Amit D. Bhrany

Crosslinking of an oesophagus acellular matrix tissue scaffold.

The oesophagus acellular matrix (EAM) tissue‐scaffold has the potential to serve as the foundation for a tissue‐engineered oesophagus for repair of ablative defects. Similar to all collagen‐based biomaterials, the EAM is subject to enzymatic degradation in vivo. The introduction of exogenous crosslinks to collagen molecules via glutaraldehyde (Glu) is the most accepted method of stabilizing collagen biomaterials, but fixation with Glu incurs adverse effects. Genipin (Gp), a naturally occurring crosslinking agent, has shown to be effective at improving the stability of collagen‐based biomaterials with less cytotoxicity and reduced in vivo inflammatory responses than Glu. The aim of this study was to show that crosslinking with Gp improves the stability of the EAM while maintaining minimal biological reactivity and preserving EAM regeneration potential in a rat model. EAMs were crosslinked with Gp and Glu. Uncrosslinked EAMs served as controls. Denaturation temperature measurement and burst‐pressure measurement after enzymatic degradation assays were used to determine the effectiveness of crosslinking on in vitro stability. Subcutaneous allograft implantation and oesophageal epithelial cell‐seeding studies assessed the crosslinking effects on biological reactivity and regeneration potential, respectively. Both Gp and Glu improved EAM stability. After 30 days of implantation, the EAM elicited a minimal inflammatory response and crosslinking did not increase inflammation. Gp‐crosslinked EAMs supported epithelial adhesion and proliferation while Glu‐crosslinked EAMs did not. Gp improves the stability of the EAM while maintaining minimal biological reactivity and preserving EAM epithelial proliferation capacity, yielding a tissue scaffold that may form the basis of a durable and biocompatible tissue‐engineered oesophagus. Copyright

Coronoidectomy for the Treatment of Trismus in Head and Neck Cancer Patients

Objectives: Trismus is a common adverse effect of tumor extension or treatment for those with head and neck malignancy. Physical therapy is the mainstay of treatment, but many patients still fail to maintain adequate mouth opening. Coronoidectomy is a treatment option for those with trismus, and the purpose of this study was to evaluate the effectiveness of coronoidectomy in treating trismus refractory to physical therapy.

Robotic surgery for primary head and neck squamous cell carcinoma of unknown site

IMPORTANCE Identification of the primary site in head and neck squamous cell carcinoma (HNSCC) is crucial because it improves the patients prognosis and minimizes morbidity from treatment. OBJECTIVES To determine the efficacy of transoral robotic surgery (TORS) in identifying unknown primary sites of head and neck squamous cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS Retrospective, multi-institutional case series from January 1, 2010, to February 28, 2013, in which data were pooled from the following 6 institutions: University of Washington Medical Center, The University of Texas MD Anderson Cancer Center, University of Alabama-Birmingham Hospital, The University of Texas Medical School at Houston, Johns Hopkins Hospital, and Oregon Health Sciences University. All patients diagnosed as having HNSCC of an unknown primary site who underwent TORS to identify the primary site were included in the study. We excluded those with recurrent disease, a history of radiation therapy to the head and neck, or evidence of a primary tumor site based on previous biopsy results. MAIN OUTCOME AND MEASURE Identification of the primary tumor site. RESULTS Forty-seven patients were eligible for the study. The tumor site was identified by TORS in 34 of 47 patients (72.3%). The primary site was located in the base of tongue for 20 patients (58.8%) and the palatine tonsil for 13 patients (38.2%), with 1 patient having a primary site in both the base of tongue and the palatine tonsil. Suspicious physical examination findings were present in 23 of 47 patients (48.9%), with positive and negative predictive values of 56.5% and 25.0%, respectively. Of those who underwent any imaging, 16 patients had suspicious findings, with positive and negative predictive values of 50.0% and 16.7%, respectively. In 18 of 47 patients (38.3%), both preoperative radiographic and physical examination failed to suggest a primary site. Of these 18 patients, 13 (72.2%) were identified after undergoing TORS. CONCLUSIONS AND RELEVANCE We demonstrate that TORS is a useful approach to identify and treat the primary site in patients with HNSCC who present with an unknown primary site.

Fast neutron radiotherapy for primary mucosal melanomas of the head and neck.

Primary head and neck mucosal melanomas (HNMMs) are rare tumors managed with surgery and/or radiotherapy and associated with poor outcomes. Given their radioresistance, high linear energy transfer radiotherapy with neutrons may improve local control.

Computer-Aided Design and 3D Printing to Produce a Costal Cartilage Model for Simulation of Auricular Reconstruction.

