Comparing donor site morbidity in osteocutaneous radial forearm versus fibula free flap for mandibular reconstruction.

PURPOSE: The osteocutaneous radial forearm free flap has gained popularity as a less morbid option for oromandibular reconstruction compared to the fibular free flap. However, there is a paucity of data regarding direct outcome comparison between these techniques. METHODS: Retrospective chart review of 94 patients who underwent maxillomandibular reconstruction intervened from July 2012-October 2020 at the University of Arkansas for Medical Sciences. All other bony free flaps were excluded. Endpoints retrieved encompassed demographics, surgical outcomes, perioperative data, and donor site morbidity. Continuous data points were analyzed using independent sample t-Tests. Qualitative data was analyzed using Chi-Square tests to determine significance. Ordinal variables were tested using the Mann-Whitney U test. RESULTS: The cohort was equally male and female, with a mean age of 62.6 years. There were 21 and 73 patients in the osteocutaneous radial forearm free flap and fibular free flap cohorts, respectively. Excluding age, the groups were otherwise comparable, including tobacco use, and ASA classification. Bony defect (OC-RFFF = 7.9 cm, FFF = 9.4 cm, p = 0.021) and skin paddle (OC-RFFF = 54.6 cm2, FFF = 72.21 cm2, p = 0.045) size were larger in the fibular free flap group. However, no significant difference was found between cohorts with respect to skin graft. There was no statistically significant difference between cohorts regarding the rate of donor site infection, tourniquet time, ischemia time, total operative time, blood transfusion, or length of hospital stay. CONCLUSIONS: No significant difference in perioperative donor site morbidity was found between patients undergoing fibular forearm free flap and osteocutaneous radial forearm flap for maxillomandibular reconstruction. Osteocutaneous radial forearm flap performance was associated with significantly older age, which may represent a selection bias.

Reconstruction for Salvage Laryngectomy With Limited Pharyngectomy.

Importance: Closure technique for optimization of postoperative and functional outcomes following salvage laryngectomy remains an area of debate among head and neck surgeons. Objective: To investigate the association of salvage laryngectomy closure technique with early postoperative and functional outcomes. Design, Setting, and Participants: This retrospective cohort study included patients from 17 academic, tertiary care centers who underwent total laryngectomy with no or limited pharyngectomy after completing a course of definitive radiotherapy or chemoradiotherapy with curative intent between January 2011 and December 2016. Patients with defects not amenable to primary closure were excluded. Data were analyzed from February 14, 2021, to January 29, 2024. Exposures: Total laryngectomy with and without limited pharyngectomy, reconstructed by primary mucosal closure (PC), regional closure (RC), or free tissue transfer (FTT). Main Outcomes and Measures: Patients were stratified on the basis of the pharyngeal closure technique. Perioperative and long-term functional outcomes were evaluated with bivariate analyses. A multivariable regression model adjusted for historical risk factors for pharyngocutaneous fistula (PCF) was used to assess risk associated with closure technique. Relative risks (RRs) with 95% CIs were determined. Results: The study included 309 patients (256 [82.8%] male; mean age, 64.7 [range, 58.0-72.0] years). Defects were reconstructed as follows: FTT (161 patients [52.1%]), RC (64 [20.7%]), and PC (84 [27.2%]). A PCF was noted in 36 of 161 patients in the FTT group (22.4%), 25 of 64 in the RC group (39.1%), and 29 of 84 in the PC group (34.5%). On multivariable analysis, patients undergoing PC or RC had a higher risk of PCF compared with those undergoing FTT (PC: RR, 2.2 [95% CI, 1.1-4.4]; RC: RR, 2.5 [95% CI, 1.3-4.8]). Undergoing FTT was associated with a clinically meaningful reduction in risk of PCF (RR, 0.6; 95% CI, 0.4-0.9; number needed to treat, 7). Subgroup analysis comparing inset techniques for the RC group showed a higher risk of PCF associated with PC (RR, 1.8; 95% CI, 1.1-3.0) and predominately pectoralis myofascial flap with onlay technique (RR, 1.9; 95% CI, 1.2-3.2), but there was no association of pectoralis myocutaneous flap with cutaneous paddle interposition with PCF (RR, 1.2; 95% CI, 0.5-2.8) compared with FTT with cutaneous inset. There were no clinically significant differences in functional outcomes between the groups. Conclusion and Relevance: In this study of patients with limited pharyngeal defects, interpositional fasciocutaneous closure technique was associated with reduced risk of PCF in the salvage setting, which is most commonly achieved by FTT in academic practices. Closure technique was not associated with functional outcomes at 1 and 2 years postoperatively.

