bluuebunny/crossref_metadata_2025 huggingface dataset:
AlloDerm with Split‐Thickness Skin Graft for Coverage of the Forearm Free Flap Donor Site
Authors: Wester Jacob L. , Pittman Amy , Litton Tyler , Gross Neil D. , Wax Mark K.
Published: August 2013

Objectives:

A major cause of forearm donor site morbidity after free flap harvest is lack of split‐thickness skin graft (STSG) take. AlloDerm alone has been shown to allow healing of the donor site, albeit prolonged healing. We sought to evaluate the use of STSG with AlloDerm as compared to STSG alone.

Methods:

Patientswho underwent fasciocutaneous free flap harvest and had composite grafting at the donor site using AlloDerm+STSG were identified at an academic medical center from 2011‐2012. 166 patients with a STSG alone acted as a control group. Morbidity data and aesthetic results were collected.

Results:

Eighty patients (50M, 30F) received AlloDerm+STSG. Overall donor site morbidity in the AlloDerm+STSG group was 27.5%, compared to 23.5% in the STSG only group, P = 0.53. Complete STSG loss (5% vs. 3%, P = 0.48), tendon exposure (5% vs. 5.4%, P = 1.0), functional impairment (2.5% vs. 1.8%, P = 0.66), infection (8.8% vs. 9.6%, P = 1.0), hematoma/seroma (5% vs. 3.6%, P = 0.73), and paresthesia (1.3% vs. 3.6%, P = 0.43) were not significant. No patients in the AlloDerm+STSG group required a second STSG after complete loss compared to 3 of 5 patients in the STSG only group, P = 0.17. Aesthetic results were superior in the AlloDerm+STSG group as rated by the surgeon (3.5 vs. 2.6, P = 0.03) and patients (3.7 vs. 2.9, P = 0.05) on a scale of 1‐5.

Conclusions:

Our results suggest that AlloDerm with STSG can provide thicker coverage of the forearm defect after fasciocutaneous free flap harvest and superior cosmetic results. There is no significant difference in other associated morbidity.
Comparison of Radial Forearm Free‐Flap Donor Site Dressing Modalities with Temporary Forearm Immobilization
Authors: Rangarajan Sanjeet V. , Melon David E. , Old Matthew O. , Teknos Theodoros N. , Agrawal Amit , Ozer Enver , Chio Eugene G.
Published: August 2013

Objectives:

1) Compare the success and complication rates of two dressing techniques for radial forearm free‐flap donor sites in patients undergoing short term limb immobilization. 2) Recognize the observed benefit of short‐term donor limb immobilization in this population.

Methods:

This was a prospective, randomized, controlled study of patients undergoing radial forearm free flap reconstruction of head and neck oncologic post‐ablative defects from 2010 to 2013 at a single tertiary care center. Participants’ donor sites were covered with split‐thickness skin grafts and were randomized into two arms: static pressure dressing and negative pressure dressing groups. All participants underwent immobilization of the donor arm using a custom‐fit removable volar splint for 30 days. Data were collected at 2 postoperative time points.

Results:

Fifty‐four patients underwent radial forearm and were enrolled in the study. Twenty‐seven patients (50%) received negative pressure dressings, and 27 patients (50%) received static pressure dressings. 100% of enrolled patients were immobilized with custom volar splints. Follow‐up data were available for 40 (74%) patients at the time of this writing. The overall complication rate was 20% (n = 8). Within the group of patients with medical co‐morbidities, 25% (n = 2) demonstrated donor site morbidity.

Conclusions:

This study reaffirms both techniques as viable methods for covering radial forearm donor sites; however, there are differences between them in cost and convenience for the patient. Additionally, this follow‐up study demonstrates that 30‐day immobilization may improve donor site outcome regardless of dressing strategy, as evidenced by an overall decrease in donor site morbidity compared to previously published results on non‐immobilized patients.
Completion Node Dissection Based on Risk of Nonsentinel Metastasis in Head and Neck Cutaneous Melanoma
Authors: Fritsch Valerie A. , Cunningham Joan , Lentsch Eric J.
Published: August 2013

Objectives:

Data describing the clinical implications of withholding completion lymph node dissection (CLND) from low‐risk patients with sentinel lymph node (SLN)‐positive melanoma are virtually non‐existent, possibly due to the intuitiveness of the notion that only patients with positive non‐SLNs will benefit from CLND. Furthermore, none of the published risk stratification models have exclusively analyzed patients with cutaneous melanoma of the head and neck (CMHN). Our objectives were: 1) Identify features associated with a low risk of non‐SLN positivity in CMHN, and 2) Analyze the effect of CLND on disease‐specific survival (DSS) among patient subgroups stratified by risk of non‐SLN metastasis.

Methods:

Using the Surveillance Epidemiology and End Results database, we identified 350 patients with SLN‐positive CMHN. Of these, 210 underwent CLND and were classified based on non‐SLN status. Clinicopathologic characteristics were compared between non‐SLN positive and non‐SLN negative subgroups. DSS was compared between SLN biopsy (SLNB)‐only and SLNB+CLND groups by Kaplan‐Meier analyses and the log‐rank test.

Results:

Minimal tumor thickness and non‐ulceration were associated with the lowest risk of non‐SLN positivity (P < 0.025). Only 1 of 19 melanomas ≤1mm had non‐SLN metastasis; however, patients <age 60 in this subgroup who underwent SLNB‐only had a 5‐year DSS rate of <25% vs. >90% among similar patients who underwent CLND (P < 0.0025). DSS was similar in the SLNB‐only and SLNB+CLND groups when melanomas were ulcerated or >2mm thick (P > 0.25).

