Depression and anxiety in patients with head and neck cancer undergoing free flap reconstruction.

PURPOSE: To determine the prevalence and severity of depression and anxiety in patients with head and neck cancer (HNC) undergoing treatment with free-flap (FF) reconstruction. METHODS: Participants with HNC undergoing FF reconstruction were given the validated 9-item Patient Health Questionnaire (PHQ-9) and a 7-item Generalized Anxiety Disorder (GAD-7) questionnaire prior to surgery. Patient factors and responses were analyzed. RESULTS: Seventy-one patients were included. Mean (SD) pre-operative PHQ-9 was 7.6 (7.04) with 34 % (n = 24) having moderate to severe depression. Mean (SD) pre-operative GAD-7 was 6.5 (6.86) with 30 % (n = 21) having moderate to severe anxiety. CONCLUSION: Prevalence of depression and anxiety is high in this cohort and undiagnosed in 22 % and 18 % of patients, respectively. Due to the findings, it is prudent to screen HNC patients at initial diagnosis and offer mental health services.

Sphenoid Sinus Giant Cell Tumor: A Case Report and Literature Review.

We describe a 27-year-old female with a giant cell tumor of her sphenoid sinus, presenting with nasal obstruction and cranial neuropathies. Both the surgical and subsequent medical management are reviewed. Additionally, we review the overall presentation, pathophysiology, and management of giant cell tumors of the skull base. Current treatment recommendations are presented.

Anatomical Variations of the Superficial Radial Nerve Encountered during Radial Forearm Free Flap Elevation.

A frequently encountered anatomical structure in the elevation of a radial forearm free flap is the superficial branch of the radial nerve. This structure has a relatively consistent anatomic location, but variations do occur. We present a case where the superficial branch of the radial nerve was in an usual position but remained superficial to the brachioradialis throughout its course. Two previous reports also describe the superficial branch of the radial nerve remaining superficial to the brachioradialis, although, in these reports, the nerve was more medial than is typical. We postulate that one of the most common anatomic variations of the superficial branch of the radial nerve is for it to remain superficial to the brachioradialis. As this variation could potentially be confused with the medial or lateral antebrachial cutaneous nerves, it is important for the reconstructive surgeon to be aware of this to prevent inadvertent injury.

Superficial Temporal Versus Cervical Recipient Vessels in Maxillary and Midface Free Vascularized Tissue Reconstruction: Our 14-Year Experience.

PURPOSE: The aims of this study are to review our surgical experience in maxillary and midface reconstruction using free vascularized tissue and to compare the postoperative outcomes based on superficial temporal versus cervical recipient vessels. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent maxillary and midface reconstruction with free vascularized tissue from March 2001 to July 2014. Two groups were analyzed: those in whom superficial temporal vessels were used as the recipient vessels and those in whom cervical vessels were used as the recipient vessels. Patient gender and age, cause and classification of the defect, flap choice for reconstruction, recipient vessels, postoperative course, and complications also were recorded and analyzed. A 2-tailed Fisher exact test was used to compare outcomes between the 2 groups. RESULTS: On the basis of the different recipient vessels, 94 patients were divided into 2 groups: those with superficial temporal recipient vessels (n = 44) and those with cervical recipient vessels (n = 50). The overall flap survival rate was 99.0%. The overall complication rate for vascular anastomoses was 5.3%. The complication rate in patients with cervical recipient vessels was higher than the complication rate in those with superficial temporal recipient vessels (8.0% vs 2.27%, P = .37). In addition, in patients in the group with superficial temporal recipient vessels, the postoperative scar in the pre-tragal region was rated as more satisfactory than the postsurgical scar in those in the cervical recipient vessel group. CONCLUSIONS: We recommend that the superficial temporal vessels be the first option for recipient vessels in free vascularized tissue maxillary and midface reconstruction because of proximity, superficial positioning, and suitability for anastomosis and monitoring and because these vessels are rarely compromised by prior operations or radiotherapy.

The Role of the Otolaryngologist in Sexual Health.

Sexual health is an often neglected topic in otolaryngology. Ironically, most sexually transmitted diseases (STDs) demonstrate head and neck manifestations. Furthermore, many aspects of human sexuality, both pathologic and nonpathologic, are also integral to the head and neck. The human papillomavirus (HPV) serves as a prime example of the otolaryngologist's increasingly important role. In recent decades, HPV-mediated head and neck cancer has surpassed HPV-mediated cancer in other parts of the body. This dramatic rise has led to not only a change in the staging system, but also a fundamental shift in the treatment paradigm. Similarly, when considering all aspects of sexual health pertaining to the head and neck, a comparable paradigm shift is needed due to the changing needs of our patients. To accomplish this, otolaryngologists must be better educated and take a leading role when it comes to sexual health.

