Multispecialty Microsurgical Course Utilizing the Blue-Blood Chicken Thigh Model Significantly Improves Resident Comfort, Confidence, and Attitudes in Multiple Domains.

BACKGROUND: The high level of technical skill required by microsurgical procedures has prompted the development of in vitro educational models. Current models are cost-ineffective, unrealistic, or carry ethical implications and are utilized as isolated experiences within single surgical specialties. The purpose of this study was to assess the educational and interprofessional effect of a microsurgical training course utilizing the nonliving "Blue-Blood" chicken thigh model (BBCTM) in a multidisciplinary environment. METHODS: A 10-hour course was developed integrating didactic lectures, case presentations, and one-on-one practical sessions utilizing hydrogel microvessels and the BBCTM. Pre- and postcourse surveys were administered assessing participants' self-reported comfort and confidence within fundamental microsurgical domains, assessments of the models utilized, and the effects of a multidisciplinary environment on the experience. RESULTS: A total of 19 residents attended the course on two separate occasions (n = 10 and n = 9, respectively). Respondents varied from postgraduate year-2 (PGY-2) to PGY-6+ and represented plastic and reconstructive surgery (n = 10), urology (n = 6), and otolaryngology (n = 3). On average, each participant performed 4.3 end-to-end, 1.3 end-to-side, and 0.4 coupler-assisted anastomoses. Following the course, participants felt significantly more comfortable operating a microscope and handling microsurgical instruments. They felt significantly more confident handling tissues, manipulating needles, microdissecting, performing end-to-end anastomoses, performing end-to-side anastomoses, using an anastomotic coupler, and declaring anastomoses suitable (all p < 0.05). The majority of participants believed that the use of live animals in the course would have minimally improved their learning. All but two respondents believed the course improved their awareness of the value of microsurgery in other specialties "very much" or "incredibly." CONCLUSION: A microsurgical training course utilizing nonliving models such as the "BBCTM significantly improves resident comfort and confidence in core operative domains and offers an in vivo experience without the use of live animals. Multispecialty training experiences in microsurgery are beneficial, desired, and likely underutilized.

p16 Immunohistochemistry Is a Useful Diagnostic Adjunct in Cases of Metastatic Cervical Carcinoma of Unknown Origin.

PURPOSE: Metastatic cervical carcinoma of unknown primary (MCCUP) is increasing in frequency owing in part to rising human papillomavirus (HPV)-driven oropharyngeal carcinoma. Identifying the primary site is valuable, because it is associated with increased survival and decreased morbidity. HPV-positive cervical nodal disease focuses attention on the oropharynx for directed biopsy examinations, including tonsillectomy. When the primary is small, carcinoma might not be apparent by traditional hematoxylin and eosin (H&E) staining alone. MATERIALS AND METHODS: This report describes 2 cases of p16-positive MCCUP in which a small primary carcinoma was not readily identified in surgical specimens using H&E staining. RESULTS: Additional evaluation of the specimens with p16 immunohistochemistry (IHC) showed carcinoma in these 2 cases. CONCLUSIONS: When H&E staining does not show carcinoma in cases of MCCUP, p16 IHC should be considered given the high prevalence of HPV-positive MCCUP and the potential for identification of a small primary tumor that might otherwise be missed with H&E staining.

Risk factors for unplanned readmission following head and neck microvascular reconstruction: Results from the National Surgical Quality Improvement Program, 2011-2014.

INTRODUCTION: Unplanned readmissions are associated with decreased healthcare quality and increased costs. This nationwide study examines causes for unplanned readmission among head and neck cancer patients undergoing immediate microsurgical reconstruction. METHODS: Patients undergoing head and neck tumor resection with microsurgical reconstruction were identified in the 2011-2014 National Surgical Quality Improvement Program database. Clinical characteristics and complications were compared among patients who did and did not undergo unplanned readmission. Univariate and multivariate logistic regression analyses were performed. RESULTS: Database search revealed 1,063 patients, 94 (8.8%) of whom had unplanned readmissions. Readmitted patients had significantly higher ASA scores (14.9% vs.7.3% ASA class 4 patients; P = 0.03) and significantly higher rates of disseminated cancer (14.9% vs.7.1%; P = 0.01), laryngopharyngectomy (17.0% vs.6.9%; P = 0.0005), deep wound infection (22.3% vs.2.4%; P < 0.0001), wound dehiscence (19.1% vs.3.3%; P < 0.0001), and blood transfusion within 72 h of surgery (44.7% vs.32.6%; P = 0.02). Multivariate logistic regression revealed deep wound infection (OR = 8.65, P < 0.0001) and wound dehiscence (OR = 3.69, P = 0.0004) to be independent predictors of unplanned readmission. CONCLUSIONS: Deep wound infection and wound dehiscence were independent predictors of unplanned readmission among head and neck cancer patients undergoing immediate microsurgical reconstruction. Institutions should focus efforts on improving wound surveillance, outpatient strategies for wound care, and optimization of discharge planning for this complex patient population.