Conclusions:

Selecting patients for CLND based on risk of NSLN metastasis may be an inappropriate strategy. In CMHN, CLND should not be withheld based on low risk features.
Cricothyrotomy Simulator with Computational Skill Assessment for Procedural Skill Training in the Developing World
Authors: White Lee , Bly Randall A. , D'Auria Daniella , Aghdasi Nava , Bartell Paul , Cheng Lei L. , Hannaford Blake
Published: August 2013

Objectives:

Cricothyrotomy is a life‐saving procedure performed when an airway cannot be established through less invasive techniques. The goals of this study were to 1) design and build a low‐cost simulator that teaches essential anatomy, and 2) provide a method of data collection for performance evaluation and guided instruction.

Methods:

The design of the simulator was optimized for materials that are low‐cost and widely available and for accurate anatomical landmarks. It was designed to electronically record instrument contact with critical anatomical locations throughout the procedure. Three simulators were constructed, and data were collected during 20 procedures performed by participants of varying surgical experience level. Surveys were completed by all participants to assess the perceived quality of the simulator. Three experts graded the recorded procedures by completing an Objective Structured Assessment of Technical Skills (OSATS) survey.

Results:

A simulator was designed and built. Procedural data of 20 subjects were collected. The survey data showed the majority of participants answered “moderate” or “very” on questions related to 1) anatomical accuracy (85%), 2) realism (50%), 3) improved understanding of procedure (65%), and 4) useful for practice (85%). The OSATS data correlated with task time.

Conclusions:

A cricothyrotomy simulator for use in a low‐resource environment was designed and produced. It collects data that can be used for performance evaluation and instruction. These were analyzed against OSATS data. A study of 20 subjects, 12 of whom were experts, demonstrated that it was realistic, anatomically accurate, and useful for practice and improving procedure knowledge.
Surgeon Dependent Variation in Perioperative Costs for Tonsillectomy and Adenoidectomy in Children
Authors: Meier Jeremy D. , Andrews Seth , Park Albert H. , Srivastava Rajendu
Published: August 2013

Objectives:

1) Identify the major expenses for routine tonsillectomy and adenoidectomy (T&A) at a children's hospital. 2) Identify sources for the greatest inter‐surgeon cost variation.

Methods:

A standardized activity based hospital accounting system was used to determine total facility costs per encounter (not including physician costs) for T&A cases at a tertiary children's hospital from 2008‐2011. Facility costs were subdivided into categories including operating room (OR), same day services (SDS), room and care (R&C), OR supplies, recovery room, pharmacy, anesthesia, and imaging. Average costs/case were determined for each surgeon who performed >50 cases. Stepwise regression analysis was performed to determine cost categories that provided the most significant inter‐surgeon variation.

Results:

The study cohort included 3,454 T&A's by 14 different surgeons (we excluded 8 surgeons who combined performed only 102 T&A's). The mean cost per T&A encounter was $1,620. The largest cost categories included OR ($479/case, 28% of total costs), SDS ($332, 19% of total costs), and R&C ($260, 16% of total costs). The average cost by surgeon per case varied from $1,163 to $2,059/case (P<0.05). The most significant categories with inter‐surgeon mean costs/case variation included OR ($358‐$643/case), R&C ($26‐$508/case), and OR supplies ($25‐$491/case).

Conclusions:

A majority of T&A expenses are accounted by OR, SDS, and R&C costs. Significant inter‐surgeon differences in costs for T&A were identified. Differences in OR, R&C, and OR supplies accounted for the greatest inter‐surgeon variation. Studies identifying the reasons for inter‐surgeon cost variations for T&A and their association to patient outcomes are warranted.
An Evidence‐Based Approach to Oncologic Scalp Reconstruction
Authors: Janus Jeffrey R. , Mirzoyev Sultan , Tombers Nicole , Moore Eric J.
Published: August 2013

Objectives:

Describe an algorithm for oncologic scalp reconstruction based on a single institution's surgical experience and analysis of outcomes.

Methods:

This is a single institution, retrospective review of patients requiring oncologic scalp ablation with subsequent reconstruction from 1992‐2012. Demographics include patient age, sex, immunosuppressive state, and type of malignancy. Measured endpoints include defect size/location/depth, the reconstruction method used, concomitant surgery (ie lymphadenectomy), adjunctive chemotherapy or radiotherapy, complication rate, and length of follow‐up.

Results:

A total of 140 patients are reviewed with an average age of 70.4 years; 76% being male. Approximately 51% of all patients required postoperative radiation, chemotherapy, or both. Defect widths range from 0.7cm to 24cm, with an average of 7.5cm. Depths range from full‐thickness skin to full‐thickness skull, the majority being up to pericranium (30%). Reconstruction varies from simple granulation to free tissue transfer. The overall complication rate for both primary and reoperative reconstruction is approximately 11%. Specific complications, spanning from hematoma to total flap failure, are statistically enumerated. Complication rates more than doubled when patients received radiation, chemotherapy, or both (14.1% versus 6.5%). Average length of follow‐up is 2.4 years.

Conclusions:

The armamentarium of scalp closure techniques is vast and can range from conservative therapy to free tissue transfer. Exposure to chemotherapy and radiation increases complication probability, propounding the need for healthy tissue coverage and tension free closure. Complication rates do not change signigicantly for primary versus revision surgery. Defect size plays only a minor role in complication rate, provided the appropriate method of reconstruction.
Facial Pain Secondary to Occult Head and Neck Tumors
Authors: Van Abel Kathryn M. , Starkman Sidney J. , Price Daniel L.
Published: August 2013

Objectives:

1) Review the natural history of occult head and neck malignancy presenting with facial pain. 2) Evaluate the risk factors, diagnostic workup, and management of facial pain in the setting of occult malignancy.