Transoral Robotic Surgery-Assisted Removal of Upper Aerodigestive Tract Foreign Bodies with Intraoperative Localization.

OBJECTIVE: To describe the use of transoral robotic surgery (TORS) in conjunction with intraoperative localization techniques for removal of challenging upper aerodigestive tract (UADT) foreign bodies. METHODS: Three cases were taken to the operating room for removal of UADT foreign bodies. Two of these cases had previously undergone failed surgery(s). TORS was performed in all 3 cases and intraoperative localization was used in 2 cases. RESULTS: All foreign bodies were successfully removed. CONCLUSION: This case series is the largest-to-date on UADT foreign body removals using TORS. Additionally, the novel use of intraoperative localization techniques in conjunction with TORS is described. Such an approach can facilitate the identification of difficult-to-identify foreign bodies, as well as potentially decreasing operative time, number of operations, and associated morbidity.

Treatment vs Prevention of Head and Neck Cancer: Are We Doing Our Best for Patients?

Along with the relief of suffering, caring for the ill, and avoiding premature death, one of the goals of medicine is disease prevention. The majority of head and neck cancer is preventable. Every head and neck surgeon should ask whether or not our resources and efforts are being used in a manner that will provide maximum benefit to patients. In this commentary, we assess what the outcome might be if all head and neck surgeons focused solely on prevention.

Diversity, Equity, and Inclusion in Otolaryngology-Head and Neck Surgery: The Big Picture.

Efforts are being made to achieve equitable health care for all, in addition to providing equal opportunity for those working within the health care system. Many challenges, however, still need to be overcome as research increasingly brings to light new areas of concern. In this commentary, we highlight recently published findings within the field of otolaryngology in the United States. These findings are then discussed within the context of global health care disparities to emphasize the importance of equitable health care on a global scale.

Climate Change and Otolaryngology-Head and Neck Surgery.

The COVID-19 pandemic has illustrated that global events can have a profound impact on our health systems. While the pandemic is unprecedented, it does underscore the need to prepare for future global health concerns. Climate change is a looming threat with significant consequences for otolaryngologists and our patients. In this commentary, we discuss the need to assess our preparedness for climate change as well as the importance of reflecting on our responsibility to minimize our footprint.

Accurate Operative Time Prediction in Thyroid Surgery: A Rural Tertiary Care Facility Experience.

OBJECTIVE: To determine whether surgeons can estimate thyroid operative time more accurately than a system-generated average time estimate. METHODS: Four otolaryngologists at a single institution with extensive endocrine surgery experience were asked to predict their operative times for all eligible thyroid surgeries. These estimates were compared to system-generated operative time predications based on averaging the surgeon's previous 10 cases with the same Current Procedural Terminology code. The surgeon-generated estimations and system-generated estimations were then compared to each other and the actual operative time. RESULTS: A final sample of 73 cases was used for all analyses. Average age was 51 years old and the majority of patients were female. Surgeon-generated operative time estimates were significantly more accurate than system-generated estimates based on time averaging (P < .001). These findings were consistent across each surgeon individually and within each procedure type (hemithyroidectomy and total thyroidectomy). These findings had a power of over 99% based on mean differences. CONCLUSION: As the financial center of modern hospitals, an efficient operating room is integral to economic success. Improving the precision of operative time estimation reduces costly unplanned staff overtime, canceled cases, and underutilization. Our research at a rural tertiary care center shows that experienced thyroid surgeons can substantially reduce the error of estimating thyroid operative times by considering individual patient characteristics. Although no objective variables have so far been identified to correlate with thyroid operative time, surgeon-generated operative time estimation is significantly more accurate than a generic system approach of averaging previous operative times.

Thyroid Abscess: A Case Series and Literature Review.

OBJECTIVE: In this retrospective case series, we chronicle six patients presenting with acute suppurative thyroiditis (AST) with progression to thyroid abscess in a single institution. METHODS: Patients ranged in age from 16 to 74 years of age. The most common presenting symptoms were progressive unilateral neck pain, swelling, and odynophagia. Other symptoms included hoarseness and systemic signs of infection. Diagnosis of thyroid abscess was made with a CT scan of the neck, fine needle aspiration, and/or incision and drainage (I&D). RESULTS: Management included antibiotic therapy, I&D, and thyroidectomy. All patients were successfully treated except for one who developed mediastinitis and died. CONCLUSION: A complete literature review was performed to determine etiologies, common findings, and management of similar cases.