The radial forearm snake flap: A novel approach to oral cavity and oropharyngeal reconstruction that reduces forearm donor site morbidity.

BACKGROUND: Radial forearm free flaps are a versatile option for head and neck reconstruction, but often complicated by donor-site problems including skin-graft loss and wound breakdown. We introduce the radial forearm "snake" flap as a technique enabling primary donor site closure and compare wound healing outcomes to flap donor sites requiring split thickness skin graft (STSG) closure. PATIENTS AND METHODS: A review of all radial forearm free flaps harvested over a 5-year period was performed. We identified 18 radial forearm snake flaps whose donor sites were closed primarily. These flaps were designed as a long, narrow ellipse parallel to the forearm. An additional 57 forearm flaps were identified whose donor sites were closed with STSGs. Patient demographics, free flap survival rates, and wound healing complications were compared. RESULTS: The survival rate for radial forearm snake flaps was 100% compared to 98.2% for wider radial forearm flaps (P = 1.00). There were 8 tendon exposures at the donor site, all of which occurred in patients whose donor sites were closed with STSGs. Delayed wound healing occurred in 1 radial forearm snake flap donor site (5.6%) compared to 18 (31.6%) donor sites closed with STSGs (P = 0.03). CONCLUSIONS: Radial forearm snake flaps are useful for reconstruction of small to medium size defects of the oral cavity and oropharynx and enable primary donor site closure. Flap success rates are not compromised by raising a radial forearm snake flap and rates of delayed healing of the flap donor site are significantly reduced compared to forearm flap donor sites closed with STSGs. © 2014 Wiley Periodicals, Inc. Microsurgery 37:6-11, 2017.

Recipient vessel selection in the difficult neck: Outcomes of external carotid artery transposition and end-to-end microvascular anastomosis.

BACKGROUND: Selection of recipient vessels for head and neck microvascular surgery may be limited in the previously dissected or irradiated neck. When distal branches of the external carotid artery (ECA) are unavailable, additional options for arterial inflow are needed. Here we propose high ligation of the ECA and transposition toward the lower neck as an alternative. METHODS: After obtaining institutional approval, patients who underwent head and neck tumor resection and simultaneous free flap reconstruction were identified over a 5-year period. Patients whose recipient artery was listed in the operative report were included. Chart review was performed to identify patient demographics, operative details, and patient and flap complications. In cases where the ECA was used, the artery was traced distally with care taken to protect the hypoglossal nerve. The ECA was then divided and transposed toward the lower neck where an end-to-end microvascular anastomosis was performed. RESULTS: The recipient artery used for head and neck microsurgery was available for 176 flaps, and the facial (n = 127, 72.2%) and external carotid (n = 19, 10.8%) arteries were most commonly used. There were 0 flap thromboses in the ECA group compared to 3 flap thromboses that occurred with other recipient arteries (P = 1.00). No cases of first bite syndrome or hypoglossal nerve injury were identified. CONCLUSIONS: The ECA may be transposed toward the lower neck and used for end-to-end microvascular anastomosis without complication of hypoglossal nerve injury or first bite syndrome. This method may be considered an alternative in patients with limited recipient vessel options for head and neck microsurgery. © 2015 Wiley Periodicals, Inc. Microsurgery 37:96-100, 2017.

Patient and tumor characteristics predictive of primary parotid gland malignancy: A 20-year experience at the University of Wisconsin.