Methods:

A retrospective chart review was conducted of all patients who presented to a tertiary care center between 1980 and 2010 with the chief complaint of facial pain and a delayed diagnosis of a head and neck cancer. Clinical, radiographic, and pathologic data were reviewed.

Results:

Thirty‐eight patients met inclusion criteria. Initial diagnoses consisted of trigeminal neuralgia, herpetic neuralgia, temporo‐mandibular joint disorder, and atypical facial pain. Average delay to diagnosis was 18.4 months (1.9 ‐ 76.8 mo). Twenty‐two patients had negative magnetic resonance imaging or computed tomography imaging between onset of symptoms and tumor diagnosis, with an average of 1.05 non‐diagnostic scans per patient. Tumor etiologies included squamous cell carcinoma (39.5%), adenocarcinoma (10.5%), adenoid cystic carcinoma (7.9%), and acinic cell carcinoma (7.9%). Primary intervention consisted of surgical tumor removal (66%); chemotherapy, radiation therapy, or both (26%); gamma knife (5%); and conservative therapy (3%). Thirty‐two out of the 33 patients (97.0%) who underwent therapy reported partial or complete resolution of their facial pain.

Conclusions:

Occult tumors of the head and neck may present as symptomatic facial pain in the absence of other clinical or radiographic findings and should be considered in the workup of facial pain. Therapeutic and palliative interventions often result in marked improvement of pain symptoms.
Feasibility Animal Study of Novel ICG Sentinel Node Detection Technique in Head and Neck Region
Authors: Araki Koji , Mizokami Daisuke , Tomifuji Masayuki , Yamashita Taku , Kosuda Shigeru , Shiotani Akihiro
Published: August 2013

Objectives:

Sentinel node biopsy (SNB) allows head and neck surgeons to avoid unnecessary neck dissection. The popular SNB method using radioisotope (RI) has some drawbacks, such as the strict legal regulations for RI use in Japan. Recently, the SNB technique using real time indocyanine green (ICG) fluorescence image has become prevalent in breast cancer testing. Some reports demonstrated improved detection sensitivity with this method. However, the major problem of ICG method is its quick migration through the lymphatic system, which results in a limited diagnostic time window and detection of downstream subsequent nodes. To overcome this problem, we modified the ICG detection method by making ICG‐colloid and demonstrated the feasibility of this technique in a mouse model.

Methods:

ICG‐colloid was formed by mixing ICG and phytate colloids, which are commercially available as a kit for 99mTc‐radiocolloid. Twenty microliters of ICG or ICG‐colloid was injected into the tongue of a nude mouse, and the fluorescent images were observed with time until 48Hrs after injection. The fluorescence intensity in detected SN was analyzed.

Results:

In ICG injected animals, SNs were detected soon after injection, and second echelon lymph nodes were detected after 30‐60min. In ICG‐colloid injected animals, SNs were also detected after 30‐60 min, and no second echelon lymph node was detected. Peak fluorescence intensity was 6‐12Hr in both animal groups. No SN was detected after 24Hr in ICG animals, whereas SNs were still detectable in ICG‐colloid animals.

Conclusions:

SNB using ICG‐colloid technique may have advantages of prolonged diagnostic time window and prevention of downstream subsequent node detection.
Decreased Healthcare Use after Implementation of Postoperative Serum Calcium Algorithm following Total and Completion Thyroidectomy
Authors: Galloway Tabitha L. , Chang C. W. David
Published: August 2013

Objectives:

Evaluate healthcare use after the implementation of an algorithm to manage postoperative serum calcium in patients undergoing total or completion thyroidectomy.

Methods:

On June 1, 2010, standardized postoperative calcium monitoring algorithm was implemented at the University of Missouri for all patients undergoing total or completion thyroidectomies. Patients were selected for analysis if the following CPT codes were billed for their hospital stay: 60240, 60252, 60260, and 60271. Patient data were collected in a retrospective fashion for 18 months prior to and 18 months after the date of implementation. The three primary outcomes assessed were post‐procedure length of stay, non‐planned readmissions or emergency visits within 30 days, and readmissions specifically for hypocalcemia.

Results:

A total of 80 patients in the pre‐algorithm group (December 1, 2008 ‐ May 31, 2010) were compared with 102 patients in the post‐algorithm group (June 1, 2010 ‐ December 31, 2011). The average length of stay went from 2.938 days to 1.5 days (p<0.0001). Total readmissions for all non‐planned procedures and all emergency department visits within 30 days post‐procedurally went from 11.25% to 6.86% of patients (p=0.2995). Readmissions for hypocalcemia went from 5% to 1% of patients (p=0.4071).

Conclusions:

Using a calcium monitoring algorithm postoperatively following total and completion thyroidectomy demonstrated a statistically significant decrease in the length of stay after procedure and a trend toward overall decrease in emergency department visits, all non‐planned readmissions, and readmissions for symptomatic hypocalcemia.
Microanatomy of Peripheral Facial Nerve Revisited
Authors: Vong Angela , Pereira Lucio M. , Lin Ho‐Sheng , Shkoukani Mahdi A.
Published: August 2013

Objectives:

Describe extraparotid course of the facial nerve via microsurgical dissection. Analyze branch distribution and endpoint muscle innervation.

Methods:

Ten cadaveric hemifaces dissected under surgical microscopes. Facial nerve was identified from stylomastoid foramen to muscle. MAS measured number, length, and width at border of parotid, at level of the pes anserinus, and muscle border (frontalis, orbicularis oculi, zygomaticus major, and depressor anguli muscles). Analysis of variance and Student T test were performed.

