Radiological and clinical correlations of the anterior ethmoidal artery in functional endoscopic sinus surgery.

OBJECTIVES: To correlate computed tomography findings and endoscopic localisation of the anterior ethmoidal artery during surgery, and to analyse the intranasal landmarks and abnormalities of the artery. METHOD: The anterior ethmoidal artery was studied with high-resolution computed tomography and endoscopic surgery in 30 patients undergoing functional endoscopic sinus surgery (group A), and with endoscopic dissection on 30 human cadavers (group B). RESULTS: The anterior ethmoidal artery was demonstrated on computed tomography in 25 patients and intra-operatively in 12 (group A). It was identified in 26 cadavers (group B). Dehiscence of bony canal and branching was noted in 10.53 per cent of cases. The mean (± standard deviation) intranasal length of the anterior ethmoidal artery was 7.29 (± 1.21) mm, the distance of the artery from the axilla of the middle turbinate was 16.24 (± 2.75) mm, and the mean distance from the ground lamella was 8.97 (± 1.46) mm. CONCLUSION: High-resolution computed tomography scanning prior to functional endoscopic sinus surgery is mandatory to identify the anterior ethmoidal artery. Endoscopically, the axilla of the middle turbinate and the ground lamella can serve as dependable reference points to identify the artery. Cadaver dissection improves understanding of anatomy.

Management of sinonasal cancers: Survey of UK practice and literature overview.

INTRODUCTION: Sinonasal malignancy is a rare and heterogenous disease, with limited evidence to guide management. This report summarises the findings of a UK survey and expert workshop discussion which took place to inform design of a proposed UK trial to assess proton beam therapy versus intensity-modulated radiation therapy. METHOD: A multidisciplinary working group constructed an online survey to assess current approaches within the UK to surgical and non-surgical practice. Head and neck clinical oncologists, ear nose and throat (ENT) and oral-maxillofacial (OMF) surgeons were invited to participate in the 42-question survey in September 2020. The Royal College of Radiologists Consensus model was adopted in establishing categories to indicate strength of response. An expert panel conducted a virtual workshop in November 2020 to discuss areas of disagreement. RESULTS: A survey was sent to 140 UK-based clinicians with 63 responses (45% response rate) from 30 centres, representing a broad geographical spread. Participants comprised 35 clinical oncologists (56%) and 29 surgeons (44%; 20 ENT and 9 OMF surgeons). There were variations in preferred sequence and combination of treatment modalities for locally advanced maxillary squamous cell carcinoma and sinonasal undifferentiated carcinoma. There was discordant surgical management of the orbit, dura, and neck. There was lack of consensus for radiotherapy in post-operative dose fractionation, target volume delineation, use of multiple dose levels and treatment planning approach to organs-at-risk. CONCLUSION: There was wide variation across UK centres in the management of sinonasal carcinomas. There is need to standardise UK practice and develop an evidence base for treatment.

Postoperative Infection Rate and Associated Factors Following Endoscopic Sinus Surgery.

OBJECTIVES: There is a paucity of data on postoperative infections after endoscopic sinus surgery and associated risk factors. Our objective was to evaluate a cohort of patients undergoing endoscopic sinus surgery (ESS) for chronic rhinosinusitis to determine which perioperative factors may be associated with infection in the 30-day postoperative period. METHODS: A retrospective cohort study of adults who underwent ESS at a tertiary academic medical center from 2015 to 2018 was performed. The primary outcome was incidence of postoperative infection, defined by identification of sinus purulence on nasal endoscopy necessitating antibiotics within 30 days of surgery. Independent variables collated included the result of postoperative cultures and use of perioperative antibiotics, oral corticosteroids, packing, and steroid-eluting stents. Statistical analysis involved bivariate analysis to identify variables that correlated with postoperative infection and subsequent multivariate logistic regression to identify independent risk factors. RESULTS: Three hundred seventy-eight unique ESS cases performed in 356 patients were reviewed. The mean age was 46 years (range, 18-87). The most common indication for surgery was chronic rhinosinusitis without nasal polyposis. The postoperative infection rate was 10.1%. The most commonly cultured pathogen was Staphylococcus aureus. Multivariate logistic regression analysis showed that postoperative systemic corticosteroid use was the only risk factor independently associated with infection (OR 3.47 [95% CI 1.23-9.76], P = .018). CONCLUSION: The incidence of postoperative infection following ESS was 10.1%. The use of postoperative systemic corticosteroids independently increased the risk of infection by 3.47-fold.