PURPOSE: To identify patient and tumor characteristics predictive of primary parotid malignancy. MATERIALS AND METHODS: Records were reviewed for patients who underwent parotidectomy at the University of Wisconsin from 1994 to 2013. Patients with primary parotid neoplasms were separated into benign or malignant subgroups. A multivariate logistic regression model was employed to compare categorical (gender, lesion side, nature of presentation, recurrence) and numerical variables (age, tumor size) between the benign and malignant groups. Mean BMI was compared between the groups by univariate analysis. RESULTS: 771 patients underwent parotidectomy from 1994 to 2013, and 474 had a primary parotid neoplasm. No relationship existed between malignancy and gender (p=0.610), lesion side (p=0.110), or BMI (p=0.196). Mean age (p=0.015) and tumor size (p=0.011) were significantly different between the benign and malignant groups. Patient presentation was classified into three categories: symptomatic (n=109), palpable and asymptomatic (n=303), and incidentally noted on imaging (n=57). From all patients with symptomatic, asymptomatic or incidentally noted masses, 41.3%, 10.6% and 5.3%, respectively, were diagnosed with malignant disease. There was a significant relationship between the patient's initial presentation and malignancy (p<0.001), and patients with facial nerve dysfunction or skin involvement had the greatest likelihood of malignancy. Finally, there was a significant association between malignancy and recurrence (p=0.001). CONCLUSIONS: In this study, age, tumor size, and nature of presentation were all associated with primary parotid malignancy. Understanding the impact of these features on the probability of malignancy is valuable in decision making and counseling of patients presenting with a newly diagnosed parotid neoplasm.

Elective free flap revision in the head and neck cancer patient: Indications and outcomes.

Elective free flap revision among head and neck cancer patients remains poorly characterized. This study evaluates patients who underwent flap revision and their surgical outcomes. Patients who underwent tumor extirpation with free flap reconstruction were identified over a 5-year period. Elective flap revision was defined as debulking or redraping of the original free flap for functional or cosmetic reasons. Patient demographics, surgical indications, and outcomes were reviewed. One hundred and eighty-six patients were identified, and 19 (10.2%) underwent flap revision. Revision of oral cavity flaps (n = 9, 47.4%) was performed to address excessive flap bulk compromising lip competence, speech, swallowing, mastication, or placement of a dental prosthesis. Revision of flaps resurfacing the face or neck (n = 10, 52.6%) was performed to address facial ptosis after facial nerve sacrifice, facial asymmetry, or soft tissue redundancy. Revisions were performed at an average of 7.3 months postoperatively and there was no age or gender bias toward undergoing flap revision. Patients whose flap skin paddles were used to resurface the facial or neck skin were significantly more likely to undergo elective revision than patients with an external paddle designed for flap monitoring (p < 0.01). We identified a 10% elective revision rate for head and neck free flaps in cancer patients, approximately half of which were performed to improve oral cavity function and half of which were performed to address facial ptosis or asymmetry. While there was no age or gender preference for flap revision, extensive facial or neck resurfacing was significantly associated with eventual flap revision.

Reconstruction After Skin Cancer Resection of the Head and Neck.

Skin cancer defects of the head and neck region can vary greatly in their complexity. Reconstructive surgeons are tasked with maintaining or restoring function as well as providing an excellent aesthetic outcome. This article provides an overview of reconstructive options following skin cancer resection broken down by different aesthetic regions and subunits. Although not meant to serve as an all-encompassing source, it provides common indications for using different sections of the reconstructive ladder based on location of defects, tissues involved, and patient factors.

Functional Outcomes After Transoral Plus Lateral Pharyngotomy Approach for Advanced Oral and Oropharyngeal Tumors.

Objective: The aim of this study was to evaluate our institutional experience with the combined transoral plus lateral pharyngotomy (TO+LP) approach in a subset of patients with advanced or recurrent oral and oropharyngeal malignancy. Study Design: A retrospective study of procedures utilizing TO+LP for cancer resection between January 2007 and July 2019. Setting: Tertiary academic medical center. Methods: Thirty-one patients underwent a TO+LP approach for the resection of oral and oropharyngeal tumors. Functional and oncologic outcomes were analyzed. Results: Eighteen (58.1%) patients were treated with TO+LP for recurrent disease. Twenty-nine required free tissue transfer and 2 (6.5%) had positive margins. The median time to decannulation was 22 days (range 6-100 days). Thirteen (41.9%) patients still required enteral feeding at their most recent follow-up. Patients without a history of prior radiation were decannulated sooner (p = .009) and were less likely to require enteral feeding at the first postoperative follow-up (p = .034) than those who had prior head and neck radiotherapy. Conclusion: A TO+LP approach can be used to achieve good functional and oncologic results for selected patients with advanced or recurrent oral and oropharyngeal cancer when minimally invasive options such as transoral robotic surgery, transoral laser microsurgery, or radiotherapy are not possible.