Profunda Artery Perforator Flaps From the Posteromedial Region of the Thigh for Head and Neck Reconstruction.

OBJECTIVE: Profunda femoris artery perforator flaps (PAPFs) have not been widely used in head and neck reconstructions. The feasibility and outcomes of PAPFs for various head and neck reconstructions need to be investigated. STUDY DESIGN: Retrospective analysis. SETTING: A single-institution review. METHODS: PAPFs were utilized in head and neck reconstructions from 2019 to 2021. Local anatomy, surgical technique, and complications were discussed. Chimeric PAPF applications with muscle components were described for coverage of extensive multiunit defects. Additionally, aesthetic and functional outcomes were compared with anterolateral thigh perforator flaps. RESULTS: A total of 33 cases were included. The average age was 54.2 years (range, 30-74). The most common underlying pathology was oral squamous cell carcinoma (n = 26, 78.8%), while the mean ± SD body mass index was 25.4 ± 2.8 kg/m2 . Middle perforators (n = 14, 42.4%) were the most commonly utilized ones. The perforator-based chimeric/composite applications were used in 9 (27.3%), with the muscular components consisting of gracilis (n = 3, 9.1%), adductor magnus (n = 5, 15.2%), or semimembranosus muscles (n = 1, 3.0%). Venous thromboses of the PAPFs were found in 2 (6.1%), though salvaged. The occurrence of postoperative 90-day morbidity (complication) was related to mandibulectomy/maxillectomy (P = .020). Postoperative validated questionnaires showed a trend of intermediate to high scores, indicating noninferior outcomes in several categories, when compared with the anterolateral thigh perforator flap counterparts. CONCLUSION: PAPFs are a good reconstructive alternative for intermediate to large head and neck reconstructions. Besides, PAPFs can provide sufficient tissue volume and versatility of potentially incorporating adjacent muscle components.

Impact of Giving Patients Your Personal Phone Number in Otolaryngology-Head & Neck Surgery.

OBJECTIVE: Patient-provider communication is a major barrier to care, with some providers giving their personal phone number (PPN) to patients for increased accessibility. We investigated participant utilization of provider's PPN, its effect on participant satisfaction, provider's ability to predict abuse of this practice, and evolving provider perceptions. STUDY DESIGN: Prospective, randomized study. SETTING: Single institution, tertiary referral center. METHODS: During a 2-week period, otolaryngology patients were randomized to either receive their provider's PPN or not. Providers predicted the likelihood of abuse. All calls/texts were documented for 4 weeks. At the study's conclusion, participants were surveyed using Press Ganey metrics. Providers were surveyed before and after to assess their likelihood of providing patients with their PPN and its impact on work demands. RESULTS: Of the 507 participants enrolled, 266 were randomized to the phone number group (+PN). Of 44 calls/texts from 24 participants, 8 were considered inappropriate. Ten participants were predicted to abuse the PPN, but only one was accurately identified. Participants in the +PN group had a greater mean composite satisfaction score than the control group (4.8 vs 4.3; Welch's t-test, P < .0011). At the conclusion of the study, providers were more likely to share their PPN (Wilcoxon signed-rank test, P < .0313), and their perceived impact of this practice on workload was lower (Wilcoxon signed-rank test, P < .0469). CONCLUSION: This study demonstrates low patient utilization of provider PPNs, and poor provider predictive ability of patient abuse. Receipt of provider's PPN was associated with improved patient satisfaction.

A comparative study on using superior thyroid artery perforator flaps versus traditional sternocleidomastoid myocutaneous flaps for reconstructions after oral cancer ablation: "New tricks for old dogs"?

OBJECTIVES: To introduce new superior thyroid artery perforator flaps (STAPF), and to compare the clinical outcomes with sternocleidomastoid myocutaneous flaps (SCMMF) for their intraoral applications. MATERIALS AND METHODS: Between January 2013 and December 2020, forty-three oral cancer patients who received post-oncologic reconstructions with one of these two regional flaps were retrospectively collected. Their techniques and outcomes were compared. All the STAPFs were preprepared with radiologic evaluations. RESULTS: Despite the common arterial origins, the compositions and harvesting procedures of STAPF and SCMMF were different. Though SCMMFs (n = 23) were designed in rotational styles, most STAPFs (n = 20) were septocutaneous perforator flaps, with 2 chimeric ones. In addition, the sizes of STAPFs were generally larger than those of SCMMFs (p = 0.006). Success rate for STAPFs was much higher, with only three partial cutaneous necroses. Radiotherapy delay was more frequently found in those reconstructed with SCMMFs (P = 0.046), mostly due to fistula formations. Besides, incomplete level IIB dissections were also reported in 9 (20.9%) patients in SCMMF group. In our study, the overall survival was affected by both flap conditions (p = 0.014, 1.333-12.881) and postoperative surgical complications (except fistula) (P = 0.005, 2.240-84.134). Functionally speaking, post-reconstructive speech and neck mobility (p < 0.001) were better in the STAPF group. CONCLUSIONS: With accumulated experiences on the use of locoregional flaps in the neck, STAPF, when well-prepared, can provide superior reconstructive outcomes for various intraoral defects. As a comparison with SCMMF in the same middle region, STAPF is a viable option with higher success rates and oncological safety for oral cancer patients.

