Free Flap Outcomes for Head and Neck Surgery in Patients with COVID-19.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state. METHODS: This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022. RESULTS: Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period. CONCLUSION: Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 2023.

The role of perineural invasion in parotid malignancy outcomes: A systematic review and meta-analysis.

PURPOSE: At present, perineural invasion is used as a histologic indicator of aggressive salivary gland disease. In other head and neck malignancies, perineural invasion impacts staging of cancer lesions and therefore affects treatment options. OBJECTIVE: To compare survival outcomes in primary parotid malignancies with and without perineural invasion.A systematic review pooled data from the scientific literature in patients with any primary parotid malignancy to investigate the prognosis of those with perineural invasion. DATA SOURCES: PubMed (Medline), Scopus and Cochrane databases were queried from inception to July 2020 without any initial search constraints. Additional publications were included from review of pertinent articles. STUDY SELECTION: Our inclusion criteria included primary parotid cancers with reported perineural invasion on survival outcomes. Exclusion criteria were non-English language text, non-human studies, reviews, textbooks, abstracts, case reports and case series. Two authors independently reviewed articles for inclusion. Of the initial 465 records, 83 articles were reviewed in full to yield a final collection of 14 studies. DATA EXTRACTION AND SYNTHESIS: PRISMA-p guidelines were used in the reporting of our studies. A MOOSE Checklist was also used. MINORS criteria were applied to assess risk of bias. Random-effects models were used to estimate pooled effect sizes. No institutional review board review was needed for our study. MAIN OUTCOMES AND MEASURES: Primary study outcomes were set prior to data collection and included overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS) and distant-metastasis-free survival (DMFS) in patients with and without perineural invasion. RESULTS: Fourteen studies contributed to this meta-analysis. Compared to patients without perineural invasion, the pooled rate of mortality (HR = 3.64), time to recurrence (HR = 3.56), disease-specific mortality (HR = 2.77) and distant metastasis (HR = 3.84) was significantly higher for patients with PNI (all p <.001). Controlling for perineural invasion status, no moderator was associated with these survival outcomes (all p >.05). Given the clinical severity of perineural invasion, few studies were null as shown in a panel of publication bias plots. CONCLUSION: Perineural invasion portends a poor survival outcome in patients with parotid malignancies.

Comparing postoperative outcomes after free flap surgery in a specialty step-down unit vs nonspecialty intensive care unit.

BACKGROUND: To determine if there was a difference in postoperative outcomes of head and neck free flap reconstruction patients treated in a specialty step-down unit compared to a nonspecialty intensive care unit (ICU). METHODS: A retrospective review was performed of all patients who underwent free flap reconstruction for head and neck defects from 2014 to 2017 at Loyola University Medical Center. Patients managed postoperatively in the ICU were compared to patients managed in a specialty step-down unit. Postoperative outcomes, length of stay, and readmission were compared. RESULTS: Three hundred and five patients were included in the study. Patients managed postoperatively in the specialty step-down unit had comparable rates of postoperative complications and flap failure as ICU patients. Step-down patients had significantly shorter lengths of stay (Mdn = 5 days, IQR = 5-7 days) than patients in the ICU (Mdn = 6 days, IQR = 5-6 days; P < .001).

Treatment of locally advanced parotid malignancies with parotidectomy and temporal bone resection.

PURPOSE: In this study we review our institution's experience and outcomes with temporal bone resection and parotidectomy in the treatment of advanced parotid malignancies. METHODS: Patients undergoing lateral temporal bone resection and parotidectomy from 2007-2013 were identified in the EPIC electronic medical record. Primary tumor location, staging, surgical procedure, and patient demographic and outcome data were collected retrospectively. RESULTS: Fifteen patients underwent combined temporal bone resection and parotidectomy for parotid malignancy. Carcinoma ex-pleomorphic and squamous cell carcinoma were the most common pathologies. Two year disease free survival was 40%. Distant metastases were the most common site of disease recurrence. Only nodal disease was predictive of reduced disease free survival, though pre-operative facial paralysis showed a trend towards significance. Margin status and operating for recurrent tumor did not influence outcome in our series. CONCLUSION: Local and regional tumor controls are attainable with combined skull base approaches to advanced parotid malignancies. Unfortunately these cases have a high rate of distant recurrence despite negative margins and local control.

Vocal Fold Paralysis after Esophagectomy for Carcinoma.

OBJECTIVES: (1) To recognize factors that contribute to vocal fold paralysis (VFP) after esophagectomy. (2) To describe the morbidity associated with VFP after esophagectomy. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: The medical records of 91 patients undergoing esophagectomy for malignancy were reviewed (2008-2014). Twenty-two patients with postoperative VFP were compared with 69 patients without VFP with regard to preoperative variables, surgical approach (transcervical vs other), and postoperative outcomes. A subset analysis of cervical approaches was performed, including those where an otolaryngologist assisted. RESULTS: There were no significant differences in preoperative variables between patients with and without VFP. Cervical approaches were associated with increased VFP (P < .0001). Recurrent laryngeal nerve (RLN) identification was associated with increased VFP (P = .0001). RLN dissection by head and neck surgeons was associated with decreased VFP (P = .0223). Patients with VFP had longer lengths of stay (P = .0078), higher rates of tracheotomy (P = .0439), and required more outpatient swallow evaluations (P = .0017). Mean time to diagnosis of VFP was 45.6 days (median, 7.5 days). CONCLUSIONS: Cervical approaches are associated with increased VFP in patients undergoing esophagectomy for malignancy. When cervical approaches and mobilization are required, the inclusion of an experienced cervical surgeon to identify the RLN may improve the rate of postoperative VFP. Patients with VFP after esophagectomy experience significantly more morbidity. Due to the potential delay in diagnosis and treatment of postoperative VFP, routine assessment of inpatient vocal fold function may be beneficial.

Pressure necrosis masquerading as a burn injury in a patient with a cervical epidural abscess producing acute quadriplegia.

A case of a patient with acute onset of quadriplegia from a cervical epidural abscess referred to our tertiary burn center is presented. The pattern of the patient's 'burns' suggested pressure necrosis. A literature review was undertaken of this unusual condition, its evaluation and management. Cervical epidural abscesses are rare and present in a variety of ways. Acute onset of quadriplegia without a history of trauma should trigger a workup to make the diagnosis. The management of complicating skin lesions or burns and the patient outcome will primarily be determined by the management of the epidural abscess.