Functional outcomes after extracapsular dissection with partial facial nerve dissection for small and large parotid neoplasms.

PURPOSE: Multiple surgical options exist for benign parotid tumors without agreement upon a single, best approach. We evaluated the short-term outcomes and rate of complications using the ECD-FND technique for small and large parotid neoplasms involving the superficial and deep lobes of the parotid gland using a categorical approach. MATERIAL AND METHODS: A single surgeon retrospective cohort study with analysis of patient demographics, outcomes, and complication rates was conducted of patients undergoing the ECD-FND for benign parotid neoplasm. Cases from May 2014 to May 2020 with at least 6 months follow up were considered. Complications were assessed by chart review and tumors were categorized by size and by European Salivary Gland Society (ESGS) classification assigned by a neuroradiologist. RESULTS: Fifty-one patients who underwent ECD-FND of suspected benign parotid mass met inclusion criteria. The most common histology was pleomorphic adenoma (56.9%) followed by Warthin's tumor (19.6%). Overall rate of complications was 31.4% with no major complications. Most patients (88.2%) had normal facial nerve function immediately after surgery and all recovered completely in the post operative period. Sialocele occurred in 15.7% of patients with 87.5% resolved within one month and seromas occurred in four patients (7.8%). There was no significant difference in complication rates between the size of tumor (p = 0.889), depth (p = 0.770), or ESGS classification (p = 0.846). CONCLUSIONS: The ECD-FND technique achieved excellent facial nerve outcomes among our cohort, which included a - proportion of large (>3 cm) and deep lobe tumors. Complications rates and outcomes were similar for larger and deep lobe tumors that underwent a ECD-FND approach. LEVEL OF EVIDENCE: 3.

Assessment of post-operative healing following endoscopic, transnasal, transsphenoidal pituitary surgery without formal sellar grafting.

INTRODUCTION: Multiple options exist for sellar reconstruction after endoscopic transnasal, transsphenoidal surgery (TSS) including free mucosa, fat, bone and synthetic materials. The objective of this study was to assess healing and mucosalization of the sellar face following TSS without formal sellar grafting or reconstruction. METHODS: Single institution retrospective chart review was conducted for patients undergoing TSS without intraoperative CSF leaks between January 2014 and March 2017 at Rush University Medical Center. No formal sellar reconstruction was performed for the entire patient group. Follow-up endoscopic data and clinical notes were coded for time to mucosalization of the sella as well as degree of abnormal mucosal healing, epistaxis, crusting and scarring. RESULTS: 83 patients were included in this study. Mean time to mucosalization was 119 days (range, 17 to 402 days). Incidence of abnormal mucosal healing, epistaxis, crusting and scarring increased from the first to the second postoperative visit but trended down by the third visit. Nasal crusting was the most common finding, followed by abnormal mucosal healing. Chi square analysis showed smoking to be associated with prolonged time to full mucosalization of the sella. Two patients (2.4%) had post-operative CSF leaks requiring lumbar drain placement. CONCLUSION: Adequate sellar healing is achievable in all cases without formal grafting or reconstruction after TSS. Great care must be exercised given the small inherent risk of unmasking a subclinical intraoperative CSF leak. Patients should be followed closely endoscopically during the first four months after TSS to minimize the impact of crusting.

Prognostic factors and survival outcomes for head and neck cutaneous adnexal cancers.

OBJECTIVES: Malignant cutaneous adnexal tumors (MCAT) are rare and comprise a heterogeneous group of cancers. There have been several studies reviewing prognostic factors of these tumors, but no studies focusing on the head and neck. This study aimed to review a large population based database to evaluate prognostic factors that could impact survival. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify patients with MCAT of the head and neck. Both overall and disease specific survival were the main outcome measures for the study. Univariate and multivariate analyses were performed to evaluate the association of suspected prognostic factors with survival. RESULTS: The five-year OS and DSS were 72.6 and 95.5%, respectively. A favorable factor for OS was surgical resection ([HR] 0.324; P = 0.001), while unfavorable factors for OS include older age (1.051; P < 0.001), higher tumor grade (1.254; P = 0.049), larger tumor size (1.293; P = 0.003), and positive nodal involvement (3.323; P = 0.002). A favorable factor for DSS was surgical resection (0.026; P < 0.001). Unfavorable factors for DSS include older age (1.058; P = 0.046), larger tumor size (2.528; 1.565-4.085; P < 0.001), and positive nodal involvement (4.761; P = 0.022). CONCLUSION: Review of the SEER database shows good 5-year OS and DSS rates, similar to those cited in other studies. We identified several prognostic factors associated with survival, while histologic sub-type does not seem to be associated with survival. Surgical resection is the mainstay of treatment.

