Nasal Septal Mucocele Causing Saddle Nose Deformity.

Nasal septal mucoceles are a rare occurance, and reports in the current literature are limited. We describe the case of a 73-year-old woman who developed a nasal septal mucocele several days after an episode of angioedema. The lesion was treated with 2 rounds of needle aspiration with antibiotics and the application of silastic splints. There was no recurrence after 1 month, though the patient developed a saddle nose deformity. She ultimately underwent reconstruction with a diced-cartilage dorsal augmentation graft with fibrin glue. We review the learning points of this case and summarize existing literature on this disease.

Shorter interval between radiation therapy and salvage laryngopharyngeal surgery increases complication rates following microvascular free tissue transfer.

PURPOSE: To evaluate how the interval between radiation and salvage surgery for advanced laryngeal cancer with free tissue transfer reconstruction influences complication rates. MATERIALS AND METHODS: This is a retrospective series of 26 patients who underwent salvage laryngectomy or laryngopharyngectomy with vascularized free tissue reconstruction (anterolateral thigh or radial forearm) following radiation or chemoradiation between 2012 and 2017 at a single academic center. The primary outcome was incidence of postoperative complications, including pharyngocutaneous fistula. Secondary outcomes included the need for a second procedure, time to resumption of oral feeding, feeding tube dependence, and hospital length of stay. RESULTS: Salvage surgery was performed for persistence (7/26, 27%), recurrence/new primary (12/26, 46%), and dysfunctional larynges (7/26, 27%). Twenty-two (85%) defects were reconstructed with an anterolateral thigh free flap and 4/26 with a radial forearm free flap (15%). There were no flap failures. There were significantly more complications in patients undergoing surgery within 12 months of completion of radiation therapy (7/12, 58%) versus those undergoing surgery after 12 months (1/14, 7%; p = .02). Patients experiencing complications more often required a second procedure (4/7 vs. 0/1; p = .02), experienced a longer delay to initiation of oral diet (61 vs. 21 days; p = .04), and stayed in the hospital longer (28 vs. 9 days; p = .01). CONCLUSIONS: Shorter intervals between definitive radiation and salvage laryngopharyngeal surgery with free tissue reconstruction increases postoperative complications, hospital length of stay, and the likelihood of feeding tube dependence. Reconstructive surgeons can use these findings to help guide preoperative patient counseling and assess postoperative risk.

Treatment with anti-Sclerostin antibody to stimulate mandibular bone formation.

BACKGROUND: Anti-Sclerostin antibody (Scl-Ab) is a promising new bone anabolic therapy. Although anti-Scl-Ab stimulates bone formation and repair in the appendicular and axial skeleton, its efficacy in the craniofacial skeleton is still poorly understood. METHODS: Using an established model of Down syndrome-dependent bone deficiency, 10 Ts65Dn mice and 10 wild-type mice were treated weekly via i.v. tail vein injection with vehicle or anti-Sclerostin for 3 weeks and euthanized 1 week after. RESULTS: Wild-type mice treated with the anti-Scl-Ab had increased mandibular bone, trabecular thickness, and alveolar height compared with controls. Anti-Scl-Ab increased Ts65Dn mandibular bone parameters such that they were statistically indistinguishable from those in vehicle-treated wild-type mandibles. CONCLUSION: Treatment with anti-Scl-Ab significantly increased mandibular bone mass and alveolar height in wild type mice and normalized mandibular bone mass and alveolar height in Ts65Dn mice. The anti-Scl-Ab therapy represents a novel method for increasing mandibular bone formation.

Does a Standalone Cancer Center Improve Head and Neck Microsurgical Outcomes?

Objectives To evaluate the role of hospital setting (standalone cancer center vs. large multidisciplinary hospital) on free tissue transfer (FTT) outcomes for head and neck reconstruction. Methods Medical records were reviewed of 180 consecutive patients undergoing FTT for head and neck reconstruction. Operations occurred at either a standalone academic cancer center (n = 101) or a large multidisciplinary academic medical center (n = 79) by the same surgeons. Patient outcomes, operative comparisons, and hospital costs were compared between the hospital settings. Results The cancer center group had higher mean age (65.2 vs. 60 years; p = 0.009) and a shorter mean operative time (12.3 vs. 13.2 hours; p = 0.034). Postoperatively, the cancer center group had a significantly shorter average ICU stay (3.45 vs. 4.41 days; p < 0.001). There were no significant differences in medical or surgical complications between the groups. Having surgery at the cancer center was the only significant independent predictor of a reduced ICU stay on multivariate analysis (Coef 0.73; p < 0.020). Subgroup analysis, including only patients with cancer of the aerodigestive tract, demonstrated further reduction in ICU stay for the cancer center group (3.85 vs. 5.1 days; p < 0.001). A cost analysis demonstrated that the reduction in ICU saved $223,816 for the cancer center group. Conclusion Standalone subspecialty cancer centers are safe and appropriate settings for FTT. We found both reduced operative time and ICU length of stay, both of which contributed to lower overall costs. These findings challenge the concept that FTT requires a large multidisciplinary hospital. Level of Evidence 4.