Results:

At parotid border, zygomatic and buccal branches branched more often than temporal or marginal mandibular branches (2.7 +1.0, 2.9 + 0.7 vs 1.8 +1.2, 2.1 +0.9 mm respectively; p=0.06), branch diameter (1.1+0.3, 1.0+0.5 vs 0.9+0.3, 0.9+0.3 mm respectively p=0.238). At muscle border, similar results were found for zygomatic and buccal branches compared to temporal or marginal mandibular branches (2.3+1.3, 3.1+1.0 vs 1.3+0.5,1.3+0.5mm; P = 0.001), diameter (0.9+0.4, 1.0+0.4 vs 0.8+0.3, 0.7+0.3mm; p=0.737). Zygomaticotemporal pes showed more branching and greater diameter compared to cervicofacial, (7.6+2.2 vs 2.6+0.5mm; P =.0001) and (2.5+0.9 vs 1.9+0.4mm; p=0.10) respectively. Branch length from pes to muscle was consistent, the longest being temporal, zygomatic, marginal mandibular, and buccal (9.6 + 1.2, 8.3 +1.4, 8.0 +1.3, 7.4 +0.9 cm respectively; p=0.007). Anastomosis between temporal/zygomatic and zygomatic/buccal branches were found more consistently across all specimens than buccal/marginal mandibular anastomosis.

Conclusions:

Consistently fewer branches of the marginal mandibular branch at parotid border and at muscle border, and fewer anastomoses, may be the reasons for increased morbidity from surgical injury. Histologic analysis will further elucidate the number of innervations to the muscles of facial function.
Mammary Analog Secretory Carcinoma of the Parotid Gland
Authors: Kozin Elliot D. , Remenschneider Aaron K. , Naunheim Matthew , Carter Margaret , Meier Josh , Vanderlaan Paul , Frankenthaler Robert A.
Published: August 2013

Objectives:

1) Describe newly classified salivary gland tumor, mammary analog secretory carcinoma (MASC) of the salivary gland. 2) Present a patient with a right parotid mass with pathology consistent with MASC and discuss our institution's diagnostic and therapeutic approach.

Methods:

We identified a rare case of MASC of the parotid gland. We conducted a PubMed literature review on MASC with reports in the pathology and otolaryngology literature.

Results:

A 58‐year‐old female presented to our clinic after noticing swelling in her right cheek. An MRI of the neck found a well‐encapsulated benign appearing parotid mass measuring 3.2 × 2.2 × 3.1 cm. A fine‐needle aspiration was performed and was concerning for high‐grade carcinoma, with a differential diagnosis including acinic cell carcinoma and mucoepidermoid carcinoma. She underwent a parotidectomy and modified radical neck dissection. Histologic evaluation was consistent with MASC. Subsequent FISH testing demonstrated the characteristic t(12;15) ETV6‐NTRK3 translocation, confirming the diagnosis of MASC.

Conclusions:

First described in 2010, MASC of the salivary gland is a newly described pathologic diagnosis. It has few reports in the literature. Our case raises the question as to when to consider MASC in the differential diagnosis based on imaging, FNA, and final pathology, including de‐differentiation from acinic cell carcinoma. Further study is needed to best delineate appropriate diagnostic and therapeutic approach for the otolaryngologist for this emerging pathologic entity.
Metatypical Basal Cell Carcinoma: Histopathological Features in Aggressive Tumors
Authors: Andrade Natalia M. M. , Calvas Oscar I. J. , Cernea Claudio R. , Brandao Lenine G. , Santos Andre B.
Published: August 2013

Objectives:

The incidence and histological characteristics of metatypical basal cell carcinoma (MBCC) are divergent in the literature, especially in large dimension lesions. Retrospective studies suggest that this neoplasm represents from 1.2% to 2.7% of all BCCs, with a particular behavior that is prone to metastasis. The purpose of this study is to compare the demographics and histopathological features of cervicofacial MBCC with other BCCs treated by head and neck surgery.

Methods:

Data from 354 basal cell carcinomas were reviewed (1994‐2012). Sex, age, histological subtype, localization, size, perineural and angiolymphatic invasions were analyzed, comparing MBCC with other basal cell carcinoma subtypes.

Results:

MBCC was found in 35 cases (10.77%), either as principal or associated subtype. Average age of MBCC was 64.8 ± 12.8, and 65.1 ± 14.2 years in the other group (P = 0.89). There was no statistical difference in the items sex and angiolymphathic invasion. Zone H tumors were in 75.6% of MBCC and 89.7% of the negative group (P = 0.02). Median size was 4.18 cm in MBCC and 2.67 cm in the negative group (P < 0.01). Perineural invasion was observed in 47.2% in MBCC, while the frequency in the general BCC group was 20.8% (P < 0.01).

Conclusions:

MBCC lesions with large dimensions, described as more aggressive behavior, present with bigger size, higher frequency of perineural invasion, and lower location in Zone H.
Orbital Exenteration for Advanced Peri‐orbital Skin Cancer: Prognostic Factors and Survival
Authors: Gerring Robert C. , Ott Cody T. , Wester Sara D. , Sargi Zoukaa B.
Published: August 2013

Objectives:

Orbital exenteration for advanced periorbital malignancies is a relatively rare but highly morbid procedure, often done for cancers arising from periorbital skin. The purpose of this research is to investigate and describe cases of cutaneous malignancy of the periorbital skin for which orbital exenteration was done.

Methods:

This is a retrospective single institution case series at a tertiary care university hospital, including all cases of orbital exenteration for advanced periorbital malignancies performed between January 2002 and January 2012 at the University of Miami/Bascom Palmer Eye Institute/Jackson Memorial Hospital. Patient demographics, tumor characteristics, operative reports, histologic, radiologic and clinical follow‐up data were recorded. Outcome measures were overall survival and disease free survival, univariate analysis for multiple clinical factors including prior surgery, bony erosion on pre‐operative CT scan, intracranial involvement, and surgical margins.