Recent advances in orthognathic surgery.

PURPOSE OF REVIEW: The aim of this article is to review the recent literature on orthognathic surgery for treatment of malocclusion and obstructive sleep apnea (OSA). The discussion outlines the refinements of the procedure and advances in technology. RECENT FINDINGS: Maxillomandibular advancement (MMA) may be performed for complex malocclusion and OSA. Although orthodontic management followed by MMA has been the gold standard in managing complex cases, the surgery first approach for treatment of malocclusion has increased in popularity because of decreased treatment time and improved patient quality of life. MMA continues to be the gold-standard for treatment of refractory sleep apnea. Technological advancements, including 3D printing and virtual surgical planning, have enhanced the patient experience and provided more efficiency to this surgery. SUMMARY: First introduced in the 19th century, orthognathic surgery has continuously been refined. Over the last few decades, there has been increasing support for a surgery first approach in the treatment of malocclusion. MMA has revolutionized the surgical treatment of OSA and provides the best opportunity for success or cure in patients with complex obstructive patterns. Technology has enhanced the surgical process and created more efficiency for the surgeon and patient. VIDEO ABSTRACT: http://links.lww.com/COOH/A40.

Enhanced recovery after surgery in head and neck surgery: Reduced opioid use and length of stay.

OBJECTIVES: Enhanced recovery after surgery (ERAS) protocols were first developed in colorectal surgery and sought to standardize patient care. There have been several studies in the head and neck surgical literature looking at outcomes after ERAS protocol, but no studies focusing on narcotic use and length of stay. This study aimed to evaluate narcotic usage and length of stay, in addition to several other outcomes, following the implementation of an ERAS protocol. METHODS: A head and neck-specific ERAS protocol was implemented at this tertiary care center beginning July 2017. A retrospective cohort study was performed comparing this cohort to that of a retrospective control group. Outcomes included mean morphine equivalent dose, mean pain score, and percentage of patients prescribed narcotics on discharge. Secondary outcomes included ICU and total length of stay. RESULTS: The mean morphine equivalent dose (MED) administered within 72 hours postoperatively was significantly lower in the ERAS group (17.5 ± 46.0 mg vs. 82.7 ± 116.1 mg, P < .001). Average postoperative pain scores in the first 72 hours were lower in the ERAS group (2.6 ± 1.8 vs. 3.6 ± 1.9; P < .001). The average length of stay was shorter for ERAS patients (7.8 ± 4.8 vs. 9.7 ± 4.7 days, P = .008); however, there was no significant difference in ICU length of stay. CONCLUSION: Following implementation of an ERAS protocol, patients undergoing head and neck surgery had decreased narcotic use in the immediate postoperative period and at discharge, while also demonstrating improved postoperative analgesia. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 130:1227-1232, 2020.

Facial reanimation: an update on nerve transfers in facial paralysis.

PURPOSE OF REVIEW: The aim of this article is to review the recent literature on nerve transfers in facial paralysis. The discussion focuses on direct nerve repair and three types of nerve transfers, cross facial nerve graft, hypoglossal, and masseter nerve transfers. RECENT FINDINGS: Masseteric nerve transfers have a high probability of creating significant movement, although tone is poor. The hypoglossal to facial nerve transfer is reliable in affording facial tone and has been updated to involve a transposition technique that offers good results with minimal morbidity. Combination nerve transfer techniques using multiple cranial nerves or cross-face nerves are increasingly described. SUMMARY: Reinnervation of the facial nerve and neural regeneration in general are areas of intense research and novel surgical approaches continue to be explored. Although direct nerve repair is the most ideal, other nerve transfers can be performed with good results. More specifically, the masseteric nerve transfer can provide excellent movement and the hypoglossal transfer good tone. Combination transfers may afford the benefits of multiple nerves.

The Effects of Endoscopic Sinus Surgery on Voice Characteristics in Chronic Rhinosinusitis Patients.