Impact of Oral Steroids on Tonsillectomy Postoperative Complications and Pain.

OBJECTIVES: To analyze the impact of steroids on postoperative tonsillectomy recovery and implement findings for improvement in postoperative management. METHODS: Institutional review board approved prospective study with retrospective analysis of private practice setting tonsillectomy patients (November 2015 to January 2017). A questionnaire was provided postoperatively to patients undergoing tonsillectomy with or without adenoidectomy. The study population was separated into 2 groups: patients who received steroids (3 days of either dexamethasone or prednisolone), postoperative steroid (POS), versus patients who did not receive steroids (PONS). RESULTS: The questionnaire had a return rate of 27.3% (254/931). Nine of the 254 responses were disqualified for lack of information; therefore, the total number of responses was 245. Of these, 115 were POS and 130 were PONS. The groups were similar in mean age (POS: 13.2 ± 10.4 years, PONS: 14.7 ± 12.1 years, P = .32) and sex (POS: Male 40.0%, PONS: Male 40.0%, P = .97). There was an overall decrease of pain and nausea/vomiting (N/V) in the steroid group (P = .0007). There was reduction in pain (P < .05) from postoperative day (POD) 2, 3, 4, and 6 in the POS group. Otherwise, there was no significant reduction in pain from POD 7 to 14, day-by-day rate of N/V, bleeding, or rate of emergency department (ED) or clinic visit (P > .05). CONCLUSION: Postoperative steroid reduced overall pain and N/V, as well as daily pain on POD 2, 3, 4, and 6. Pain from POD 7 to 14, rate of ED or clinic visit, or daily N/V and bleeding rate were not significantly different between cohorts.

Risk Stratification of Acute Invasive Fungal Rhinosinusitis in Patients With Hematologic Pathology.

OBJECTIVE: The purpose of this study is to identify objective perioperative diagnostic factors for acute invasive fungal rhinosinusitis (AIFS) to create a diagnostic scoring system using objective criteria. METHODS: Retrospective case-control study performed at an academic, tertiary care center. Biopsy-proven cases of AIFS identified from pathology records (2015-2019) were compared to patients the otolaryngology service was consulted to "Rule out AIFS" in the year 2019, only including those with underlying hematologic malignancy. Eighteen patients with AIFS and 20 patients without were included. One and two tailed T-tests were used for p-values. Receiver operating characteristic curves were generated for the significant data, and Youden's J-statistic was used to create the ideal cutoff values for each. Likelihood ratios were used to give a power for the scoring system. RESULTS: Compared to patients with non-hematologic malignancy-related AIFS, patients with hematologic malignancy-related AIFS have significantly elevated C-reactive protein (CRP) and blood glucose; while albumin, hematocrit, platelet count, and absolute neutrophil count (ANC) were found to be significantly lower. In addition, Lund-Mackay score asymmetry, extra-sinus spread, aspergillus antigen, and pre-existing diabetes mellitus correlated with disease. A scoring system with three categories: AIFS Unlikely, Indeterminate/AIFS Suspicious, and AIFS Highly Likely was developed. CONCLUSION: Patients with hematologic malignancy-related AIFS have measurable differences in lab values and standard imaging that could be used in determining the diagnostic probability of AIFS including: CRP, albumin, hematocrit, platelets, ANC, blood glucose, aspergillus antigen, Lund-Mackay score asymmetry, extra-sinus spread, and pre-existing diabetes mellitus. A novel scoring system was proposed that will require prospective validation. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1059-1064, 2023.

Early postoperative complications following tracheotomy: Does suturing technique influence outcomes?