Results:

There were 64 patients with a mean age of 70 years (41 male, 23 female) who underwent orbital exenteration for periorbital skin cancers. Of these, 24 patients had squamous cell carcinoma, 24 basal cell carcinoma, 11 sebaceous carcinoma, and 5 cases of malignant melanoma. The most common sites of origin were facial skin (17), medial canthus (14), inferior lid (14), and upper lid (11).

Conclusions:

Surgical outcome and survival were reviewed with relation to significant prognostic variables.
Perineural Invasion in Head and Neck Basal Cell Carcinomas: A Major Factor in Mutilating Tumors
Authors: Andrade Natália M. M. , de Oliveira Santos Andre Bandiera , Cernea Claudio R. , Brandao Lenine Garcia
Published: August 2013

Objectives:

Basal cell carcinoma is the most frequent neoplasia in Caucasians. Morbidity is mainly related to local invasion. Perineural invasion (PI) was recently included in TNM staging and is rare in this skin malignancy. Our goal was to characterize the cases of basal cell carcinoma with PI submitted to surgery by head and neck surgeons, in its clinical, epidemiological and histopathological features.

Methods:

From 1994 to 2012, 354 basal cell carcinomas were submitted to surgery under general anesthesia. Sex, age, hystological subtype, localization, size and PI were retrospectively analyzed. The cases with and without PI were compared.

Results:

PI was positive in 23.1% of the tumors. 58.5% were men, whereas 49.6% were men in the PI negative patients (P = 0.16). Mean age in the positive group was 65.4‚±13.2 years, while in the negative group mean age was 65.0‚±14.4 years (P = 0.8). Mean size of primary tumors in the positive group was 3.8‚±2.2cm and 2.5‚±1.8cm in the negative group (P < 0.01). Morpheaform subtype was predominant in 48.2% in the positive group and 26.4% in the negative group (P < 0,001). Nodular subtype was predominant in 33.7% in the positive and 53.2% in the negative group (P = 0.002).

Conclusions:

In this series of aggressive and mutilating tumors, with a 8‐fold increase of PI, basal cell carcinomas with PI had higher mean tumor size and more frequency of morpheaform as predominant subtype.
Pharyngolaryngoesophagectomy with Gastric Transposition Reconstruction: Comparison of Single Institution Outcomes from 1965 to Today
Authors: Lambert Aileen L. , Giddings Charles E. , Vaz Francis M. , O'Flynn Paul E.
Published: August 2013

Objectives:

1) Comparison of our current operative and functional outcomes with those published previously from our institution for pharyngolaryngoesophagectomy (PLO) with gastric transposition reconstruction. 2) Analysis of the role of this reconstructive option in contemporary head and neck surgery.

Methods:

Retrospective review of patients who underwent PLO with gastric transposition and feeding jejunostomy from 2010 to 2013. Comparison was made with previously published data from our institution dating back to 1965 for the same procedure, and with more recent literature reports.

Results:

Nine patients were identified: 3 had primary T4 squamous cell carcinoma, 3 had local recurrence from radical radiotherapy, and 3 had previously treated metastatic tumor. There was no in‐hospital mortality. Early complications occurred in 44% including salivary fistula (n = 1). Average length of stay was 36.4 days. 1 patient had local recurrence at 6 months. Disease free survival was 89% at last follow up (range 1‐28 months). Method of communication at 12 months included esophageal speech, electrolarynx and voice prosthesis. Time to jejunostomy removal was 2‐16 months.

Conclusions:

The in‐hospital mortality rate of zero in this series compares with rates of 7‐12% previously in our institution. However our contemporary morbidity rates are higher than the 8% and 29% previously reported, which may reflect our 67% rate of salvage surgery and exclusively T4 or metastatic caseload. Our complication rates are comparable with those published in the last decade for both gastric transposition and free tissue transfer reconstruction and highlights that gastric transposition is an effective reconstruction option in these advanced tumors.
Predictive Factors for Gastrostomy Tube Placement in Patients Undergoing Surgery for Upper Aerodigestive Tract Cancers
Authors: Biddy Ashley C. , Moustafa Farah , Waltonen Joshua D.
Published: August 2013

Objectives:

1) Determine which factors of the pre‐operative assessment, cancer location, and planned surgical resection are predictive of postoperative need for gastrostomy placement in patients undergoing resection of upper aerodigestive tract cancers. 2) Determine if a pre‐operative assessment algorithm can accurately predict need for gastrostomy placement.

Methods:

Retrospective chart review of all adult patients diagnosed with head and neck cancers that subsequently underwent cancer resection at Wake Forest Baptist Medical Center from 2007‐2012. Patient charts were screened for placement of postoperative gastrostomy tube, patient demographics (ie, gender, age), tumor characteristics including size, location, bilaterality, and surgical treatment type. Univariate analysis was run on all patient variables and compared against gastrostomy placement.

Results:

Gastrostomy tube placement was found to be strongly associated with the patient characteristics of pre‐operative weight loss (<.001), history of radiation (.001) and prior dysphagia (.001). Characteristics of the disease including clinical nodal disease (.04) and tongue base tumor location (.05) were also associated. Tracheostomy placement (<.001), supracricoid laryngectomy (.01), floor of mouth resection (.02), total glossectomy (.025) and free flap reconstruction (<.001) were the procedures most significantly associated with gastrostomy tube placement. Post‐operative failed swallowing evaluation was most strongly associated with G tube placement (2.8 × 10‐22).