OBJECTIVES: Functional endoscopic sinus surgery (FESS) is a standard treatment modality for patients with chronic rhinosinusitis (CRS) who have failed appropriate medical therapy. However, FESS entails modification of the upper airway tract that may alter phonatory resonance and produce voice changes. The effects of FESS on postoperative voice characteristics in patients with CRS have yet to be quantitatively assessed. METHODS: Patients with severe CRS who underwent FESS at a tertiary care referral center between May and October 2017 were prospectively enrolled. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and the Voice Handicap Index (VHI) were used to quantitatively evaluate voice characteristics and quality of life, respectively. Preoperative and postoperative CAPE-V and VHI scores were compared with postoperative scores for each patient. Sino-Nasal Outcome Test (SNOT-22) scores were also obtained to assess changes in patient symptoms. RESULTS: 18 CRS patients undergoing FESS were enrolled. The average preoperative Lund-Mackay score was 14, indicating baseline severe CRS. Postoperative assessments demonstrated a statistically significant decrease in CAPE-V (45-27, p = .005) and VHI (10-4.7, p < .001) scores. These correlated with a statistically significant decrease in SNOT-22 scores (42-13, p < .001). CONCLUSIONS: Patients with CRS experience a significant improvement in voice characteristics and vocal quality of life following FESS. Furthermore, this appears to correlate with a significant decrease in self-reported disease severity. These findings may augment the discussion of potential benefits of FESS to a new potential domain for voice quality.

Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction.

IMPORTANCE: An increase in narcotic prescription patterns has contributed to the current opioid epidemic in the United States. Opioid-sparing perioperative analgesia represents a means of mitigating the risk of opioid dependence while providing superior perioperative analgesia. OBJECTIVE: To assess whether multimodal analgesia (MMA) is associated with reduced narcotic use and improved pain control compared with traditional narcotic-based analgesics at discharge and in the immediate postoperative period after free flap reconstructive surgery. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed a consecutive sample of 65 patients (28 MMA, 37 controls) undergoing free flap reconstruction of a through-and-through mucosal defect within the head and neck region at a tertiary academic referral center from June 1, 2017, to November 30, 2018. Patients and physicians were not blinded to the patients' analgesic regimen. Patients' clinical courses were followed up for 30 days postoperatively. INTERVENTIONS: Patients were administered a preoperative, intraoperative, and postoperative analgesia regimen consisting of scheduled and as-needed neuromodulating and anti-inflammatory medications, with narcotic medications reserved for refractory cases. Control patients were administered traditional narcotic-based analgesics as needed. MAIN OUTCOMES AND MEASURES: Narcotic doses administered during the perioperative period and at discharge were converted to morphine-equivalent doses (MEDs) for comparison. Postoperative Defense and Veterans Pain Rating Scale pain scores (ranging from 0 [no pain] to 10 [worst pain imaginable]) were collected for the first 72 hours postoperatively as a patient-reported means of analyzing effectiveness of analgesia. RESULTS: A total of 28 patients (mean [SD] age, 64.1 [12.3] years; 17 [61%] male) were included in the MMA group and 37 (mean [SD] age, 65.0 [11.0] years; 22 [59%] male) in the control group. The number of MEDs administered postoperatively was 10.0 (interquartile range [IQR], 2.7-23.1) in the MMA cohort and 89.6 (IQR, 60.0-104.5) in the control cohort (P < .001). Mean (SD) Defense and Veterans Pain Rating Scale pain scores postoperatively were 2.05 (1.41) in the MMA cohort and 3.66 (1.99) in the control cohort (P = .001). Median number of MEDs prescribed at discharge were 0 (IQR, 0-18.8) in the MMA cohort and 300.0 (IQR, 262.5-412.5) in the control cohort (P < .001). CONCLUSIONS AND RELEVANCE: The findings suggest that after free flap reconstruction, MMA is associated with reduced narcotic use at discharge and in the immediate postoperative period and with superior analgesia as measured by patient-reported pain scores. Patients receiving MMA achieved improved pain control, and the number of narcotic prescriptions in circulation were reduced. LEVEL OF EVIDENCE: 3.

Large Parotid Gland Lipoblastoma in a Teenager.

BACKGROUND: Lipoblastomas are rare benign neoplasms that arise from fetal white fat cells. They are typically found in children under the age of 3 and have been reported in the mediastinum, extremities, and infrequently in the head and neck. We present a rare case of a lipoblastoma arising from the parotid gland and the first known report of a parotid lipoblastoma in a teenager. CASE PRESENTATION: A 15-year-old male presented with a painless, slowly enlarging parotid mass and left facial swelling. A fine needle aspiration was non-diagnostic and initial MRI showed a 3.8 cm × 5.0 cm × 4.0 cm fatty lesion involving the superficial and deep lobes of the left parotid gland and masticator space with widening of the stylo-mandibular tunnel and thinning of the adjacent mandibular condyle. The patient was taken to the operating room, and the mass was excised under general anesthesia via a transcervical parotid approach with facial nerve monitoring. The most superficial aspect of the parotid bed was spared and with upper and lower divisions of the facial nerve preserved. The tumor, which primarily involved the deep lobe of the parotid, was entirely excised. Final pathology revealed a 5.2 cm lipoblastoma. The patient did well post-operatively with full function of the facial nerve and 20 months of follow up without evidence of recurrence. CONCLUSION: This is the first reported case of a lipoblastoma of the parotid gland in a teenager. Although a rare tumor, it should be considered in the differential diagnosis of a parotid mass in this population.