Survey of Anesthesiologists on Topical Vasoconstrictors and Intravenous Tranexamic Acid for Endoscopic Sinus Surgery.

OBJECTIVES: Topical vasoconstrictors and intravenous tranexamic acid (IV TXA) are safe and efficacious to decrease bleeding and improve the surgical field during endoscopic sinus surgery (ESS). The purpose of this study was to investigate practice patterns, awareness of clinical evidence, and comfort levels among anesthesia providers regarding these hemostatic agents for ESS. METHODS: A total of 767 attending anesthesiologists, residents, and certified registered nurse anesthetists (CRNAs) at 5 United States academic centers were invited to participate in a survey regarding their experience with IV TXA and 3 topical vasoconstrictor medications (oxymetazoline, epinephrine, and cocaine) during ESS. RESULTS: 330 (47%) anesthesia providers responded to the electronic survey. 113 (97%) residents, 92 (83%) CRNAs, and 52 (68%) attendings managed 5 or fewer ESS cases per month. Two-thirds of providers had not reviewed efficacy or safety literature for these hemostatic agents. Oxymetazoline was perceived safest, followed by epinephrine, IV TXA, and cocaine. Respondents considered potential side effects over surgical field visibility when selecting agents. The majority of providers had no formal training on these agents for ESS, but indicated interest in educational opportunities. CONCLUSION: Many anesthesia providers are unfamiliar with safety and efficacy literature regarding agents used to improve hemostasis for ESS, highlighting a need for development of relevant educational resources. Rhinologic surgeons have an opportunity to communicate with anesthesia colleagues on the use of hemostatic agents to improve the surgical field during ESS.

The Patient Perspective: Evaluating the Accessibility of Transoral Robotic Surgery Online Resources.

PURPOSE: The varied treatment options available to patients with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) can cause significant patient confusion. In particular, transoral robotic surgery (TORS) has become widely used for treatment of HPV-positive OPSCC. As patients commonly refer to the internet for additional information, we aim to evaluate the quality of online patient educational materials for TORS in comparison to other otolaryngology surgical procedures. METHODS: The terms "transoral robotic surgery," "glossectomy," "thyroidectomy," and "neck dissection" were searched on Google. Flesch reading ease, Flesh-Kincaid Grade Level, MD review rates, and PEMAT understandability and actionability were assessed for each search term. Google trends was used to determine search interest for each term between May 2015 and May 2020. RESULTS: Of the 30 TORS websites that met inclusion criteria, the average FRE and FKGL scores were 40.74 and 11.60 (that of an average high school senior). The FRE and FKGL scores for TORS were all statistically significantly lower than those of all comparator search terms (P < .05). Only 1 out of 30 TORS sites were MD reviewed, representing the lowest MD review rate across all search terms. Understandability and actionability scores for TORS were also the lowest across all search terms at 77.71% and 2.66%, respectively. TORS had the lowest search interest. CONCLUSIONS: In comparison to other common otolaryngology procedures, TORS websites are the least patient friendly. As TORS becomes a more widely used procedure, it is critical that TORS websites become higher quality resources that patients can reliably reference.

Clinical experience and treatment approaches in sinonasal osteomas from a Tertiary Care Hospital in Turkey.

OBJECTIVE: Osteomas are slow-growing benign osseous tumors that particularly located in the paranasal sinuses (PS). Here, we aimed to define the clinical symptoms and features, diagnostic conditions caused by osteomas located in four different PSs, to evaluate the surgical indications and methods, to compare the factors that can affect the surgical decision, radiological findings, and prognosis. METHODS: The data of patients with paranasal sinus lesions and diagnosed as osteoma according to the radiological imaging, who applied to our clinic between 2010 and 2020, were retrospectively collected and re-evaluated in the light of clinical, radiological, and pathological data. Patients who underwent surgical treatments and were definitively diagnosed as osteoma by pathology were enrolled in this study. RESULTS: We presented the data of 117 patients retrospectively. Most of these cases (n = 77, 65.8%) had an osteoma located in the frontal sinus, while 32 cases (27.4%) had osteoma in the ethmoid, two cases (1.7%) had in sphenoid and six cases (5.1%) had in maxillary sinus. We found that the presence of symptoms, diameter of osteoma, surgical indications including state of sinus drainage, and chronic/recurrent sinusitis influence the choices of physicians in management of frontal sinus osteomas. Moreover, we found a significant correlation between the grading systems defined to classify the frontal sinus osteoma to be operated (r = 0.878, 95% CI: 0.724-0.949, P<0.0001). CONCLUSION: There are several grading systems useful for the choice of surgical approaches, however, the clinical symptoms and surgical indications should not be neglected in the follow-up of patients with frontal sinus osteoma. If there are concerns about the grade of osteoma and the endoscopic approach is considered not to be sufficient for resection, the surgical procedure may be initiated endoscopically, and, if necessary, it can be combined with an external approach.