Interstitial Brachytherapy for Lip Cancer: Technical Aspects to Individualize Treatment Approach and Optimize Outcomes.

Primary radiation therapy using interstitial brachytherapy (IBT) provides excellent local tumor control for early-stage squamous cell carcinoma of the lip. Technical aspects of treatment are important to optimize outcomes. In this report, we discuss patient selection criteria, procedural details, and dosimetric considerations for performing IBT for cancers of the lip. Catheters are inserted across the length of tumor entering and exiting approximately 5 mm beyond the palpable tumor extent. A custom mouthpiece is fabricated to facilitate normal tissue sparing. Patients undergo computed tomography imaging, the gross tumor volume is contoured based on physical examination and computed tomography findings, and an individualized brachytherapy plan is generated with the goals of achieving gross tumor volume D90% ≥ 90% and minimizing V150%. Ten patients with primary (n = 8) or recurrent (n = 2) cancers of the lip who received high-dose-rate lip IBT using 2.0- to 2.5-week treatment regimens are described (median prescription: 47.6 Gy in 14 fractions of 3.4 Gy). Local tumor control was 100%. There were no cases of acute grade ≥4 or late grade ≥2 toxicity, and cosmesis scores were graded as good to excellent in all patients. IBT represents an excellent treatment option for patients with lip squamous cell carcinoma. With careful attention to technical considerations furthered described in the present report, high rates of tumor control, low rates of toxicity, and favorable esthetic and functional outcomes can be achieved with IBT for lip cancer.

Patterns of failure for hypopharynx cancer patients treated with limited high-dose radiotherapy treatment volumes.

PURPOSE: Optimal radiotherapy treatment volumes for patients with locally advanced hypopharynx squamous cell carcinoma should ensure maximal tumor coverage with minimal inclusion of normal surrounding structures. Here we evaluated the effectiveness of a direct 3-mm high-dose gross tumor volume to planning target volume expansion on clinical outcomes for hypopharynx cancers. MATERIALS AND METHODS: We performed a retrospective analysis of patients with hypopharynx carcinoma treated between 2004 and 2018 with primary radiotherapy using a direct high-dose gross tumor volume to planning target volume expansion and with or without concurrent systemic therapy. Diagnostic imaging of recurrences was co-registered with the planning CT. Spatial and volumetric analyses of contoured recurrences were compared with planned isodose lines. Failures were initially defined as in field, marginal, elective nodal, and out of field. Each failure was further classified as central high-dose, peripheral high-dose, central intermediate/low-dose, peripheral intermediate/low-dose, and extraneous. Clinical outcomes were analyzed by Kaplan-Meier estimation. RESULTS: Thirty-six patients were identified. At a median follow-up at 52.4 months, estimated 5-year overall survival was 59.3% (95% confidence interval [CI], 36.3%-74.1%), 5-year local and nodal control was 71.7% (95% CI, 47.1%-86.3%) and 69.9% (95% CI, 57.0%-82.6%), respectively. The most common failure was in the high-dose primary target volume. The gastrostomy tube retention rate at 1 year among patients without recurrence was 13.0% (95% CI, 3.2%-29.7%). CONCLUSION: Minimal high-dose target volume expansions for hypopharynx cancers were associated with favorable locoregional control. This approach may enable therapy intensification to improve clinical outcomes.

Prospective Study of PET/MRI Tumor Response During Chemoradiotherapy for Patients With Low-risk and Intermediate-risk p16-positive Oropharynx Cancer.