Introduction: Tracheotomy is one of the most commonly performed procedure by otolaryngologists, but no consensus exists on the effect of suturing techniques on postoperative complications. Stay sutures and Bjork flaps are utilized frequently for securing the tracheal incision to the neck skin in order to create a tract for recannulation. Methods: Retrospective cohort study of tracheotomies performed by Otolaryngology-Head and Neck Surgery providers (May 2014 to August 2020) was conducted to determine the effect of suturing technique on postoperative complications and patient outcomes. Patient demographics, medical comorbidities, indication for tracheostomy, and postoperative complications were analyzed with a statistical alpha set of .05. Results: Out of 1395 total tracheostomies performed at our institution during the study period, 518 met inclusion criteria for this study. Three hundred and seventeen tracheostomies were secured by utilizing a Bjork flap, while 201 were secured with up and down stay sutures. Neither technique was noted to be more commonly associated with tracheal bleeding, infection, mucus plugging, pneumothorax, or false passage of the tracheostomy tube. One mortality was noted following decannulation during the study period. Conclusion: Though various techniques exist; adverse outcomes are not associated with the manner in which a new tracheostomy stoma is secured. Medical comorbidities and the indications for tracheostomy likely play a more significant role in postoperative outcomes and complications. Level of evidence: Level 3.

A randomized study on the value of self-directed versus traditional mentor-led microsurgical training.

Objective: Analyze efficacy of self-directed resident microvascular training versus a mentor-led course. Study Design: Randomized, single-blinded cohort study. Setting: Academic tertiary care center. Methods: Sixteen resident and fellow participants were randomized into two groups stratified by training year. Group A completed a self-directed microvascular course with instructional videos and self-directed lab sessions. Group B completed a traditional mentor-led microvascular course. Both groups spent equal time in the lab. Video recorded pre and post-course microsurgical skill assessments were performed to assess the efficacy of the training. Two microsurgeons, blinded to participant identity, evaluated the recordings and inspected each microvascular anastomosis (MVA). Videos were scored using an objective-structured assessment of technical skills (OSATS), a global rating scale (GRS), and quality of anastomosis scoring (QoA). Results: The pre-course assessment identified that the groups were well matched with only "Economy of Motion" on the GRS favoring the mentor led group (p = .02). This difference remained significant on the post assessment (p = .02) Both groups significantly improved in OSATS and GRS scoring (p < .05). There was no significant difference in OSATS improvement between the two groups (p = .36) or improvement in MVA quality between groups (p > .99). Time to completion of MVA significantly improved overall by a mean of 8 min and 9 s (p = .005) with no significant difference between post training times to complete (p = .63). Conclusion: Different microsurgical training models have previously been validated as effective methods for improved MVA performance. Our findings indicate that a self-directed microsurgical training model is an effective alternative to a traditional mentor driven models. Level of Evidence: Level 2.

Individual SNOT-22 Items Aid in Differentiating Between Spontaneous Cerebrospinal Fluid Rhinorrhea and Chronic Rhinosinusitis Without Nasal Polyps.

OBJECTIVES: Spontaneous cerebrospinal fluid (CSF) rhinorrhea is a diagnostic challenge due to its overlapping symptomatology with other sinonasal diseases. The objective of this study was to investigate whether items on the sinonasal outcome test (SNOT)-22 could suggest a diagnosis of spontaneous CSF rhinorrhea versus chronic rhinosinusitis without nasal polyps (CRSsNP). METHODS: A multi-institutional retrospective chart review of patients with spontaneous CSF rhinorrhea and a control group of CRSsNP patients was performed. Individual SNOT-22 scores and domain scores were compared. RESULTS: One hundred fifteen patients were included in both cohorts. Of the patients in the CSF rhinorrhea group, 48% were misdiagnosed as chronic rhinosinusitis (CRS) prior to the correct identification of a CSF leak. On bivariate analysis, the CSF rhinorrhea group scored significantly higher on the SNOT-22 for runny nose (P < .001) and was more likely to designate this symptom as most important (P < .001). The CRSsNP group scored significantly higher in nasal blockage (P < .001), thick nasal discharge (P < .001), facial pain/pressure (P < .001), and in the ear/facial (P < .001) and rhinologic (P = .003) domains. Multivariable logistic regression revealed that runny nose (P < .001) was most predictive of spontaneous CSF rhinorrhea while nasal blockage (P < .001), thick nasal discharge (P < .001), and facial pain/pressure (P = .001) were predictive of CRSsNP after adjusting for relevant confounders. No significant difference was observed in total SNOT-22 scores between groups (P = .676). CONCLUSIONS: Spontaneous CSF rhinorrhea is commonly misdiagnosed as other sinonasal pathologies. However, individual SNOT-22 items can help aid in suggesting a CSF leak. Spontaneous CSF rhinorrhea should be suspected in patients who have high SNOT-22 scores for runny nose and report this symptom as most important, but have lower scores related to the other cardinal symptoms of CRS.