Implantable Doppler Removal After Free Flap Monitoring Among Head and Neck Microvascular Surgeons.

OBJECTIVE: Investigate current practice patterns of head and neck microvascular reconstructive surgeons when removing an implantable Doppler after free flap surgery. STUDY DESIGN: Cross-sectional survey study. METHODS: Survey distributed to head and neck microvascular reconstructive surgeons. Data regarding years performing free tissue transfer, case numbers, management of implantable Doppler wire, and complications were collected. RESULTS: Eighty-five responses were analyzed (38,000 cases). Sixty-six responders (77.6%) use an implantable Doppler for postoperative monitoring, with 97% using the Cook-Swartz Doppler Flow Monitoring System. Among this group, 65.2% pull the wire after monitoring was complete, 3% cut the wire, and 31.8% have both cut and pulled the wire. Of those who have cut and pulled the wire, 48% report cutting and pulling the wire with equal frequency, 43% formerly pulled the wire and now cut the wire, and 9% previously cut the wire but now pull the wire. Of those who pull the wire, there were two injuries to the pedicle requiring return to the operating for flap salvage, and one acute venous congestion. Of the nine who previously pulled the wire, six (67%) cited concerns with major bleeding/flap compromise as the reason for cutting the wire. CONCLUSION: In this study, most surgeons use an implantable Doppler for monitoring of free flaps postoperatively. In extremely rare instances, pulling the implantable Doppler wire has resulted in flap compromise necessitating revision of the vascular anastomosis. Cutting the wire and leaving the proximal portion in the surgical site has been adopted as a management option. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:554-559, 2022.

Barbed reposition pharyngoplasty (BRP) in obstructive sleep apnea treatment: State of the art.

PURPOSE: In this paper, we perform a systematic review that discusses the state of the art and evolution on the barbed reposition pharyngoplasty (BRP) in the velo-pharyngeal surgery. Clinical evidence and published outcomes of this surgical technique are reported and discussed. MATERIALS AND METHODS: We performed a systematic review of the current literature through the analysis of the last 10 years of literature on barbed palate surgery. Study design, number of patients enrolled, inclusion criteria, pre- and posttreatment outcomes (AHI, ODI), surgical success rate, follow-up time and complication has been collected and reported. RESULTS: 15 studies for a total of 1531 patients, out of which 1061 underwent barbed reposition pharyngoplasty. Five trials were uncontrolled prospective studies (215 patients, 14% of total), nine were retrospective studies (1266 patients, 82,6% of total), and one randomized prospective clinical trial (RCT) (50 patients, 3,32% of total). All analyzed studies reported good outcomes after BRP surgery. Average preoperative values of AHI and ODI reduced in all studies considered with a significative statistical difference between preoperative and postoperative values (p < 0.05 in all cases). The postoperative surgical success rate ranged between 65.4 and 93% of cases. There were no significant intra-operative or post-operative complications in all studies considered in this systematic review. CONCLUSIONS: Barbed reposition pharyngoplasty has proven to be an easy to learn, quick, safe and effective new palatopharyngeal procedure, that can be used in a single level surgery or as a part of multilevel procedures.

Awake Rhinology Surgery in Response to the COVID-19 Pandemic in Europe.