Conclusions:

Preliminary data suggest that certain patient characteristics, tumor features, and types of surgical procedures can predict post‐operative gastrostomy tube placement. A risk stratification algorithm can likely be developed given the strength of multiple positive and negative associations between patient and tumor variables.
Predictors of Single Adenoma versus Four Gland Disease in Normohormonal Patients with Parathyroid‐Induced Hypercalcemia
Authors: Hunt Jason , Patel Rusha J.
Published: August 2013

Objectives:

1) Examine differences in spatial measurements of parathyroid glands in normohormonal patients with parathyroid‐related hypercalcemia. 2) Determine a predictive value to stratify which patients will require single‐ or four‐gland surgery.

Methods:

A retrospective chart review was conducted of parathyroidectomy patients from 2008‐2011 at our tertiary care institution. Patients with parathyroid hormone levels < 65 pg/ml were included and divided into single adenoma (SA) or four gland surgery (FGS). Exclusion criteria included diagnoses of secondary or tertiary hyperparathyroidism. Preoperative ultrasound measurement (cm), intraoperative gland weight (g), and intraoperative parathyroid hormone (iPTH) were recorded and used to calculate gland volume (cm3) and density (g/cm3). Significant differences between groups were examined with the student t‐test (P < 0.05).

Results:

24 patients were included, 18 (75%) with SA and 6 (25%) with FGS. There was no significant difference in age or gender between included patients and those with elevated PTH levels. SA patients were significantly more likely to have larger maximum ultrasound measurements, larger gland volume, weight and density, and greater iPTH values than patients with FGS. Of the spatial measurements collected, a cut‐off density of < 0.3 g/cm3 was 100% specific and sensitive for predicting patients who required FGE surgery. Positive predictive value was 100%.

Conclusions:

Normohormonal patients with hypercalcemia have a higher incidence of four gland disease than those with elevated PTH levels. Regardless, single adenomas can be found in these patients. Pre‐operative ultrasound and intraoperative calculation of gland density are easily done and may be an alternative to iPTH for surgical decision making.
Risk Factors in Development of Incidental Papillary Thyroid Microcarcinoma: A Review of 2100 Patients
Authors: Subramaniam Somasundaram , Tan Hiang K. , Lim K. W. K. , Siow J. B.
Published: August 2013

Objectives:

Risk factor analysis of incidental papillary thyroid microcarcinoma in a cohort of 2100 patients undergoing thyroid surgery.

Methods:

Retrospective review of 2103 patients over a 10 year period (2000‐2010) treated at Singapore General Hospital and Singapore National Cancer Centre. Outcome measurement Risk factors for developing incidental papillary thyroid microcarcinoma including sex (male vs female), age, size of thyroid nodule, fine needle aspiration cytology (FNAC) and ultrasound features at diagnosis.

Results:

Of the cohort of 2103 patients who underwent thyroid surgery for benign causes, 168 patients had incidental papillary microcarcinoma identified post‐operatively. There was a preponderance of females (2:1), older age (>45), larger nodule size (>4cm). Ultrasound features that were commonly associated with this diagnosis included hypoechogenicity and increased vascularity of nodules, although these were noted to be benign on FNAC.

Conclusions:

Presence of the abovementioned risk factors in patients undergoing thyroid surgery for benign diseases may be included in the decision making process for advocating surgery in these patients.
Perineural Invasion in Oral Cavity Squamous Cell Carcinoma Does Not Affect Survival
Authors: Schleiffarth Jack R. , Kowalski Christopher , Karnell Lucy , Pagedar Nitin A.
Published: August 2013

Objectives:

1) Determine if the presence of perineural invasion (PNI) affects survival in oral cavity cancer patients. 2) Determine what factors affect survival in oral cavity cancer patients.

Methods:

We performed a retrospective review of patients who underwent surgical resection with or without a neck dissection for treatment of primary oral squamous cell carcinoma from January 1, 2000, to December 31, 2009. Data were extracted from the institute's cancer registry and the electronic medical record. Univariate and multivariate analysis were used to test the significance of pathologic characteristics including: PNI, extra‐capsular extension, site, and positive surgical margin on survival.

Results:

443 patients were identified, and 374 patients fit selection criteria. Mean age at diagnosis was 60.9 years. 59.1% were male. PNI was present in 38.5% and positive surgical margin in 28.3%. Patients with PNI had poorer disease specific survival rate than those without (p=0.001) (5‐year survival, 64.4% vs 79.8%). Univariate analysis found that patients with PNI (P < 0.001), palate site (P = 0.013) (sub‐sites were compared to all other cases of oral cavity cancer), retromolar trigone site (P = 0.015), positive margins (P = 0.013), and extra‐capsular extension (P < 0.001) had significantly worse survival. Those patients who had tumors of the gums (P = 0.013) had significantly better survival. Multivariate analysis found that patients with tumors of the palate (P =0.12), extra‐capsular extension (P = 0.004), and positive surgical margins (p=0.004) had significantly worse survival. Those with tumor of the gums (P = 0.006) had significantly better survival.

Conclusion:

The presence of perineural invasion in oral cavity squamous cell carcinoma does not independently affect survival.
The Role of Intraoperative Facial Nerve Monitoring during Parotidectomy for Benign Parotid Gland Tumors
Authors: Lin Jiahui , Kuhel William I. , Voigt Erich P. , Cohen Marc A. , Kutler David I.
Published: August 2013

Objectives:

1) Compare outcomes of parotidectomy with and without electrophysiologist‐assisted intraoperative nerve monitoring (IOM) for the treatment of benign parotid gland tumors. 2) Recognize potential benefits of IOM in parotidectomy.