OBJECTIVE: The objective of this study was to examine tumor response with positron emission tomography (PET)/magnetic resonance imaging (MRI) during chemoradiotherapy as a predictor of outcome in patients with p16-positive oropharynx cancer. MATERIALS AND METHODS: Patients with p16-positive oropharynx cancer were treated with chemoradiotherapy. Low-risk (LR) disease was defined as T1-T3 and N0-2b and ≤10 pack-years and intermediate-risk (IR) disease as T4 or N2c-3 or >10 pack-years. Patients underwent a PET/MRI scan pretreatment and at fraction 10. Change in value of imaging means were analyzed by analysis of variance. K-means clustering with Euclidean distance functions were used for patient clustering. Silhouette width was used to determine the optimal number of clusters. Linear regression was performed on all radiographic metrics using patient and disease characteristics. RESULTS: Twenty-four patients were enrolled with 7 LR and 11 IR patients available for analysis. Pretreatment imaging characteristics between LR and IR patients were similar. Patients with LR disease exhibited a larger reduction in maximum standardized uptake value (SUV) compared with IR patients (P<0.05). Cluster analysis defined 2 cohorts that exhibited a similar intratreatment response. Cluster 1 contained 7 of 7 LR patients and 8 of 11 IR patients. Cluster 2 contained 3 of 11 IR patients. Cluster 2 exhibited significant differences compared with cluster 1 in the change in primary tumor peak SUV and largest lymph node median SUV. CONCLUSIONS: We identified that IR p16-positive oropharynx cancers exhibit heterogeneity in their PET/MRI response to chemoradiotherapy. These data support further study of intratreatment imaging response as a potential mechanism to identify patients with IR oropharynx cancer suitable for treatment deintensification.

The radial forearm snake flap: An underutilized technique for fasciocutaneous and osteocutaneous forearm flaps with primary closure.

BACKGROUND: The radial forearm free flap (RFFF) is associated with troublesome donor site morbidity related to split thickness skin grafting (STSG). The radial forearm snake flap with primary closure of the donor site may reduce donor site complications. METHODS: Single institution, retrospective cohort study comparing rates of delayed donor site wound healing and tendon exposure in 52 patients undergoing radial forearm snake flap and 95 patients undergoing conventional RFFF with STSG closure of the donor site. RESULTS: Tendon exposure occurred in zero (0%) patients undergoing snake flap and four (4.2%) patients undergoing conventional RFFF (0/52 vs. 4/95; p = 0.297). Delayed wound healing occurred in zero (0%) patients undergoing snake flap and 19 (20.0%) patients undergoing conventional RFFF (0/52 vs. 19/95; p < 0.001). CONCLUSIONS: The radial forearm snake flap provides an alternative to conventional RFFF harvest, which enables primary donor site closure with reduced rates of delayed donor site healing.

Pre-tracheotomy for Potentially Emergent Airway Scenarios: Indications and Outcomes.

OBJECTIVES/HYPOTHESIS: Airway access in the setting of unsuccessful ventilation and intubation typically involves emergent cricothyrotomy or tracheotomy, procedures with associated significant risk. The potential for such emergent scenarios can often be predicted based on patient and disease factors. Planned tracheotomy can be performed in these cases but is not without its own risks. We previously described a technique of pre-tracheotomy or exposing the tracheal framework without entering the trachea, as an alternative to planned tracheostomy in such cases. In this way, a tracheotomy can be easily completed if needed, or the wound can be closed if it is not needed. This procedure has since been used in an array of indications. We describe the clinical situations where pre-tracheotomy was performed as well as subsequent patient outcomes. METHODS: Retrospective series of patients undergoing a pre-tracheotomy from 2015 to 2020. Records were reviewed for patient characteristics, indication, whether the procedure was converted to tracheotomy or closed at the bedside, and any post-procedural complications. RESULTS: Pre-tracheotomy was performed in 18 patients. Indications included failed extubation after head and neck reconstruction, subglottic stenosis, laryngeal masses, laryngeal edema, thyroid masses, and an oropharyngeal bleed requiring operative intervention. Tracheotomy was avoided in 10 patients with wound closed at the bedside; procedure was converted to tracheotomy in the remaining eight. There were no complications. Indications for conversion included failed extubation, intraoperative hemorrhage, significant stridor with dyspnea, and inability to ventilate. CONCLUSION: Pre-tracheotomy offers simplified airway access and provides a valuable option in scenarios where tracheotomy may, but not necessarily, be needed. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2802-E2809, 2021.