BACKGROUND: European health-care systems are faced with a backlog of surgical procedures following the suspension of routine surgery during the COVID-19 crisis. Routine rhinology surgery under general anaesthetic (GA) is now faced with significant challenges which include limited theatre capacity, the negative ramifications of surgical prioritization, reduced patient throughput in secondary care, and additional personal protective equipment requirements. Delayed surgery in rhinology, particularly with regards to chronic rhinosinusitis, has previously been shown to have poorer surgical outcomes, a detrimental effect on quality of life and long-term negative health socio-economic effects. Awake rhinology surgery under local anaesthetic (LA) provides an ideal alternative to GA. It provides a means of operating on patients in a setting alternative to currently oversubscribed main theatres, by utilizing satellite facilities, while ensuring identical surgical outcomes for patients who may otherwise have been forced to wait a long time for their procedure. It also confers additional benefits in terms of shorter recovery time and hospital stay for patients. OBJECTIVES: We have developed a set of recommendations that are intended to help support clinicians and managers to better adopt LA rhinology protocols and minimize the risk to the patient and health-care professionals involved. METHODOLOGY: International roundtable forums were conducted and supplemented by individual interviews. The international board consisted of 12 rhinologists experienced in awake rhinology surgery. Feedback was analysed and shared to develop a consensus of best practice. RECOMMENDATIONS: Local and national guidelines need to be adhered to with specific focus on patient and clinician safety. When performing awake rhinology procedures in the COVID-19 recovery process, consider implementing specific safety measures and workflow practices to safeguard patients and staff and minimize the risk of infection. CONCLUSION: Awake surgery potentially provides quicker access to routine rhinology surgery in the post-COVID-19 recovery phase, ensuring patients are treated in a timely matter, thereby avoiding higher downstream costs, and improving outcomes.

The impact of a double vein anastomoses on doppler's loss of signal rates.

BACKGROUND: Impact on blood flow by double vein anastomosis in head and neck free flaps is unclear. We aimed to assess venous doppler loss of signal (LOS) rates of double vein system compared with a single vein system. METHODS: Consecutive free flaps with implanted venous flow couplers between 2015-2017 were included. LOS rates were compared between groups and with regard to flap type, defect site and recipient vein within double vein group. RESULTS: 92 double-vein (184 veins) and 48 single-vein flaps were included. LOS was similar in single- and double-vein flaps (11/48 (25%) versus 46/184 (25%), p = 0.765). Double veins had fewer flap takebacks compared with single vein (4.3% vs. 12.5%, p = 0.075). Common facial vein (CFV) anastomosis showed superior LOS rates compared with external jugular and CFV branches (p = 0.026). CONCLUSIONS: Double vein anastomosis does not impact LOS rates, results in fewer flap takebacks, yet LOS rates depend on selected recipient vein.

Rates of Revision and Obstructive Sleep Apnea after Surgery for Velopharyngeal Insufficiency: A Longitudinal Comparative Analysis of More Than 1000 Operations.

BACKGROUND: The purpose of this study was to evaluate the comparative incidence of obstructive sleep apnea following velopharyngeal insufficiency surgery in the United States. METHODS: A retrospective analysis of cleft and noncleft pediatric patients who underwent velopharyngeal insufficiency surgery was performed using the IBM MarketScan Commercial Database. Patients were tracked longitudinally from 2007 to 2016 to evaluate the incidence of obstructive sleep apnea. Multivariable regression was used to evaluate predictors of postoperative obstructive sleep apnea and surgical revision. RESULTS: A total of 1098 patients underwent a pharyngeal flap (61.0 percent), sphincter pharyngoplasty (22.2 percent), or palatal lengthening with or without island flaps (16.8 percent). Diagnoses were predominantly cleft lip and/or palate (52.8 percent) and congenital oropharyngeal anomalies (42.6 percent). Eighty patients (7.3 percent) developed obstructive sleep apnea at an average of 10.2 months postoperatively. Predictors of obstructive sleep apnea included older age (p = 0.014) and head and neck neoplasm (p = 0.011). The obstructive sleep apnea rate following sphincter pharyngoplasty was 11.1 percent, compared to 7.2 percent after pharyngeal flap surgery. Compared to sphincter pharyngoplasty, pharyngeal flap surgery was associated with a lower risk of further surgery (OR, 0.43; p = 0.010). Of patients with cleft lip and/or palate, 35 developed obstructive sleep apnea (6.0 percent) without a significant association with procedure type. CONCLUSIONS: In this national claims database analysis of cleft and noncleft pediatric patients, the rate of obstructive sleep apnea following velopharyngeal insufficiency surgery was not significantly different for pharyngeal flap compared to sphincter pharyngoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Using thermal effect of 970 nm diode laser to reduce nasal swell body.