A novel application of superior thyroid artery perforator flaps for medium-sized intraoral reconstructions: Retrospective analysis of 12 cases.

BACKGROUND: To describe the indications, technique, and preliminary experience in the application of the superior thyroid artery perforator flap (STAPF) for the reconstruction of various medium-sized intraoral defects. METHODS: From September 2018 to September 2019, 12 consecutive cases of oral squamous cell carcinoma underwent reconstruction with a STAPF. Clinical details were collected, and postoperative function was analyzed. RESULTS: The venous drainage of the STAPF is variable with drainage into the internal jugular vein in six cases, into both the internal and external jugular veins in four cases, and into the external jugular vein in two cases. Ten cases were harvested as pedicled flaps, while two cases required a venous anastomosis due to inadequate length of the venous pedicle. Ten flaps survived completely, whereas two flaps had partial necrosis that ultimately resolved with secondary healing. CONCLUSIONS: STAPF is a reliable method for the reconstruction of medium-sized intraoral defects.

Transverse cervical artery anterior perforator flap for head and neck oncological reconstruction: Preliminary study.

BACKGROUND: To describe the indications, technique, and our experience in the application of the transverse cervical artery anterior perforator flap (ap-TCAF) for reconstruction of head and neck oncological defects. METHODS: From September 2016 to September 2019, 11 patients underwent surgical treatment for head neck squamous cell carcinoma and were subsequently reconstructed with ap-TCAFs. The clinical details were recorded, and the postoperative appearance and function were analyzed. RESULTS: The ap-TCAF was used to reconstruct intraoral defects in eight patients and to repair an oropharyngeal defect in one patient. In two remaining patients, the ap-TCAF was divided into two to restore defects with both an intraoral and extraoral component. The flap size ranged from 6 × 4 cm to 15 × 9 cm. All flaps healed uneventfully. There was no delayed wound healing or dysfunction at the donor site. CONCLUSIONS: The ap-TCAF is reliable with characteristics making it useful for head and neck oncological reconstruction, especially in male patients.

Implantation of Squamous Cell Carcinoma in a Free Flap Donor Site.

INTRODUCTION: It is well known that malignant cells can be implanted at distant donor sites due to iatrogenic surgical contamination. Only a small number of reports, however, have been published describing this. CASE PRESENTATION: We present a case of oral cavity Squamous Cell Carcinoma (SCC) reconstructed with a radial forearm free flap in which SCC developed in the subcutaneous tissues beneath the donor incision site 6 months after surgery. MANAGEMENT: The implanted tumor was excised and the field was subsequently treated with radiation. The patient remains disease-free on follow-up. DISCUSSION: We present the second report of tumor implanted in a free flap donor site. Additionally, we discuss the risks of tumor implantation, review the literature, and make recommendations to avoid this complication.

Awake thyroidectomy.

OBJECTIVE: In this article, we present a series of 28 patients who underwent thyroid surgery using local anesthesia. We describe our technique, report outcomes, and assess how well the procedure was tolerated from a patient perspective. METHODS: Three surgeons performed awake thyroidectomies and recorded data, including the patient's age and gender, surgery being performed, operative time, weight of the surgical specimen, quantity and type of local anesthetic used, additional medications, patient-reported pain assessment, and any complications. RESULTS: Twenty-seven of 28 patients (96%) successfully underwent awake thyroidectomy. One patient had to be converted to general anesthesia due to airway concerns. There were no complications; however, one patient had a panic attack. Based on a 0 to 10 scaled pain score, the average amount of pain reported was 3.4. The amount of pain the patient reported was significantly dependent on the amount of experience the operating surgeon had with this technique. Seventy-one percent of patients tolerated surgery with local anesthesia only and did not require additional medications. CONCLUSION: Awake thyroidectomy is a well-tolerated and safe procedure in appropriately selected patients, with many potential benefits over general anesthesia. In most cases, only local anesthesia is required. Increased experience with this technique may be associated with increased patient comfort. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:685-690, 2020.