M icrotia, or underdevelopment of the auricle, affects approximately 0.03% of live births. Carving an auricular cartilage framework from autogenous cartilage—the most common technique for auricular reconstruction—is one of the most challenging skills for the reconstructive surgeon to learn. Given the potential morbidity associated with technical errors in framework carving, opportunities for acquisition of this skill are limited. It is critical for surgeons to be able to practice their carving skills. This presents an opportunity for surgical simulation. Materials previously used for simulation of auricular framework carving include carrots, potatoes, porcine/bovine/human cadaveric costal cartilage, and dental impression material. These materials poorly represent the geometry, texture, and size of the harvested costal cartilage presented to the reconstructive surgeon. There is a commercially available model (Medicon, Tuttlingen, Germany) that is based on adult rib and is costly. To better represent pediatric rib geometry and texture, techniques were developed to produce negative molds from harvested pediatric rib cartilage. While these methods are an improvement on the simulation of shape and size, questions remained on the similarity of the material to costal cartilage. In this report, we aim to use computer-aided design and 3dimensional (3D) printing to create a representative pediatric costal cartilage model for simulation of auricular framework reconstruction. Furthermore, with computed tomography scan data, the potential for patient-specific simulation is introduced, allowing for surgical planning.

Use of nasotracheal intubation in patients receiving oral cavity free flap reconstruction

The aim of this study was to evaluate the effect airway management has on perioperative outcomes of patients undergoing oral cavity free flap reconstruction.

The Effects of Intensive Care Unit Staffing on Patient Outcomes Following Microvascular Free Flap Reconstruction of the Head and Neck: A Pilot Study

OBJECTIVE To determine if the implementation of the closed intensive care unit (ICU) at our institution altered clinical outcomes in patients who had undergone microvascular free flap reconstruction of the head and neck by the Otolaryngology-Head and Neck Surgery Service. DESIGN Retrospective medical chart review. SETTING A single tertiary medical center. PATIENTS The open ICU cohort had 52 flaps performed on 50 patients, and the closed ICU cohort had 52 flaps performed on 52 patients. MAIN OUTCOME MEASURES Fifty-two free flap reconstructions of head and neck defects were performed on 50 patients who were admitted to an open ICU. The length of stay (LOS) in the ICU and hospital and incidence of complications were compared with those of 52 patients who underwent 52 free flap reconstructions and were admitted to a closed ICU over a separate period. RESULTS The mean length of stay in the ICU was 44 and 45 hours in the open and closed ICU cohorts, respectively (P = .90). The incidence of surgical and medical complications was similar in the open and closed ICU cohorts (P > .05). CONCLUSIONS There does not appear to be a significant difference in patient outcome between open and closed ICU care in our study.

Ocular protection in facial paralysis.

Purpose of reviewFacial nerve paralysis has a profound impact on patients’ quality of life, of which one of the most important sequelae is a risk of corneal surface disease. Herein, we discuss methods to protect the eye following insult to the facial nerve. Recent findingsProtection of the ocular surface in patients with facial nerve injury is of paramount importance to prevent corneal injury and potential blindness. Many interventions on the eye are temporary and therefore easily reversible. A systematic approach to managing the eye is required in these patients. SummaryThis article provides a review of current methods used for ocular protection in patients with facial nerve paralysis.

Evaluation of a Sphere-Templated Polymeric Scaffold as a Subcutaneous Implant

OBJECTIVE To evaluate the performance of a sphere-templated poly(2-hydroxyethyl methacrylate) (poly[HEMA]) tissue scaffold as a subcutaneous implant by comparing it with widely used high-density porous polyethylene (HDPPE) implant material. DESIGN We implanted sphere-templated porous poly-(HEMA) and HDPPE disks into the dorsal subcutis of C57BL/6 mice for 4 and 9 weeks. Excisional biopsy specimens of the implants and surrounding tissue were assessed for host inflammatory response, tissue ingrowth, and neovascularization using trichrome, picrosirius red, and anti-endothelial cell antibody staining. RESULTS The poly(HEMA) and HDPPE implants showed resistance to extrusion and elicited a minimal inflammatory response. Both implants supported cellular and collagen ingrowth, but ingrowth within the HDPPE implant was thicker owing to the larger porous structure (>100 μm) of HDPPE, whereas the poly(HEMA) implant had much thinner collagen fibrils within much smaller (40-μm) pores, suggestive of less scar-type reaction. Neovascularization was supported by both implants. Blood vessels were identified within the fibrous ingrowth of the HDPPE and within individual pores of the poly(HEMA). CONCLUSIONS Sphere-templated poly(HEMA) implanted as a subcutaneous tissue scaffold stimulates a minimal inflammatory response and supports cellular infiltration, collagen formation, and neovascularization. Because of its tightly controlled porous structure, poly-(HEMA) appears to induce less scar-type ingrowth compared with HDPPE.

Complex Nasal Reconstruction: A Case Study: Reconstruction of Full-Thickness Nasal Defect

Reconstruction of complex full-thickness nasal defects requires the reconstitution of the mucous internal nasal lining, the cartilaginous framework, and the aesthetic contour of the cutaneous nasal covering. Goals of reconstruction include restoration of a functional nasal airway and redefinition of the contours of the nose as well as its relationship to the cheek and lip with the least amount of morbidity to the patient. This article details a multistaged approach to repairing such a defect using an ipsilateral septal mucoperichondrial flap, multiple cartilage grafts, a paramedian forehead flap, and a cheek flap in a woman who had undergone Mohs surgery.