In recent decades, semiconductor lasers have been successfully used in rhinology. However, their usage in the reduction of the nasal swell body (NSB) is barely studied. Our research aimed to conduct an experimental selection of the laser exposure mode in the NSB zone using a 970 nm diode laser for safe and effective NSB reduction. The thermometric parameters of a diode laser with a wavelength of 970 nm were evaluated in a continuous contact mode of exposure at the power from 2 W to 10 W with 2 W step. The laser was targeted at the liver of cattle, given its similar optical properties to the NSB region. After a series of experiments with every power rate and the analysis of temperature data, we estimated an optimal exposure mode at a power of 4 W. The collected thermometric data demonstrate the safety of this mode in a clinical setting for NSB reduction due to causing no thermal damage to the adjacent tissue. Based on the experiment, a technique for laser reduction of the NSB was developed to improve nasal breathing in patients with severe hypertrophy of this area. The proposed technique was applied to 39 patients with chronic vasomotor rhinitis and the NSB. All patients were divided into 2 groups. Group 1 consisted of 20 patients who underwent surface contact laser-turbinectomy and the NSB reduction using a 970 nm diode laser. Group 2 included 19 patients with the same pathology who underwent laser-turbinectomy, without reduction of the NSB. No statistically significant difference was observed during the dynamic observation with an objective assessment of nasal respiration according to active anterior rhinomanometry when comparing these subgroups with each other according to the t-criterion for independent samples (p > 0.05). As a result of comparing the data obtained on the NOSE scale using the Student's t-test, a statistically significant difference is observed (p < 0.001). Thus, patients who did not perform the reduction of the NSB subjectively noted the insufficiency of nasal breathing. This fact indicates that the NSB is involved in the regulation of airflow.

Trans-hyoid hyoidthyroidpexy: A modified technique for selected cases of obstructive sleep apnea.

OBJECTIVE: Hypopharyngeal collapse (HC) considered a challenge in surgery of obstructive sleep apnea (OSA). Several procedures were presented to deal with HC indirectly via providing support to the lateral walls of the hypopharynx preventing transverse collapse but hyoidthryoidpexy had gained more popularity. The procedure aimed to fix the mobile hyoid bone to a rigid mid-line neck structure, thus preventing the bone and its attached muscles from collapsing during sleep with the negative intrathoracic pressure on inspiration. STUDY DESIGN: A prospective case series study. METHODS: From April 2018 to January 2020, A Modified Technique of Trans hyoid hyoidthyroidpexy was applied for all included patients (24) patients with symptoms of OSA showing predominant lateral wall collapse of the hypopharynx (with retro-palatal collapse) with other OSA surgery. RESULTS: 6-8 months postoperatively, the Apnea Hypopnea index dropped from 43.75 ± 8.44 to 16.28 ± 7.35 (P < 0.0001; t = 10.6988). 14 patients (58.33%) were reported as successful while 7 patients (29.17%) were considered responders and three patients (12.5%) were considered non responders. The mean lowest oxygen desaturation elevated from 77.56 ± 5.64 to 92.38 ± 6.25 (p < 0.0001). Epworth Sleepiness Scale improved (P < 0.0001) from 16.85 ± 4.23 to 5.17 ± 3.89. CONCLUSION: Trans-hyoid hyoidthyroidpwxy is a modified technique of hyoidthyroidpexy. The procedure reported good outcomes in treating OSA. It is a simple, cost-effective and less traumatic technique. It could be combined with other multilevel surgical procedures.

Consistent multimodality approach to oral cavity and high-risk oropharyngeal cancer in veterans.

