The profunda artery perforator flap for head and neck reconstruction.

INTRODUCTION: The profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity. METHODS: Cadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy. RESULTS: 22 PAP flaps were studied. Each contained 1-6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3-15 cm), 11.4 cm (range 5-17 cm), and 17.5 cm (range 12.5-22 cm). Average pedicle length was 11.07 cm (range 7-16 cm), 11.78 cm (range 9-16 cm), and 11.23 cm (range 9-15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27-4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27-3.82 mm). Range of maximal primary closure was 6-11 cm. CONCLUSION: PAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.

Early discharge after free-tissue transfer does not increase adverse events.

INTRODUCTION: Demonstrate that carefully selected free flap patients may be discharged early after surgery without increasing the rates of postoperative complications or readmissions. METHODS: Based on a published article in Laryngoscope 2016 of 51 free-tissue transfers, a retrospective chart review was performed on an expanded cohort who underwent free-tissue transfer for head and neck reconstruction between February 2010 and May 2018 and discharged by postoperative day 3. RESULTS: 101 patients who underwent 104 free flaps with average age of 56 (3-84) years old were reviewed. Free flap indications included orbital and maxillary defects (n = 22), palatal defects (n = 16), nasal and septal defects (n = 16), cranioplasty and scalp defects (n = 16), mandibular defects due to osteoradionecrosis (n = 14), facial contouring and parotid defects (n = 12), and complex postsurgical and radiotherapy wounds or fistula closure (n = 8). Free flaps performed were anterolateral thigh (n = 97), radial forearm (n = 2), serratus (n = 2), latissimus (n = 1), fibula (n = 1) and supraclavicular (n = 1). The recipient vessels used via minimal access approaches were facial (n = 43), superficial temporal (n = 29), angular (n = 20) and others. There were 3 flap failures (2.9%) recognized in follow-up. No flap failures or perioperative complications were associated with early discharge. There were only 2 patients readmitted and 1 watched in observation within 30 days postoperatively. CONCLUSION: An updated review of our institutional experience with more than double the cohort size substantiates previous conclusions that early discharge after free-tissue transfer is a safe option in select patients. Moreover, earlier discharge is a critical management choice that reduces cost and decreases hospital-related adverse events.

Osseocartilaginous Rib Graft L-Strut for Nasal Framework Reconstruction.

BACKGROUND: In the setting of major nasal framework reconstruction, it is critical to create a stable, warp-resistant L-strut to resist the contractile forces of healing to achieve a durable outcome. OBJECTIVES: The authors sought to demonstrate the effectiveness of the osseocartilaginous rib graft for nasal framework reconstruction. METHODS: Retrospective analysis was performed of all patients who underwent osseocartilaginous rib graft for L-strut reconstruction from 2007 to 2017 at a tertiary care hospital. Only patients with severe framework-only defects (Type IV, Daniel Classification) or total/subtotal nasal defects (Type V, Daniel Classification) were included. Primary outcome measures were: (1) maintenance of projection; (2) graft warping; and (3) graft resorption. RESULTS: Twenty-six patients aged an average of 54.6 years underwent nasal framework reconstruction with an osseocartilaginous rib graft L-strut. Eighteen patients had framework-only deformities (Daniel Type IV) and 8 had total or subtotal nasal deformities (Daniel Type V). Twelve patients underwent reconstruction for autoimmune mediated deformity, 10 for malignancy, 3 for traumatic injury, and 1 for an iatrogenic deformity. Average follow-up was 21 months. There was no observed warping of the L-strut construct, and all but 2 patients demonstrated total maintenance of projection. Resorption of the caudal cartilage graft was identified as the etiology of partial loss of projection in 2 patients. CONCLUSIONS: The osseocartilaginous rib graft L-strut provides a stable, warp-resistant construct for patients lacking major dorsal and caudal support, which may be applied to reconstruction of defects due to malignancy, autoimmune, traumatic, or iatrogenic etiologies.

Pyogenic granuloma of the larynx: A rare cause of hemoptysis.

Pyogenic granuloma (PG) may involve gingival mucosa (granuloma gravidarum) in pregnancy but rarely involves the airway. This case report is perhaps the only reported presentation of PG in the larynx causing hemoptysis at a late stage of pregnancy. On laryngoscopic exam, a vascular, right false vocal fold neoplasm was identified with pathological characteristics consistent with PG. Conclusions: Pyogenic granuloma is a relatively common tumor of pregnancy but rarely involves the larynx. In the case of airway involvement during pregnancy, it is best managed in coordination with the high-risk obstetrical team and can be removed safely via standard microsurgical techniques.