Methods:

Retrospective case control of 151 consecutive patients undergoing parotidectomy for treatment of benign tumors between March 2006 and December 2011 at Weill Cornell Medical College. Interventions included parotidectomy and IOM. Outcome measures included complications from intervention(s).

Results:

Sixty‐four percent of patients were female, and the median age at surgery was 57 years (range 17 ‐ 86 years). The majority of patients (70%) had pleomorphic adenomas. One surgeon performed all 81 parotidectomies with IOM (54%), while another surgeon performed the remainder without IOM (46%). IOM use depended on the attending surgeon and was not due to any other factor. Superficial parotidectomies comprised 81% and 70% of surgeries performed with and without IOM, respectively. Temporary facial nerve dysfunction occurred in 10.6% of patients. No statistically significant difference was seen in temporary facial nerve paralysis rates post‐operatively between groups with IOM (9.9%) and those without (11.4%) (P = 0.76). In cases with IOM, electrical mapping and presence of transient nerve irritation did not influence the rate of complications (P = 0.19).

Conclusions:

Use of IOM does not appear to impact the rate of facial paralysis post‐parotidectomy for benign parotid gland tumors. However, IOM may be beneficial in aiding the surgeon in difficult cases, to preserve smaller branches, or when the tumor lies particularly close to the facial nerve.
Sentinel Lymph Node Biopsy in Cutaneous Squamous Cell Carcinoma of the Head and Neck
Authors: Lipin Rosa , Moore Brian A.
Published: August 2013

Objectives:

1) Recognize the potential indications for sentinel lymph node biopsy (SLNB) in the treatment of aggressive cutaneous squamous cell carcinoma of the head and neck (CSCCHN). 2) Understand how to incorporate SLNB into the multidisciplinary management of high‐risk CSCCHN.

Methods:

A retrospective review was performed on patients with CSCCHN at a tertiary care head and neck surgical oncology center who underwent SLNB between August 2011 and January 2013. This is a pilot, feasibility study with the main outcome measures of regional failure and surgical complications.

Results:

Five patients (4 males, 1 female) with a median age of 69 (range 55‐80) were identified with an average follow up of 34 weeks (range 2‐63). No patients were immunocompromised. 4 had poorly differentiated lesions, 2 of which were recurrent. Traditional wide local excision was performed in 4 patients, while Mohs surgery was performed on 1 patient. An average of 1.6 sentinel lymph nodes were identified on preoperative imaging (range 1‐3), with an average of 4.6 SLN excised (range 2‐8). One patient demonstrated a positive sentinel node (20%), facilitating additional treatment with radiation to the primary and regional lymphatics, as he refused completion lymphadenectomy. There were no postoperative complications, including facial nerve weakness. All patients are alive without evidence of disease at the last reported encounter.

Conclusions:

SLNB is feasible in patients with high‐risk CSCCHN, allowing prompt treatment of the regional lymphatics. Further multi‐center, multidisciplinary, prospective studies are required to clarify the indications and impact of SLNB in CSCCHN.
Swallowing Outcomes in Mandibular Osteoradionecrosis Treated with Free Tissue Transfer
Authors: Ranasinghe Viran , Oyer Samuel L. , Nguyen Shaun A. , Hornig Joshua D.
Published: August 2013

Objectives:

Evaluate swallowing outcomes after free tissue transfer (FTT) reconstruction for mandibular osteoradionecrosis (ORN), using aspiration and postoperative tube feed (TF) dependence as surrogates for swallowing ability.

Methods:

Study Design: Case series with chart review. All patients undergoing osteocutaneous FTT reconstruction in an academic tertiary‐care hospital for mandibular ORN from 2004‐2012 were reviewed. Preoperative patient characteristics, postoperative aspiration, and postoperative TF dependence were noted for each patient. Analysis of patient factors associated with aspiration or TF dependence was performed using Pearson correlation and Fisher's exact test (when appropriate).

Results:

Sixteen patients met inclusion criteria with an average age of 63.4 years (range 36‐81 years) and median follow up of 20 months (range 3‐72 months). TF dependence pre‐ and post‐operatively was total dependence in 25% vs. 31%, partial in 25% vs. 31%, and none in 50% vs. 38%, with strong correlation between pre and post‐operative TF dependence (r = 0.524, P = 0.04). Aspiration at postoperative follow‐up correlated with long‐term TF dependence (r=0.701, P < 0.01). Less aspiration was seen after scapular FTT compared to fibular, but this did not reach statistical significance (22% vs. 57% respectively, P = 0.62). Females had lower aspiration rates than males (r = 0.595, P = 0.02), and all females in this study were treated with scapular FTT. Tracheostomy decannulation was achieved in 94% (15/16) of patients.

Conclusions:

TF dependence following osteocutaneous FTT for ORN correlates with pre‐operative TF dependence and post‐operative aspiration. Aspiration is less likely in females and patients receiving scapular FTT.
Vitamin D Levels and Their Relationship to Thyroid Malignancy
Authors: Marino Matthew , Siegel Eric R. , Bodenner Don , Stack Brendan C.
Published: August 2013

Objectives:

Vitamin D deficiency is endemic in the USA. Vitamin D deficiency has been observed in many cohorts of cancer patients and thought to be a possible risk factor. We sought to compare the 25‐hydroxyvitamin D levels between a cohort of patients undergoing completion and total thyroidectomy for benign and malignant thyroid diseases.

Methods:

A retrospective institutional review board (IRB) approved study with chart review was done at a tertiary referral academic medical center. Data were retrospectively collected on consecutive patients who underwent completion and total thyroidectomy at the University of Arkansas for Medical Sciences between October 2005 and December 2012. Postoperative 25‐hydroxyvitamin D levels were collected universally and reported when available. Statistical analysis was performed to determine if vitamin D levels varied based on pathology, categorized as either benign or malignant.