SNOT-22 Quality of Life Scores Improve After Endoscopic Endonasal Repair of Spontaneous Cerebrospinal Fluid Rhinorrhea.

OBJECTIVES: Patients with spontaneous cerebrospinal fluid (CSF) rhinorrhea can experience significant sinonasal symptom burden, leading to poor quality of life (QOL). The objective of this study was to investigate sinonasal outcome test-22 (SNOT-22) scores in patients undergoing endoscopic endonasal surgery for spontaneous CSF rhinorrhea and compare them to patients undergoing endoscopic sinus surgery (ESS) for chronic rhinosinusitis without nasal polyps (CRSsNP). METHODS: A multi-institutional retrospective review of patients with spontaneous CSF rhinorrhea and CRSsNP was performed. Pre-surgery and post-surgery SNOT-22 scores and domains were compared within each group. Improvements in SNOT-22 scores after surgery were compared between the groups. RESULTS: Ninety-one patients were in the CSF rhinorrhea group and 105 patients were in the CRSsNP group. Within each group, surgery significantly improved total SNOT-22 scores, domain scores, and most of the individual symptoms. Comparing the 2 groups revealed similar improvements in total SNOT-22 scores (P = .244). The CSF rhinorrhea group improved more in runny nose (P < .001), postnasal discharge (P < .001), wake up at night (P = .024), and embarrassed (P = .002). The CRSsNP group improved more in sneezing (P = .027), nasal blockage (P < .001), decreased sense of smell/taste (P = .011), thick nasal discharge (P < .001), facial pain/pressure (P = .008), and the ear/facial domain (P = .010). CONCLUSIONS: Patients with spontaneous CSF rhinorrhea experience significant symptom burden. Those who undergo CSF leak repair should experience significant improvement in QOL similar to patients who undergo ESS for CRSsNP as measured by SNOT-22.

Comparative Morbidity Profile of Elective vs Therapeutic Neck Dissection.

OBJECTIVE: Neck dissection (ND) is one of the most commonly performed procedures in head and neck surgery. We sought to compare the morbidity of elective ND (END) versus therapeutic ND (TND). STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary care center. METHODS: Retrospective chart review of 373 NDs performed from January 2015 to December 2018. Patients with radical ND or inadequate chart documentation were excluded. Demographics, clinicopathologic data, complications, and sacrificed structures during ND were retrieved. Statistical analysis was performed with χ2 and analysis of variance for comparison of categorical and continuous variables, respectively, with statistical alpha set a 0.05. RESULTS: Patients examined consisted of 224 males (60%) with a mean age of 60 years. TND accounted for 79% (n = 296) as compared with 21% (n = 77) for END. Other than a significantly higher history of radiation (37% vs 7%, P < .001) and endocrine pathology (34% vs 2.6%, P < .001) in the TND group, no significant differences in demographics were found between the therapeutic and elective groups. A significantly higher rate of structure sacrifice and extranodal extension within the TND group was noted to hold in overall and subgroup comparisons. No significant difference in rate of surgical complications was appreciated between groups in overall or subgroup analysis. CONCLUSION: While the significantly higher rate of structure sacrifice among the TND population represents an increased morbidity profile in these patients, no significant difference was found in the rate of surgical complications between groups. The significant difference seen between groups regarding history of radiation and endocrine pathology likely represents selection bias.