Post-treatment sequelae and management of primary laryngeal NK/T-cell lymphoma: A case report.

OUTCOME OBJECTIVES: METHODS: Case Report, April 2016. RESULTS: A 27-year-old female presented with a three-week history of flu-like symptoms including sore throat, myalgia and insidious nasal congestion. Her hospital course was complicated by pancytopenia, extensive GI bleed of unknown origin and fever. Radiographic studies revealed multifocal centrilobular ground-glass lung nodules, splenomegaly, frontal and paranasal sinus opacification and mucosal thickening and inflammatory process of false and true vocal cords with concentric multi-level narrowing. Extensive rheumatologic, hematologic and infectious workup failed to demonstrate an etiology. Flexible laryngoscopic and bronchoscopic examinations with biopsies exhibited a diffuse supraglottic and glottic exophytic, "heaped-up" infiltration; limited vocal cord motion; and airway narrowing to 3 mm. Pathology yielded NK/T-Cell lymphoma with PET/CT confirming nasopharyngeal and laryngeal involvement sparing the brain and other distant structures. During treatment, the patient's airway became increasingly compromised requiring tracheostomy. Flexible laryngoscopic examination after four rounds of SMILE (dexamethasone, methotrexate, ifosfamide, l-asparaginase, and etoposide) chemotherapy and subsequent radiotherapy with 50 Gy in 25 fractions revealed complete glottic stenosis with alteration of the laryngeal anatomy and a pin-hole aperture seen posteriorly through the tracheostomy. Two dilation procedures performed one month apart, improved her airway considerably which allowed for successful decannulation. She continues to be disease-free post treatment but has persistent supraglottic and glottic scar and has developed tracheal stenosis at her tracheostomal site. CONCLUSIONS: NK/T-Cell lymphoma of the larynx has been rarely described. Herein, we describe the sequalae of treatment and the requisite airway management.

Augmentation Autologous Adipose Injections in the Larynx.

OBJECTIVE: Autologous adipose injection (AAI) is a recognized method for vocal fold augmentation. The study's purpose is to explore short- and long-term outcomes of AAI. METHODS: Retrospective chart review of 43 patients undergoing AAI was performed; patient perception of outcome, Voice Handicap Index (VHI), maximum phonatory time (MPT), and disposition were evaluated. RESULTS: Over 5 years, 43 AAI patients had documented postoperative follow-up (25 paralysis, 8 paresis, 9 bowing/presbylarynges, and 5 scar/sulci). Mean follow-up was 32 weeks. There was gradual patient loss to follow-up. Thirty-nine of 40 (98%) had patient-reported improvement at 6 weeks, 28 of 34 (82%) had improvement at 2 to 6 months, with 10 of 12 (83%) sustaining their improvement for >1 year. Significant improvement in mean VHI was observed at 4 to 6 weeks (mean reduction, 26; P < .0001) and 2 to 6 months (mean reduction, 23; P < .0001). Improvement in mean MPT was observed at 4 to 6 weeks (mean increase, 8 s; P < .0001), 2 to 6 months (6 s; P = .007), and >1 year (4 s; P = .03). Eight patients went on to medialization laryngoplasty. CONCLUSION: AAI successfully augments vocal folds in short-term outcomes with some gradual decrease in effectiveness. Although patient attrition limited conclusions, objective long-term benefit may occur in >50% of patients.

Teaching Application of 3D-printed Models for Nasal Analysis.

Background: A major challenge in learning rhinoplasty is correlating patients' external and internal nasal structures. We aim to explore the application of three dimensional (3D)-printed models of nasal bony-cartilaginous structures in identifying accurate nasal anatomy. Methods: Otolaryngology-head and neck surgery and plastic and reconstructive surgery residents matched patient photograph models, described relative nasal bony-cartilaginous anatomy, completed pre- and postactivity self-evaluations (based on otolaryngology "nasal deformity" milestones including "anatomy," "function," "aesthetic," and "etiology"), and rated the 3D-printed models' usefulness. Descriptive statistics were measured. Results: Thirty-seven residents correctly matched four of six model-photograph pairs and correctly described 15 of 30 anatomic relationships, on average. There was a moderate, statistically significant correlation between postgraduate year and number of correctly matched model-photograph pairs (Spearman rho = 0.58, 95% CI 0.24-0.79) and total items correct (Spearman rho = 0.61, 95% CI 0.28-0.81). Self-ratings on milestones decreased postexercise in all subcategories except "function." From 0 (low) to 100 (high), learners found the exercise useful (median 85 of 100) with a high recommendation for future use (median 87 of 100). Conclusions: Three-dimensional printed models are a valuable tool for understanding nasal anatomy. Continued standardization of designs and assessments of their educational utility will enhance their broader dissemination and implementation.

