnostic test assessment. SETTING: Hearing Center of Excellence laboratory. SUBJECTS AND METHODS: A Polytec OFV-5000 scanning vibrometer was used to measure the vibrational response of 256-Hz, 512-Hz, and 1024-Hz tuning forks after activation. The tuning forks were activated to varying intensities by striking 4 unique surfaces: the head, palm, a metal surface, and a wood table. RESULTS: The fundamental frequency of the individual tuning fork was the dominant observed frequency in all testing scenarios. Additional nonharmonic frequencies were noted when the 256-Hz and 512-Hz tuning forks were struck off metal and wooden surfaces. CONCLUSIONS: Additional nonfundamental sound frequencies produced secondary to striking a tuning fork off a metal object or a wooden table could affect clinical tuning fork examination and complicate decisions regarding surgical candidacy.

A rare case of occult uterine inversion at an Army community hospital: a case report.

Uterine inversion is a rare occurrence in obstetrics, but it is a life-threatening complication. Most cases of inversion are caused by excessive cord traction during management of the third stage of labor. We describe a rare case of a complete uterine inversion in a 19-year-old G1P0 dependent spouse of a deployed active duty soldier. After failure of manual correction of the inversion, the patient was taken emergently to the operating room, where the inversion was successfully corrected using surgical methods. The patient required 3 units of packed red blood cells over the next 24 hours, but was discharged home in good condition on postoperative day 3. This case demonstrates the importance of a rapid diagnosis and management of uterine inversion, as it is a rare but serious complication of vaginal delivery.