Controversies in Parotid Defect Reconstruction.

Reconstruction of the parotid defect is a complex topic that encompasses restoration of both facial form and function. The reconstructive surgeon must consider facial contour, avoidance of Frey syndrome, skin coverage, tumor surveillance, potential adjuvant therapy, and facial reanimation when addressing parotid defects. With each defect there are several options within the reconstructive ladder, creating controversies regarding optimal management. This article describes surgical approaches to reconstruction of parotid defects, highlighting areas of controversy.

Benefits of Immediate Extubation Following Free Tissue Transfer for Head and Neck Reconstruction.

Background Immediate postprocedure extubation (cessation of mechanical ventilation) after free tissue transfer for head and neck reconstruction may improve outcomes, reduce intensive care unit and hospital length of stay, and reduce overall cost compared with delayed extubation in the intensive care unit. Methods Medical records of 180 consecutive patients undergoing free tissue transfer for head and neck reconstruction were reviewed. Patients immediately extubated in the operating room (immediate group, N = 63) were compared with patients who were extubated in the intensive care unit (delayed group, N = 117) by univariate and multivariate analysis. Results Medical complication rates and intensive care unit length of stay were significantly higher in the delayed extubation group (55.5 vs. 12.7%, p < 0.001, and 4.4 vs. 2.9 days, p < 0.001, respectively). Although the rate of preoperative alcohol use was similar between the two groups, significantly fewer patients underwent treatment for alcohol withdrawal or agitation in the immediate extubation group (3.2 vs. 27.4%, p = 0.001). There were no significant differences in surgical complication rates. Conclusion Immediate postprocedure extubation is associated with shorter intensive care unit length of stay, reduced medical complications, and reduced incidence of treatment for agitation/alcohol withdrawal for patients undergoing free tissue transfer for head and neck reconstruction.

Utility of preoperative computed tomography and magnetic resonance imaging in adult and pediatric cochlear implant candidates.

OBJECTIVES/HYPOTHESIS: Determine the utility of preoperative imaging in adult and pediatric cochlear implant candidates. STUDY DESIGN: Retrospective chart review. METHODS: Medical records of 101 consecutive adult and 20 consecutive pediatric patients who underwent 137 cochlear implantation (CI) procedures at a single institution were reviewed. RESULTS: Computed tomography (CT) was obtained preoperatively in 110 (90.9%) patients, preoperative magnetic resonance imaging (MRI) was obtained in 102 (84.3%) patients, and both were obtained in 94 (77.7%) patients. MRI revealed one acoustic neuroma and two meningiomas, which affected surgical planning for three (2.2%) procedures. MRI identified enlarged vestibular aqueduct (EVA) in 2.0% of adult patients. CT demonstrated middle ear disease in four (3.3%) patients. CT was useful in indicating round window and cochlear patency in three (2.2%) patients with cochlear otosclerosis. Twenty pediatric patients underwent 27 CI procedures. Preoperative CT in the pediatric cohort demonstrated five (25%) dysplastic cochleae, three (15%) dysplastic vestibules and/or semicircular canals, and three (15%) EVAs. In one patient, CT demonstrated a duplicated right internal auditory canal (IAC) and hypoplastic left IAC; MRI confirmed hypoplastic cochlear nerves. CONCLUSIONS: Preoperative MRI can demonstrate retrocochlear pathology, cochlear patency, and EVA in adults being evaluated for cochlear implantation. CT may provide additional information in patients with chronic otitis media or otosclerosis. However, in postlingually deafened adults without conductive or asymmetrical hearing loss, imaging is unlikely to affect surgical decision making. Both CT and MRI can identify anomalies in pediatric patients. MRI does not offer substantial benefit over CT for routine evaluation of pediatric inner ear and temporal bone anatomy. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:1440-1445, 2016.

Salvage of free-flaps in vessel-depleted mandibular osteoradionecrosis cases using catheter-directed thrombolysis and angioplasty.

OBJECTIVES: To evaluate the efficacy of highly selective catheter-directed thrombolysis (CDT) and angioplasty for salvage of compromised free flaps that were performed for treatment of mandibular osteoradionecrosis (ORN). DESIGN: Case series SETTING: University of California, Los Angeles (UCLA) Medical Center PATIENTS: Two patients with ORN who underwent highly selective CDT to salvage threatened free flaps are reported. One patient experienced arterial thrombosis on postoperative day 8 and underwent arterial CDT and angioplasty. A second patient underwent central venous CDT for a subclavian vein thrombosis that was diagnosed during the immediate postoperative period.Interventions Highly selective CDT and angioplasty for salvage of compromised free flaps MAIN OUTCOMES MEASURED: Flap survival, patient survival, hemorrhagic complications. RESULTS: Both patients underwent successful thrombolysis. One patient required two CDT procedures over a 48-hour period; the other patient received continuous CDT infusion of tissue plasminogen activator (TPA) for 24 hours. There were no procedure-related complications. Long-term follow-up demonstrated complete flap survival with no flap necrosis. CONCLUSION: Free flaps performed for mandibular ORN have increased complication rates, and the surgical options for salvage of flap ischemia are often limited in patients with a heavily radiated, vessel-depleted neck. Aggressive CDT and angioplasty appears to be a useful modality in managing difficult cases of free-flap salvage in patients with mandibular ORN.