Nasal Tip Support and Management of the Tip Tripod Complex.

Controlling the nasal tip to achieve excellent structural and cosmetic outcomes is challenging in rhinoplasty surgery. A strong foundation and understanding of the nasal tripod complex and the various methods for restoring tip support mechanisms when disrupted either from surgery or other means is critical. The columellar strut graft, septal extension graft, and tongue-in-groove suture technique are well-described methods to control and support the nasal tip. There are advantages and disadvantages to each method, but one should be comfortable with the nuances of each to master nasal tip surgery.

Statin Therapy in Patients Undergoing Thoracic Aorta Replacement for Aortic Aneurysms.

BACKGROUND: Patients undergoing surgery for thoracic aortic aneurysms receive statin therapy out of proportion to cardiovascular comorbidity. We sought to determine the prevalence of statin use among patients presenting for thoracic aortic aneurysm surgery and investigate its effect on outcomes. METHODS: From January 1, 2005 to January 1, 2011, 1,839 consecutive patients underwent aortic replacement for degenerative thoracic aortic aneurysm at Cleveland Clinic. Of these, 771 (42%) were on statins preoperatively. Statin users (vs. nonstatin users) were older (65 ± 11 vs. 56 ± 16 years) and had more hypertension (78 vs. 59%). Propensity matching based on 56 preoperative variables other than lipid levels was used to compare outcomes among 570 matched patient pairs (74% of possible pairs). RESULTS: Propensity-matched statin and nonstatin users were aged 64 ± 11 years, 394 (69%) versus 387 (68%) were male, and 437 (77%) versus 442 (78%) had ascending aortic aneurysms, respectively. Overall, 25% of patients were followed for more than 8.2 years and 10% for more than 10 years. Perioperative outcomes were similar, including hospital mortality (11 [1.9%] vs. 5 [0.88%]) and stroke (22 [3.9%] vs. 13 [2.3%]), but 16 statin users (2.8%) versus 5 nonstatin users (0.88%) required temporary dialysis after surgery (p = 0.02). At 6 years, 3.7% of statin users versus 5.1% of nonstatin users (p[log-rank] = 0.5) underwent further aortic surgery, and at 10 years, mortality was 25% in both groups (p > 0.5). CONCLUSION: Patients presenting for thoracic aortic aneurysm surgery frequently receive unnecessary statins. Additionally, statin use was associated with more postoperative renal failure, but not less intermediate-term risk for aortic reintervention or all-cause mortality after surgery. Therefore, presence of a thoracic aortic aneurysm should not be considered an indication for statin therapy in the absence of well-established indications.

Angular Vessels for Free-Tissue Transfer in Head and Neck Reconstruction: Clinical Outcomes.

OBJECTIVES/HYPOTHESIS: To evaluate the efficacy and reconstructive applications of angular vessel microvascular anastomosis in free-tissue transfer. STUDY DESIGN: Retrospective cohort study. METHODS: A study of patients treated from January 2010 to July 2017 was performed. Four hundred thirty patients undergoing free-tissue transfer at the Cleveland Clinic by a single reconstructive surgeon were reviewed. Patients in whom free-tissue transfer was performed using angular vessels were included. Patients in whom free-tissue transfer was performed using another vascular supply of the head and neck were excluded. Primary outcome was free-flap failure. Secondary outcomes included other postoperative complications and hospital length of stay. RESULTS: Thirty-one patients underwent free-tissue transfer with microvascular anastomosis to the angular vessels during the study period. Seventy-one percent of patients underwent reconstruction immediately following tumor ablation. A variety of primary subsites were reconstructed; 58% underwent nasal reconstruction, 16% orbit/skull base reconstruction, 13% palatal reconstruction, 6% maxillary reconstruction, and 6% mandible reconstruction. Eighty-seven percent of patients underwent free-tissue transfer from an anterolateral thigh donor site. Ninety-seven percent of patients had successful free-tissue transfer with a viable flap during the follow-up period; only one patient experienced flap failure attributed to vascular insufficiency. Average length of stay was 4.7 days, and the most common length of stay was 3 days. CONCLUSIONS: The angular vessels provide excellent arterial supply and venous drainage to serve as a viable option for microvascular anastomosis during free-tissue transfer for head and neck reconstructive surgery. They are an ideal vascular source for central face and skull base reconstruction. LEVEL OF EVIDENCE: NA Laryngoscope, 130:2589-2592, 2020.