Results:

A total of 220 total and completion thyroidectomies were performed during the study period. Total thyroidectomy (n = 172) was more common than completion (n = 48). Of these, 166 had vitamin D levels available for analysis: 38 with malignant disease and 128 with benign disease. Average vitamin D levels were 29.8 µg/dl for those with malignant disease versus 28.3 µg/dl for those with benign disease. There was no statistically significant difference in vitamin D levels between those with benign versus malignant pathology in this cohort of patients (P = 0.81).

Conclusions:

There is no correlation between perioperative Vitamin D status and pathological findings in patients undergoing completion and total thyroidectomy.
Anticholinergic Use Is a Major Risk Factor for Chronic Laryngitis
Authors: Haft Sunny , Mirza Natasha , Thompson Nikki
Published: August 2013

Objectives:

Dysphonia in the setting of chronic laryngitis is a common complaint within an otolaryngology practice. Often, the exact causes are poorly understood. We hypothesize that much of the laryngitis is a form of sicca caused by anticholinergic medication use and aimed to determine their association.

Methods:

A case‐control study evaluating 185 patients presenting to a laryngology practice was conducted over an 8 week period. Patients with a chief complaint of hoarseness secondary to chronic laryngitis rated a variety of symptoms (hoarseness, throat clearing, cough, post‐nasal drip, globus sensation) on a scale of 1‐5. Controls had few to no symptoms of laryngitis. After controlling for subjects with known causes of laryngitis, laryngitis scores were compared with subjects’ medication lists, age, and gender, and then evaluated using logistic regression via odds ratios (OR), with confidence intervals set at 95%.

Results:

Any patient taking at least one anticholinergic medication had a 3.86 increased odds (confidence interval [CI] 1.18‐12.60) of experiencing chronic laryngitis. If the patient was taking 2 or more anticholinergic medications, those odds rose to 7.94 (CI 1.88‐33.50). Polypharmacy was also an independent risk factor for chronic laryngitis (OR 4.46, CI 1.49‐13.07), while increasing age potentiated this risk.

Conclusions:

This is the first study to our knowledge that implicates medication use as a major risk factor, and possible cause, of chronic laryngitis. The striking association with anticholinergic use suggests that much laryngitis is due to sicca, or a drying effect. An awareness of this important association is invaluable when attributing cause to chronic laryngitis and considering treatment options.
Displacement of Residual Gore‐Tex Thyroplasty Implant Presenting as a True Vocal Fold Mass
Authors: Lalich Ian J. , Ekbom Dale C.
Published: August 2013

Objectives:

Describe the unique presentation and management of a patient with an ipsilateral true vocal fold mass following revision thyroplasty that was identified to have migration of residual Gore‐Tex thyroplasty implant into the superficial lamina propria of the anterior true vocal fold.

Methods:

A single case of a patient who underwent revision type I thyroplasty after an unsuccessful attempt elsewhere using a Gore‐Tex implant is reported. At the time of revision surgery, it was thought that all prior implant material was extricated, and the patient underwent revision type I thyroplasty using a carved silastic Netterville Implant with arytenoid adduction.

Results:

After initial improvement following the revision type I thyroplasty, the patient experienced deterioration of her voice. Indirect laryngeal examination revealed fullness on the superior surface of the right true vocal fold affecting mucosal wave and glottic closure. Microdirect laryngoscopy with endoscopic evaluation revealed migration of residual implant material into the superficial lamina propria. Using microflap technique, excision of the residual Gore‐Tex thyroplasty implant was successfully performed with a combination of carbon dioxide laser and cold‐dissection techniques.

Conclusions:

This case report describes the unique presentation of a displaced, non‐extruded residual Gore‐Tex thyroplasty implant, which presented as new onset dysphonia and mass involving the superior surface of the true vocal fold. This case demonstrates that displaced or migrated Gore‐Tex thyroplasty implant material can be successfully removed endoscopically using a modified microflap technique.
Severe Glotto‐Subglottic Stenosis in Children: Surgical Treatment with Extended Cricotracheal Reconstruction Technique
Authors: Hernandez Enrique G. O. , Grub Jaime P. , Neri Hiram A. , Morales Gustavo T. , Rodriguez Gerardo B.
Published: August 2013

Objectives:

Evaluate the efficacy of an extended variant to the CTR technique in patients diagnosed with severe glottic‐subglottic stenosis (GGS), which consists of expanding the glottis stenosis by placing a costal graft over the posterior cricoid plate and then performing a tyrotracheal anastomosis.

Methods:

Between 2004 to 2011 at the Hospital Infantil de Mexico “Federico Gomez,” patients with severe GSS based on laryngeal endoscopic evaluation, underwent an extended double‐stage CTR. They had a silastic stent for 3‐4 weeks and a temporal tracheotomy, which was removed when an appropriate size of the glottis and subglottis was confirmed. Results were analyzed, basing the success of the treatment on the patient's decannulation.

Results:

A total of 19 patients were identified, 8 male and 11 female, within an age range from 1 year 7 months to 13 years old, with a mean age of 6.2 years. All patients depended on tracheotomy and were sent to surgery. Fourteen had a favorable outcome and were decannulated (74%); the remaining 5 patients presented restenosis. From these 5, 1 patient has improved and is now waiting for decannulation. Only 1 patient presented anastomosis dehiscence and was successfully reoperated upon. There were no fatalities, and the 14 patients have good respiratory function.

Conclusions:

The combination of an extended technique to amplify the posterior glottis, where the scar is located, and the tirotracheal anastomosis, which eliminates the subglottic damage, is the only effective procedure to solve a severe glottis subglottic stenosis, as shown in our series.