Vascularity Outcomes of Lingual Artery Ligation in Transoral Robotic Base of Tongue Resections.

To explore the effect of lingual artery ligation on tongue vascularity, we performed an analysis of 25 patients who underwent transoral robotic surgery for base of tongue cancers (May 2011 to December 2019). Hounsfield units of the intrinsic muscles (IMs) and genioglossus muscles (GGs) were measured in postoperative imaging (mean 4 months) as a surrogate for vascularity. In ligated patients (n = 15), the values from the ligated/resected side of the tongue were compared with the contralateral side and the nonligated side of resection. Individually, IMs and GGs on the ligated side demonstrated no significant difference to the contralateral side (P = .662 and .618, respectively). Ligation produced a significant decrease in IM measurements but no difference between GG values vs nonligated patients (P = .050 and .818, respectively). No difference was appreciated in mean values for combined IMs and GGs between cohorts (P = .212). No gross tongue atrophy or complications were incurred. Future studies are warranted to delineate long-term effects.

Postoperative and 1-Year Functional Outcomes After Free Flap Surgery Among Patients 80 Years or Older.

OBJECTIVE: To evaluate the postoperative and 1-year functional outcomes after free flap surgery among patients ≥80 years old. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care center. METHODS: We conducted a retrospective review of 596 patients who underwent head and neck ablation and reconstruction with free tissue over a 7-year period. Patients ≥80 years of age were included. RESULTS: Fifty patients were ≥80 years old, with an average age of 83.7 years. Ninety-day mortality was 12.0%, and those who died were of older age (87.5 vs 83.1 years, P = .036). Prior radiation therapy (odds ratio, 6.8 [95% CI, 1.1-42.7]) and a Charlson Comorbidity Index ≥3 (odds ratio, 10.0 [95% CI, 1.5-67.0]) were associated with an increased risk of 90-day mortality. Overall 21 (42.0%) patients experienced a 30-day complication; 7 (14.0%) were readmitted within 30 days; and 5 (10.0%) underwent additional flap-related operations. Flap failure occurred in 2 (4.0%) patients. Before surgery, 45 (90%) patients were living independently or within assisted living; among these, 19.5% declined to dependent functional status at 90-day follow-up. At 90 days, 2 (8.3%) of 24 patients remained tracheostomy dependent, and 20 (66.7%) of 30 patients required feeding tube supplementation. Among 42 patients, 36 (85.7%) had unrestricted or modified oral diets at 90 days. Charlson Comorbidity Index ≥2 was associated with an increased risk of 1-year mortality (odds ratio, 5.1 [95% CI, 1.4-18.6]). CONCLUSION: The potential for functional decline and risk of 90-day mortality should be discussed with patients aged ≥80 years.

Bedside Neck Exploration for Venous Flow Coupler Signal Loss in Postoperative Free Tissue Transfer Monitoring.

OBJECTIVE: To describe the role and efficacy of bedside neck exploration following free tissue transfer. STUDY DESIGN: Retrospective case series. SETTING: Single tertiary care institution. METHODS: A retrospective chart review was conducted of 353 patients who underwent free tissue transfer between January 2017 and April 2021. Bedside exploration was performed under mild sedation in patients who had loss of venous Doppler signal with equivocal clinical signs of venous insufficiency. RESULTS: A total of 11 patients underwent bedside assessment of the microvascular pedicle. In 6 cases, a return to the operating room was avoided. Five of these patients had coupler malfunction, and in 1 patient a venous kink was discovered and remedied at the bedside. Five patients required return to the operating room. Venous thrombosis requiring thrombectomy and revision of the venous anastomosis was discovered in 3 patients. One patient had a developing hematoma necessitating evacuation in the operating room, and 1 returned to the operating room due to sternocleidomastoid muscular compression of the venous pedicle. There were no flap failures within the study group. In all cases, broad-spectrum intravenous antibiotic coverage was prophylactically used, and no instances of wound infection were observed. Avoidance of returning to the operating room prevented an estimated $9222 of hospital charges per event. CONCLUSION: Bedside neck exploration can be incorporated as a safe and cost-effective intermediary for definitive determination of need for return to the operating room.