Fascia Lata Free Flap Reconstruction of Limited Hard Palate Defects.

Objective  The anterior-lateral thigh (ALT) free flap is a flexible reconstructive option with fascia lata, fasciocutaneous, and musculocutaneous options. The objective of this study is to evaluate ALT fascia lata free flap reconstruction of isolated hard palate defects. Methods  Retrospective chart review of all palate reconstructions with ALT free flap from 2008-2017 by a single surgeon, at a tertiary academic institution. Patients with defects limited to the hard palate were selected for review. Results Forty-eight patients were identified, of which 14 patients had limited palatal defects repaired with fascia lata free flaps and were selected for review. The average hospital stay for all patients was 2.8 days (range 1-4 days). Eighty-five percent of patients were started on an oral diet from post-operative day (POD) one. Ten of 14 were extubated at the end of the case, with four being extubated on POD one. One patient suffered donor site morbidity, which required intervention (one seroma requiring drainage). Two patients underwent minor palatal revisions with local tissue rearrangement for recurrent fistula. No patients suffered long-term velopharyngeal inadequacy (VPI) or dysphagia, and all reported normal nasal respiration. Conclusion The ALT fascia lata free flap is a versatile reconstructive option for hard palate defects, with minimal morbidity, short hospital stays, and excellent long-term results.

Prevalence of atopic disease in patients with eosinophilic esophagitis.

BACKGROUND: The objective of this work was to evaluate prevalence of eosinophilic esophagitis (EoE) in the United States, and analyze prevalence of atopic disease in patients with EoE. The study design was a retrospective administrative database analysis in U.S.-based outpatient settings. METHODS: A retrospective claims analysis in the inpatient and outpatient setting (using MarketScan) was conducted to analyze prevalence of atopic disease diagnoses in patients with EoE in 2012, and timing of those diagnoses vs EoE. RESULTS: From published evidence, prevalence of EoE was estimated at 1 to 5 patients per 10,000 and prevalence of asthma, allergic rhinitis (AR), and atopic dermatitis (AD) concurrent to EoE ranged from 20% to 50%, 50% to 75%, and 2% to 19% cases, respectively. From 2009 and 2013, the estimated prevalence of EoE in MarketScan increased from 2.7 to 5.6 per 10,000 enrollees age 34.5 ± 18.43 years (mean ± standard deviation). Age followed a bimodal distribution with peaks at 12 and 41 years. Women accounted for 35.6% cases. Prevalence of asthma, AR, AD, and food allergies up to 12 months post-EoE diagnosis reached 44.7%, 27.1%, 25.2%, and 16.9%, respectively, with 63.5% of all patients suffering from at least 1 of these 4 diseases and 3.0% suffering from all 4. CONCLUSION: The diagnosis of EoE is associated with the diagnoses of asthma, AR, AD, and food allergies. The high prevalence of these conditions in EoE patients further strengthens the hypothesis of a common pathogenesis.

Cricothyroid Muscle Botulinum Toxin Injection to Improve Airway for Bilateral Recurrent Laryngeal Nerve Paralysis, A Case Series.

Bilateral vocal fold paralysis most commonly results from iatrogenic trauma to the recurrent laryngeal nerve during surgical procedures in the anterior neck. Patients may require tracheostomy because of acute or gradual onset of dyspnea and airway compromise. The intralaryngeal injection of Botox has been considered as a possible therapy for these airway symptoms of bilateral vocal fold paralysis. Chronic unopposed activity of intact cricothyroid muscles could potentially result in gradual medialization of the vocal folds in patients with bilateral recurrent laryngeal nerve paralysis. This case series describes three patients who successfully underwent injections of botulinum toxin into the bilateral cricothyroid muscles to offer sustained relief of dyspnea resulting from bilateral vocal fold paralysis.