The Temporoparietal Fascia Flap is an Effective Strategy for Cochlear Implant Wound Coverage.

OBJECTIVE: To report the rate of major soft tissue complications after cochlear implantation and to describe the use of the temporoparietal fascia (TPF) flap for such complications. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care, University Hospital. SUBJECTS AND METHODS: Chart review of all patients who underwent cochlear device implantation over a 5-year period to identify patients and to determine the rate of soft tissue complications. Five patients with major soft tissue complications underwent TPF flap with device salvage or explantation/reimplantation. RESULTS: The rate of major skin complications was 6 out of 281 (2.1%) over 5 years, with 5 patients undergoing TPF flap. The average follow-up was 25.8 months (range, 5-58 months). TPF flap represented the definitive, successful solution for all 5 patients. One postoperative hematoma occurred after TPF flap, with no long-term sequelae. The average hospital length of stay was 2.2 nights (range, 1-5 nights). One patient required IV antibiotics for 4 weeks; the remaining patients were treated with a postoperative course of oral antibiotics. The original device remained in place for 4 patients, while one case required device explantation and staged re-implantation. Post-TPF flap hearing results were equal to if not superior to their preoperative results. CONCLUSION: Major soft tissue complications following cochlear device implantation are rare. The temporoparietal fascia flap is an excellent option for reconstruction of device site soft tissue dehiscences when local wound care and primary closure are not sufficient, and can potentially prevent explantation of a functional implant.

Clinical outcomes for larynx patients with cancer treated with refinement of high-dose radiation treatment volumes.

BACKGROUND: To evaluate disease control, toxicities, and dose to dysphagia/aspiration risk structures (DARS) using a direct gross tumor volume (GTV70Gy ) to planning target volume expansion (dPTV70Gy ) for patients with squamous cell carcinoma of the larynx (LSCC). METHODS: A retrospective review was performed on patients with LSCC treated between 2003 and 2018. Clinical outcomes, toxicities, and dosimetric data were analyzed. RESULTS: Seventy-three patients were identified. Overall survival at 5-years was 57.8%. Five-year local and regional control was 79.8% and 88.2%, respectively. Distant metastatic-only failure was 2.7%. Eighty percent of failures were 95% contained within the dPTV70Gy . Mean dose and the volume of DARS receiving 70 Gy was significantly lower for dPTV70Gy compared to a consensus-defined PTV70Gy . DISCUSSION: Judicious reduction in high-dose target volumes can preserve high tumor control rates while reducing dose to normal surrounding structures underscoring the potential benefit of this approach in enabling local therapy intensification to improve locoregional control.

Opioid use in patients undergoing treatment for oral cavity cancer.

OBJECTIVE: In the context of the opioid epidemic, there is value in examining the use of opioids in specific cancer patient cohorts. We analyzed opioid use in patients undergoing adjuvant therapy for oral cavity cancer to define the incidence of new persistent use beyond 3 months. STUDY DESIGN: Retrospective. SETTING: Comprehensive academic cancer center. SUBJECTS AND METHODS: We performed a retrospective IRB-approved analysis of opioid use in patients who received adjuvant radiotherapy with or with concurrent systemic therapy for surgically resected oral cavity cancer between 2003 and 2016. Factors associated with opioid use were evaluated by Chi-square test and one-way ANOVA. The Kaplan-Meier method was used to estimate overall survival. RESULTS: Of 77 identified patients, 10 (13%) patients received opioid prescriptions at 3 months or greater following completion of radiotherapy. Patients who were opioid naive prior to surgery required significantly fewer opioid prescriptions than intermittent or chronic opioid users. No specific factors were associated with new persistent opioid use. CONCLUSIONS: Patients undergoing surgery and adjuvant radiotherapy for oral cavity cancer who required opioids for cancer treatment related pain are at minimal risk for new dependency. Judicious pain management should be applied for patients with a history of prior opioid use. Larger patient cohorts will be needed to identify patient, disease, and treatment characteristics associated with new persistent use given its limited incidence.

Preoperative coagulation screening for adenotonsillectomy: a review and comparison of current physician practices.