PURPOSE: High-risk oropharyngeal squamous cell carcinoma (OPSCC) associated with tobacco exposure remains difficult to treat due to high rates of locoregional recurrence similar to oral cavity squamous cell carcinoma (OCSCC). Current NCCN guidelines allow for surgical management of this disease, but oncologic and functional data in the modern era remain scarce. We sought to compare and contrast oncologic and functional considerations for surgical management of OPSCC and OCSCC in a cohort of Veterans. MATERIALS AND METHODS: We conducted a retrospective review of patients treated at the Michael E. DeBakey Veterans Affairs Medical Center between 2017 and 2020, treated using a homogenous, multi-modality algorithm. RESULTS: OPSCC tumors presented with a higher rate of perineural invasion (p < 0.05) and extranodal extension (p = 0.02) compared to OCSCC tumors. Compliance with NCCN guidelines for adjuvant treatment were lower for OPSCC patients primarily due to a higher rate of previous irradiation; re-irradiation could be delivered in 75% of patients when recommended by NCCN guidelines. Total glossectomy was accompanied by concomitant total laryngectomy in 100% of OPSCC patients and 0% of OCSCC. CONCLUSION: Surgical resection and free flap reconstruction of high-risk OPSCC generates oncologic outcomes comparable to OCSCC with comparable complication rates but a lower overall functional status. Reconstruction focused on rapid healing allows for high-rates of re-irradiation and minimal treatment delays. LEVEL OF EVIDENCE: level 4.

Infrahyoid myocutaneous flap: A systematic review.

INTRODUCTION: The infrahyoid myocutaneous flap (IHMCF) is an often-overlooked flap of the anterior neck used for reconstruction of oral cavity and laryngopharyngeal defects. The primary goal of this systematic review is to evaluate the postoperative outcomes and efficacy of this flap. METHODS: A comprehensive search of PubMed, Biological Abstracts, CINAHL Plus, and Web of Science was conducted. Two researchers independently scrutinized the studies to determine inclusions based on relevance, sample size, and English language publications. RESULTS: Twenty-eight studies containing 1027 IHMCF cases met the inclusion criteria. Primary outcomes included flap necrosis and postoperative functional outcomes. The rate of flap survival was 99%. Total skin necrosis and partial skin necrosis were minor complications that occurred in 2.5% and 5.8% of cases respectively. Poor speech and swallowing outcomes were reported in 6.4% and 6.5% of cases respectively. The included studies were predominantly retrospective. An average MINORS score of 9.6 suggests moderate bias among the studies. CONCLUSIONS: The IHMCF is both safe and effective for repairing medium sized mucosal lesions of the head and neck region in carefully selected patients. IHMCF use in oral cavity reconstruction is particularly appealing although functional outcomes remain difficult to statistically assess. Complications of IHMCFs are rare and often minor. To ensure the best outcome, pre-surgical planning needs to be conducted and all contraindications should be respected. Further large prospective multi-centered trials are needed for more accurate analysis.

Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma.

OBJECTIVE: Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN: Retrospective case series and subsequent prospective cohort study SETTING: Tertiary care academic teaching hospital SUBJECTS AND METHODS: Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 - December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 - December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost. RESULTS: Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD. CONCLUSION: Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments.

Systematic review of submental artery island flap versus free flap in head and neck reconstruction.

PURPOSE: The aim of this systematic review is to compare the perioperative characteristics and outcomes of submental artery island flap (SAIF) to free tissue transfer (FTT) in head and neck reconstruction. MATERIALS AND METHODS: Screening and data extraction were done with Pubmed, Embase, and Web of Science databases by two independent authors to identify randomized and observational studies that compared patient outcomes for SAIF vs. FTT for reconstruction head and neck cancer ablative surgery. Data were pooled with random-effects meta-analysis to determine pooled difference in means (DM), absolute risk differences, and 95% confidence intervals (CI). Heterogeneity was assessed with the I-squared statistic. RESULTS: Initial query yielded 997 results, of which 7 studies met inclusion criteria. The pooled sample sizes for the SAIF and FTT cohorts were 155 and 198, respectively. SAIF reduced mean operative time by 193 min (95% CI -160 to -227), reduced hospital stay by 2.1 days (95% CI -0.9 to -3.4), and had a smaller flap area of 22.5cm2 (95% CI 6.5 to 38.4). SAIF had a 5% higher incidence of partial flap necrosis than FTT (95% CI, 1 to 10), but all other perioperative complications, including recurrence rate in malignant cases, were statistically comparable. CONCLUSIONS: The SAIF requires less operative time, hospital stay, and has comparable perioperative outcomes to FTT, but the area of flap harvest is significantly smaller. The findings of this study add to the growing body of evidence demonstrating the safety and reliability of SAIF in head and neck reconstruction.