Model of an Advanced Practice Provider-Led Head and Neck Cancer Survivorship Clinic: Evaluation of a 4-Year Experience.

OBJECTIVE: To report the efficacy and safety of an advanced practice provider-led head and neck cancer survivorship clinic. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic medical center. METHODS: Patients were enrolled into the survivorship clinic after undergoing 1-year follow-up with the primary head and neck surgeon. Those enrolled between December 2016 and October 2020 were retrospectively reviewed for diagnosis, staging, pattern of recurrence, visit frequency, and compliance. Surgical respectability of recurrent disease was used as a surrogate for timely diagnosis. RESULTS: An overall 570 patients were followed within the survivorship clinic. The mean length of follow-up was 13.6 months. Mucosal primaries represented 72.6% of patients. A majority of the primary malignancies were squamous cell carcinoma (77.7%). The most common primary subsites were the oropharynx (26.7%), oral cavity (25.1%), cutaneous (17.0%), and larynx (15.3%). Recurrence was detected in 50 patients (8.8%): 26 local, 12 regional, and 14 distant. Two patients had multiple synchronous recurrences. Twelve (2.1%) second primary cancers were detected. Of the 36 cases of locoregional recurrence, 32 (88.9%) were deemed amenable to salvage surgical intervention, with or without adjuvant therapy. Negative margins were obtained in 21 of the 23 (91.3%) local recurrences that underwent salvage resection. CONCLUSION: Advanced practice provider-based surveillance of head and neck cancer, without risk stratification, appears to be a sound model but needs further prospective evaluation. Consistent with literature, 88.9% of patients with locoregional recurrence were candidates for curative-intent salvage surgery, emphasizing that recurrences are identified in a timely fashion.

Infantile Hemangioma Treated with Propranolol Readmission Trends, Complications of Therapy, and Cost: A PHIS Database Study.

Objective: To examine admission trends, complications, and costs for inpatient infantile hemangioma (IH) associated with propranolol therapy utilizing the Pediatric Health Information System (PHIS) database. Study Design. A retrospective cohort study was completed using the PHIS database. The PHIS database was queried from 2008 to 2020 for children without cardiac disease and between the ages of three weeks and one year who were admitted with a diagnosis of IH and administered propranolol. Admissions were trended annually and by geographic region. Primary outcomes were length of stay (LOS), readmission, mortality, propranolol-related complications, and costs. Bivariate and multivariable analyses were employed to identify predictors of the primary outcomes. Results: A total of 2290 unique patient encounters were identified. Admissions steadily decreased after 2011, with variations by geographic region. There was no mortality and only 60 (2.6%) propranolol-related complications. African-American race (odds ratio (OR) 1.20 [95% CI: 1.02-1.41]), respiratory comorbidities (OR 2.04 [95% CI: 1.42-2.93]), neurologic conditions (OR 1.34 [95% CI: 1.09-1.59]), admission to an intensive care unit (OR 1.31 [95% CI: 1.09-1.59]), bronchospasm (OR 1.37 [95% CI: 1.22-1.55]), and hyperkalemia (OR 1.86 [95% CI: 1.08-3.20]) were associated with increased LOS. Neurologic conditions (OR 2.87 [95% CI: 1.76-4.67]) and respiratory comorbidities (OR 2.48 [CI: 1.43-4.30]) were associated with readmission. Average cost per admission was $5,158 ($3,259 to $8,560 range). Conclusion: There is an overall national decline in rate of admissions for IH propranolol therapy. Inpatient admission may be beneficial for patients with neurologic or respiratory conditions.

Hemorrhage and secondary infection of an infantile hemangioma during involution: A case report.

Bleeding complications due to IHs are generally limited. Secondary abscess formation after hemorrhage has not been reported. Rapid expansion of an IH should raise concern for hemorrhage in IHs that have been an involutionary phase.

Perioperative Indicators of Prognosis in Acute Invasive Fungal Sinusitis.