Light Chain Amyloidosis Presenting as Bilateral External Auditory Canal Obstructing Masses.

: A morbidly-obese 57-year-old diabetic and hypertensive man with chronic kidney disease, diastolic heart failure, and bilateral hearing loss was found to have soft tissue masses/densities in the lateral aspect of both auditory canals on local examination and on imaging. He underwent biopsies of both ear canal masses and histologic examination revealed amyloid deposits in the dermis. These deposits were confirmed as AL (amyloid light chain) kappa-type amyloid by laser mass spectrometry. A systemic work-up showed plasma cell dyscrasia with 9% kappa light chain restricted plasma cells in the bone marrow as well as amyloid deposits on a kidney biopsy.Involvement of the external auditory canals is a rare manifestation of systemic amyloidosis with only 13 cases reported so far, of which four cases had bilateral external auditory canal involvement, associated with multiple myeloma. Interpretation of small biopsies can be challenging especially with early, scant amyloid deposits, but a sufficient biopsy to type amyloid by immunohistochemistry or laser mass spectrometry is imperative for further management. Early diagnosis and treatment of systemic light chain amyloidosis translates to better patient outcomes, while delay in management could lead to dismal prognosis.

Eccentric, mature osseous cap: A distinct imaging feature of sinonasal osteoblastoma.

BACKGROUND: With the exception of osteomas, bone neoplasms that originate in the sinonasal cavity are seldom diagnosed on preoperative imaging due to a lack of characteristic radiographic features. Here we described the unusual occurrence of an osteoblastoma in the paranasal sinuses, and we drew focus to its salient imaging features. A highly unique imaging sign was indicated, and its pathologic basis was explained, with concurrent review of the literature. METHODS: Case series and review of the literature. RESULTS: Two cases of sinonasal osteoblastoma were managed by definitive surgical resection. Both tumors on preoperative computed tomography demonstrated an expansile, heterogeneous fibro-osseous lesion with an eccentric, mature osseous cap. The dense osseous cap seen on imaging corresponded to a rim of mature bone on histopathology. A review of existing literature revealed the presence of this imaging sign in all reported cases. CONCLUSION: Sinonasal osteoblastoma is an extremely rare entity with undefined imaging characteristics to guide preoperative decision-making. Here we reported, to our knowledge, the first description of a characteristic imaging sign of an eccentric, mature osseous cap, which corresponded histologically to a single peripheral layer rim of osteoblasts, a unique trait of osteoblastoma.

Urinary bladder smooth muscle regeneration utilizing bone marrow derived mesenchymal stem cell seeded elastomeric poly(1,8-octanediol-co-citrate) based thin films.

Bladder regeneration studies have yielded inconclusive results possibly due to the use of unfavorable cells and primitive scaffold design. We hypothesized that human mesenchymal stem cells seeded onto poly(1,8-octanediol-co-citrate) elastomeric thin films would provide a suitable milieu for partial bladder regeneration. POCfs were created by reacting citric acid with 1,8-octanediol and seeded on opposing faces with human MSCs and urothelial cells; normal bladder smooth muscle cells and UCs, or unseeded POCfs. Partial cystectomized nude rats were augmented with the aforementioned POCfs, enveloped with omentum and sacrificed at 4 and 10 weeks. Isolated bladders were subjected to Trichrome and anti-human gamma-tubulin, calponin, caldesmon, smooth muscle gamma-actin, and elastin stainings. Mechanical testing of POCfs revealed a Young's modulus of 138 kPa with elongation 137% its initial length without permanent deformation demonstrating its high uniaxial elastic potential. Trichrome and immunofluorescent staining of MSC/UC POCf augmented bladders exhibited typical bladder architecture with muscle bundle formation and the expression and retention of bladder smooth muscle contractile proteins of human derivation. Quantitative morphometry of MSC/UC samples revealed muscle/collagen ratios approximately 1.75x greater than SMC/UC controls at 10 weeks. Data demonstrate MSC seeded POCfs support partial regeneration of bladder tissue in vivo.