Postoperative ethmoid sinus mucoceles: Late complication of endoscopic ethmoidectomy and MWA management in outpatient.

OBJECTIVE: The aim of this study was to investigate the feasibility of intranasal endoscopic microwave ablation (MWA) on the management of postoperative ethmoid sinus mucoceles. METHODS AND MATERIALS: The patients with postoperative ethmoid sinus mucoceles were ablated through intranasal endoscopic MWA. Postoperative pain intensity was measured via visual analogue scale (VAS), post-operative complications were recorded. RESULTS: Of the 26 patients with unilateral postoperative ethmoid sinus mucoceles, the mucoceles were diagnosed 3 to 11 years with average time of time of 6.9 ± 2.7 years after endoscopic ethmoidectomy. The ipsilateral middle turbinate was present and intact in 24 patients and partially resected during the original surgery in the remaining 2. There were adhesions in the middle meatus in one case. All 26 patients were successfully treated with the intranasal endoscopic ablation technique in outpatient. The ablation time was 6 to 11 min, with an average duration of 6.84 ± 1.27 min. The mean VAS pain score was 2.41 ± 1.22. There were no perioperative complications reported in this series. No evidence of recurrence was observed in any patients during follow-up periods. CONCLUSIONS: The present study demonstrates the safety and efficacy of intranasal endoscopic MWA in the office. The procedure is well tolerated by patients with low complication rates. Thus, it is alternative to conventional endonasal endoscopic marsupialization for treatment of postsurgical ethmoid sinus mucoceles.

Regional pedicled flaps in prevention and repair of pharyngocutaneous fistulas.

BACKGROUND: Pharyngocutaneous fistula (PCF) is a common complication after laryngopharyngeal surgery. It presents incredible difficulties to both doctors and patients and can lead to prolonged hospitalization. OBJECTIVE: To analyze the pros and cons of the pedicled skin flap in the prevention and repair of PCF and put forward the authors' views and experience about the selection and application of flaps for the treatment of PCF. METHODS: A literature review of pedicled flap application in PCF was carried out. RESULTS: Based on the analysis of the characteristics of the pedicled flap in PCF treatment, the advantages and disadvantages are compared. RESULTS: In the literature, the pectoralis major myocutaneous flap is the most widely used regional pedicled flap for PCF. Many other flaps can be used to prevent and treat PCF. Each kind of pedicled flap has advantages and limitations. This plays a role in the individualized selection and design of PCF to maximize the benefits of patients. CONCLUSIONS: Taking unity of function, aesthetics, and proficiency of operators into account, choosing the appropriate flap to repair PCF can reduce the occurrence rate of PCF and improve the patient's quality of life.

Surgical management of benign cervical tracheoesophageal fistulas: A single-tertiary academic institution experience.

PURPOSE: Despite improvements of diagnosis and management, acquired benign tracheoesophageal fistulas (AB-TEFs) remain a challenging clinical problem and a life-threating condition. In the present study, we reviewed the early results and the long-term outcomes after surgical treatment of cervical AB-TEFs treated in our institution during the last 9 years. METHODS: This retrospective study included patients who underwent transcervical repair of benign cervical AB-TEFs. Patients were identified from a prospectively filled electronic database which included patients' demographics, medical history, disease presentation, prior treatments, operative report, morbidity and mortality, hospital stay, postoperative results and follow-up information. RESULTS: A total of 13 patients affected by cervical AB-TEF were treated. Most of the patients (91%) in our series were treated with a lateral cervicotomic approach with interposition of either sternocleidomastoid muscle flap (72.7%) or pectoralis major myocutaneous flap (9.1%) or infrahyoid muscle flap (9.1%). The univariate analysis of showed that the etiology and surgical technique were significantly associated with immediate postoperative outcome. Esophageal diversion was removed in all patients but 3 due to their neurological status, which was the only significant factor related to post-operative oral-intake (p =0.016). We experienced 2 (18.2%) failures of the reconstruction, which occurred in patients previously treated with chemoradiation for head and neck malignancies. None of the remaining patients (72.8%) relapsed after a long-term follow-up restoring a normal oral diet was restored. CONCLUSION: The lateral cervicotomic approach with sternocleidomastoid flap interposition showed its effectiveness and safety in the treatment of AB-TEFs in our single-institution experience.