OBJECTIVE: The purpose of this study is to identify perioperative independent prognostic factors that are available to the consulting team to aid in determining prognosis in patients with acute invasive fungal sinusitis. STUDY DESIGN: Retrospective chart review of patients with biopsy-proven acute invasive fungal sinusitis from 2015 to 2018. SETTING: Academic tertiary care center. METHODS: Twenty-one patients were included from our single-center retrospective review. Kaplan-Meier graphs were created, and the Breslow test used to compare the curves to obtain P values. A univariate Cox regression analysis was performed on the data that were significant at 3 months from diagnosis. RESULTS: Twenty-one patients were included, and 17 (76%) had an underlying hematologic malignancy. Overall survival was 71% and 52% at 1 and 3 months, respectively, and 94% of patients with hematologic malignancy had an absolute neutrophil count ≤1 at diagnosis. Absolute neutrophil count values and fungal species were not associated with a difference in prognosis. Factors associated with decreased survival included current smoking and the absence of a rhinologist on the treatment team at the initial or subsequent debridement (hazard ratio, 3.03). Laboratory values such as beta-D-glucan and galactomannan were assessed in addition to disease extension at diagnosis. CONCLUSION: This study presents a retrospective review of a single institution's experience with acute invasive fungal sinusitis. Subspecialty level of care likely improves overall survival in these patients, whereas current smoking may imply a worse prognosis.

Preemptive Utilization of Anterior Belly of the Digastric Muscle Flaps in Transoral Robotic Radical Tonsillectomy.

OBJECTIVE: To demonstrate the use of an anterior belly of the digastric muscle flap (ABDMF) during transoral robotic radical tonsillectomy (TORRT) with concomitant neck dissection with the intent of preventing the formation of postoperative pharyngocutaneous fistulas. STUDY DESIGN: Retrospective study. SETTING: Single academic tertiary care center. METHODS: In this study, all patients were included who underwent TORRT plus limited pharyngectomy with concomitant neck dissection and ABDMF for the treatment of oropharyngeal squamous cell carcinoma between September 2012 and September 2020. The rate of fistula formation was assessed in patients with preemptive utilization of ABDMF. RESULTS: A total of 43 patients underwent TORRT with neck dissection and ABDMF. No patients developed a fistula in the postoperative period or associated morbidity with the use of this flap. CONCLUSION: Preemptive use of ABDMF in TORRT with concomitant neck dissection represents a reconstructive option that may help prevent the formation of pharyngocutaneous fistula by reinforcing the posteroinferior boundary of the parapharyngeal space.

Association of Continuous Intraoperative Vasopressor Use With Reoperation Rates in Head and Neck Free-Flap Reconstruction.

Importance: Continuous vasopressor use in free-flap reconstruction is a point of contention among microvascular surgeons despite data demonstrating safety. Objective: To investigate the association between continuous vasopressor use and the incidence of reoperation in the early postoperative period. Design, Setting, and Participants: In this cohort study, a retrospective medical record review was conducted of patients who underwent head and neck free-flap reconstructions between May 1, 2014, and October 31, 2019, in an academic tertiary care center. All patients undergoing free-flap reconstruction for head and neck defects were included. Exposures: Continuous intraoperative vasopressors. Main Outcomes and Measures: Patient medical records were queried for demographic variables; intraoperative use of vasopressors; vasopressor type, duration, and infusion rate; reoperation within the first 5 postoperative days; and reason for reoperation. Results: Four hundred forty-nine consecutive free-flap reconstructions were performed on 426 patients. The mean age was 62 years (IQR, 55.7-71.1); 293 patients were men (65.3%), 380 were White (84.6%), 55 were Black (12.2%), and 14 were of other race or ethnicity (3.1%). A total of 174 patients received a continuous vasopressor during their reconstruction. Twenty-three reoperations occurred within 5 days postoperatively, 8 of which included vasopressors during initial intervention. Vasopressor type had no association with reoperation (4.5% vs 5.5% [8/174 vs 15/275, respectively] for patients who received vasopressors vs those who did not) (dobutamine odds ratio [OR], 1.02 [95% CI, 0.21-2.91]; dopamine OR, 1.48 [95% CI, 0.33-4.26]). No difference was seen in the duration (dobutamine OR, 1.50 [95% CI, 0.78-2.90]; dopamine OR, 0.87 [95% CI, 0.59-1.28]) or infusion rate (dobutamine OR, 1.50 [95% CI, 0.99-1.02]; dopamine OR, 1.00 [95% CI, 0.99-1.01]) of vasopressors between patients who underwent reoperation and those who did not. Analysis after the exclusion of reasons for reoperation that did not represent possible microvascular anastomosis failure (eg, Doppler malfunction, donor site complications) showed no increased propensity for reoperation (OR, 1.18; 95% CI, 0.27-3.9). Conclusions and Relevance: In this cohort study, use of vasopressors for extensive periods intraoperatively during free-tissue transfer appeared to have no association with the rate of reoperation within 5 days of intervention, regardless of agent used, simultaneous use of agents, type of free-flap operation performed, or reason for reoperation. This study adds to the body of literature supporting the judicious use of vasopressors in patients requiring intraoperative pharmacological pressure support during free-flap reconstruction.