Brachytherapy-mediated bone damage in a rat model investigating maxillary osteoradionecrosis.

OBJECTIVES: To assess clinical and radiologic findings from targeted radiotherapy to the rat maxilla and to compare findings with a recently developed rat model of mandibular osteoradionecrosis (ORN). DESIGN: A prospective, controlled animal study. SUBJECTS: Ten male Sprague-Dawley rats were divided into an experimental group receiving catheter-assisted high-dose-rate brachytherapy (n = 6) and a control group with catheter-assisted sham therapy (n = 4). INTERVENTIONS: The second left maxillary molar was extracted 1 week after radiation, and the maxilla was harvested 3 weeks after dental extraction. MAIN OUTCOME MEASURE: We used a standardized method with micro-computed tomography to determine the ratio of bone volume to total volume of the dental extraction socket. RESULTS: On the gross clinical examination, all rats had mucosal coverage of the dental extraction site, whereas only the brachytherapy group demonstrated scarring of the mucosa. The median bone volume to total volume was 0.21 for the brachytherapy group and 0.49 for the control group (P = .01). CONCLUSIONS: Similar to the mandible, the maxilla is susceptible to radiogenic bone injury as demonstrated by the significant decrease in bone volume of the radiated dental extraction socket. Despite radiologic similarities to mandibular ORN in the rat model, the maxilla demonstrated a more benign clinical course with a complete absence of bone exposure. Differences in the maxillary bone and microenvironment of the maxilla compared with the mandible may explain the subclinical response to radiation and lower incidence of maxillary ORN seen in patients. This maxillary model can be combined with our high-dose-rate mandibular ORN model to investigate these differences and better understand ORN.

Standardized analysis of mandibular osteoradionecrosis in a rat model.

OBJECTIVE: To develop a rat model of mandibular osteoradionecrosis(ORN) that uses novel micro-computed tomography bone volume analysis and detailed histology to provide a more effective, quantifiable, and standardized way to study ORN in vivo. STUDY DESIGN: Animal model. SETTING: Academic medical center. SUBJECTS AND METHODS: Modifications to our previously published rat model of mandibular ORN were done to develop an ideal protocol consisting of 10 rats (6 experimental and 4 controls) with their left middle mandibular molar removed 7 days after either 20 Gy high dose rate brachytherapy or sham irradiation. Rats were sacrificed 21 days after extraction for landmark defined bone volume and histologic analysis. RESULTS: A standardized method of quantification was achieved in all samples. The radiated group (XRT) had a mean bone volume/total volume (BV/TV) of 13.8% compared to 65.9% for controls (P < .001). There were increases in osteoclasts and fibrosis, decreases in osteoblasts,and less bone in radiated samples with a mean (SD)of 5.91 (3.77) osteoclasts/high-powered field (HPF) and 4.00(1.83) osteoblasts/HPF in XRT samples compared to 1.08(1.08) osteoclasts/HPF and 22.49 (6.00) osteoblasts/HPF for controls (P <.001). CONCLUSION: Our updated model continues to be clinically analogous to human mandibular ORN and improves the radiologic and histologic analysis of bony defects, providing a method for quantification of bone loss. Further cell-specific staining, including immunohistochemistry, can be used with this model to study potential cellular mechanisms of mandibular ORN and test any future therapeutic options.

Animal model of radiogenic bone damage to study mandibular osteoradionecrosis.

OBJECTIVE: The objective of the study was to create an animal model to study mandibular osteoradionecrosis (ORN) using high-dose rate (HDR) brachytherapy. METHODS: Ten Sprague-Dawley male rats were used in this study. Six rats received a single dose of 30 Gy using an HDR remote afterloading machine via a brachytherapy catheter placed along the left hemimandible. The remaining 4 rats served as controls with catheter placement without radiation (sham). On the day following irradiation or sham, all 3 left mandibular molars were atraumatically extracted. Twenty-eight days after irradiation, mandibles were examined using nondecalcified histology with sequential fluorochrome labeling, decalcified histology, and micro-computed tomography scanning. RESULTS: Irradiated rats demonstrated exposed bone at the extraction sockets, whereas the control animals had complete mucosalization. Alopecia was also seen in the irradiated group. Both histologic and radiologic analyses of the mandible specimens demonstrated a reduction in bone formation in the radiated mandibles as compared with controls. CONCLUSIONS: Our HDR brachytherapy model incorporating postradiation dental extractions has successfully demonstrated reproducible radiogenic mandibular bone damage analogous to the clinical ORN. Although clinical criteria continue to be used today in describing ORN, this model can serve as a platform for future studies to define ORN and delineate its pathogenesis.