OBJECTIVE: To determine the current practice of pediatric otolaryngologists on a national level and general otolaryngologists on a regional level regarding preoperative coagulation screening prior to adenotonsillectomy. STUDY DESIGN: A five-question survey of members of the American Society of Pediatric Otolaryngology (ASPO) and the Massachusetts Society of Otolaryngology-Head and Neck Surgery (MSO-HNS). SUBJECTS AND METHODS: Surveys results were analyzed to determine current preoperative screening practices relative to awareness of screening recommendations published in the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 1999 Clinical Indicators Compendium. RESULTS: The survey response rate was 27 percent (54/190) and 29 percent (76/260) for MSO-HNS and ASPO members, respectively. In patients with no known bleeding risk, 21 percent of respondents continue to obtain coagulation screening including, at a minimum, a partial thromboplastin time and a prothrombin time. MSO-HNS respondents reported ordering more preoperative coagulation studies than did ASPO respondents (35% vs 10%). Interestingly awareness of the AAO-HNS consensus statement was similar between the two groups and did not impact screening practices. CONCLUSIONS: The survey results indicate a discrepancy between current practice relative to pre-adenotonsillectomy coagulation screening and the recommendations of the AAO-HNS 1999 consensus statement.

Aggressive, Multidisciplinary Staged Microsurgical Resection of a Giant Cervicomedullary Junction Chordoma.

Chordomas of the cranial base are locally destructive tumors since they are surrounded by significant complex neurovascular structures. Thus, their surgical removal is challenging, recurrence rates are high, and their therapeutic strategies remain controversial. In this video, we present a 47-year-old man with a recent onset of swallowing difficulties, hoarseness, and weight loss for several weeks. In the neurological examination, he had complete paralysis of the 9th, 10th, 11th, and 12th cranial nerves. Magnetic resonance imaging (MRI) showed a heterogeneously enhancing expansile invasive mass lesion centered within the clivus and involving the C1, the occipitocervical junction, the retropharynx, and the hypoglossal canal. The decision was made to proceed with multiple staged surgeries. In the first surgical stage, we performed a mastoidectomy with the infralabyrinthine approach to perform a test clip ligation of the sigmoid sinus and to resect the tumor component that extended into the infralabyrinthine space. In the second stage, we performed a far-lateral transcondylar approach for tumor resection and occipitocervical fusion. In the third stage, we used a transoral approach with endoscopic assistance to complete the excision of the remaining tumor in the retropharyngeal space and anterior aspect of C1 and C2 bodies that were not accessible in the first two stages. The surgeries and postoperative course were uneventful. Postoperative MRI showed a gross total resection of the tumor. Histopathology indicated a chordoma. The patient subsequently received proton radiotherapy and has continued to do well without recurrence at 14 months' follow-up. The link to the video can be found at: https://youtu.be/uP9OSlKg_rE .

Auriculotemporal Nerve Involvement in Parotid Bed Malignancy.

OBJECTIVE: To identify and evaluate patients with parotid bed malignancy demonstrating radiographic findings of auriculotemporal (AT) nerve involvement. METHODS: A retrospective review of patients with parotid bed malignancy was performed to identify patients with imaging findings of AT nerve involvement and record associated clinical findings, symptoms, and pathology information. Independent, blinded review of radiographic images by a senior neuroradiologist was performed to identify imaging characteristics and categorize patients into highly likely or possible involvement groups. RESULTS: Of 547 patients identified with parotid bed malignancy, 23 patients exhibited radiographic findings suggestive of AT nerve involvement. Thirteen patients met criteria for highly likely involvement, and 10 patients met criteria for possible involvement. Cutaneous malignancy with metastasis to the parotid bed accounted for 11 of 23 patients, and the most common histology was squamous cell carcinoma (9 patients). Primary parotid malignancy accounted for 12 of 23 patients, and the most common histology was salivary ductal carcinoma (3 patients). All 13 highly likely patients reported periauricular pain, and 11 of 13 demonstrated facial weakness. Features suggesting advanced disease included radiographic findings of intracranial involvement (10/23 patients), nonsurgical primary treatment (13/23 patients), and positive margins on pathology report (7/10 patients). CONCLUSION: AT nerve involvement is an uncommon but important phenomenon that often occurs in the setting of advanced disease and is commonly associated with periauricular pain and coexisting facial weakness. Awareness of the associated clinical features and imaging patterns can allow for appropriate identification of this pattern of spread and help to optimize treatment planning.