Free Tissue Transfer for Repair of Chronic Esophageal Perforations.

OBJECTIVE: Anterior cervical discectomy and fusion have become a common intervention for cervical spine stabilization. However, complications can cause life-threatening morbidity. Among them, esophageal perforation is associated with severe morbidity, including dysphagia, malnutrition, and infection with the potential development of mediastinitis. Presentation is variable but often results in chronic morbidity. Herein we examine our experiences in the management of esophageal perforation with microvascular free tissue transfer. STUDY DESIGN: Retrospective review from January 2013 to September 2020. SETTING: Single academic tertiary care center. METHODS: This study comprised all patients (age, 41-73 years) undergoing free tissue transfer for the repair of chronic esophageal perforation secondary to anterior cervical discectomy and fusion at an academic tertiary care center. Four patients underwent repair via vastus lateralis myofascial onlay grafting for defects ≤2 cm in greatest dimension, while 1 patient underwent a fasciocutaneous radial forearm free flap repair of an 11 × 5-cm defect. RESULTS: Defect location ranged from hypopharynx to cervical esophagus. Mean operative time was 6.2 hours; the average length of stay for all patients was 6.6 days. Of 5 patients, 1 required additional hardware placement for spine stabilization. All patients underwent gastrostomy tube placement to bypass the surgical site during healing, and all eventually resumed an oral diet postoperatively. Recurrent fistula occurred in 1 of 5 patients. No flap failures were encountered in the study population. CONCLUSION: Vastus lateralis myofascial onlay grafting and fasciocutaneous radial forearm free flap are robust, relatively low-morbidity interventions with a high success rate for definitive repair of chronic esophageal perforation. Repair should be undertaken in concert with a spine surgeon for management of the cervical spine.

Outcomes of Single Anastomoses for Superficial and Deep-System Venous Drainage of Radial Forearm Free Flaps.

OBJECTIVE: Venous insufficiency occurs in radial forearm free flaps (RFFFs) when either the deep venous system (DVS) or superficial venous system (SVS) is used as the venous outlet. We report our experience using the antecubital perforating vein (APV) in a single-vessel anastomosis to the median-cubital or cephalic vein to drain both systems. STUDY DESIGN: Retrospective review. SETTING: Single, academic, tertiary care center. METHODS: Data were collected from 72 patients who underwent RFFF from October 2009 to January 2017. In all cases, DVS and SVS were dissected, and an APV single-vessel anastomosis was attempted. RESULTS: Anatomical variations precluded single-vessel anastomosis in 11 (15.3%) cases. In 61 (84.7%) cases, single-vessel anastomosis produced unobstructed drainage for DVS and SVS without intrinsic venous insufficiency. Venous thrombosis and total loss occurred in 2 (3.3%) and 1 (1.6%) patients, respectively. Proximal dissection of the cephalic vein addressed a vessel-depleted neck in 3 cases. CONCLUSION: The antecubital perforating vein is present and functional in most patients, allowing for single anastomosis techniques for RFFF. Antecubital perforators capture DVS and SVS outflow through a single, extended venous pedicle, eliminating the risk of venous insufficiency and need for vein grafts.