Avinash V. Mantravadi

Ability of the National Surgical Quality Improvement Program Risk Calculator to Predict Complications Following Total Laryngectomy.

Importance The accuracy of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) risk calculator has been assessed in multiple surgical subspecialties; however, there have been no publications doing the same in the head and neck surgery literature. Objective To evaluate the accuracy of the calculators predictions in a single institutions total laryngectomy (TL) population. Design, Setting, and Participants Total laryngectomies performed between 2013 and 2014 at a tertiary referral academic center were evaluated using the risk calculator. Predicted 30-day outcomes were compared with observed outcomes for return to operating room, surgical site infection, postoperative pneumonia, length of stay, and venous thromboembolism. Main Outcomes and Measures Comparison of the NSQIP risk calculators predicted postoperative complication rates and length of stay to what occurred in this patient cohort using percent error, Brier scores, area under the receiver operating characteristic curve, and Pearson correlation analysis. Results Of 49 patients undergoing TL, the mean (SD) age at operation was 59 (9.3) years, with 67% male. The risk calculator had limited efficacy predicting perioperative complications in this group of patients undergoing TL with or without free tissue reconstruction or preoperative chemoradiation or radiation therapy with a few exceptions. The calculator overestimated the occurrence of pneumonia by 165%, but underestimated surgical site infection by 7%, return to operating room by 24%, and length of stay by 13%. The calculator had good sensitivity and specificity of predicting surgical site infection for patients undergoing TL with free flap reconstruction (area under the curve, 0.83). For all other subgroups, however, the calculator had poor sensitivity and specificity for predicting complications. Conclusions and Relevance The risk calculator has limited utility for predicting perioperative complications in patients undergoing TL. This is likely due to the complexity of the treatment of patients with head and neck cancer and factors not taken into account when calculating a patients risk.

Three-Dimensional Printing and Its Applications in Otorhinolaryngology–Head and Neck Surgery

Objective Three-dimensional (3D)-printing technology is being employed in a variety of medical and surgical specialties to improve patient care and advance resident physician training. As the costs of implementing 3D printing have declined, the use of this technology has expanded, especially within surgical specialties. This article explores the types of 3D printing available, highlights the benefits and drawbacks of each methodology, provides examples of how 3D printing has been applied within the field of otolaryngology–head and neck surgery, discusses future innovations, and explores the financial impact of these advances. Data Sources Articles were identified from PubMed and Ovid MEDLINE. Review Methods PubMed and Ovid Medline were queried for English articles published between 2011 and 2016, including a few articles prior to this time as relevant examples. Search terms included 3-dimensional printing, 3D printing, otolaryngology, additive manufacturing, craniofacial, reconstruction, temporal bone, airway, sinus, cost, and anatomic models. Conclusions Three-dimensional printing has been used in recent years in otolaryngology for preoperative planning, education, prostheses, grafting, and reconstruction. Emerging technologies include the printing of tissue scaffolds for the auricle and nose, more realistic training models, and personalized implantable medical devices. Implications for Practice After the up-front costs of 3D printing are accounted for, its utilization in surgical models, patient-specific implants, and custom instruments can reduce operating room time and thus decrease costs. Educational and training models provide an opportunity to better visualize anomalies, practice surgical technique, predict problems that might arise, and improve quality by reducing mistakes.

Androgen treatment and recovery of function following recurrent laryngeal nerve injury in the rat

PURPOSE To investigate the effects of the androgen testosterone propionate (TP), on regeneration of the recurrent laryngeal nerve (RLN) after unilateral crush injury using assessment of vocal fold mobility (VFM) as a measure of behavioral recovery. METHODS 48 adult male rats underwent standardized crush injury of left RLN and received treatment in the form of 2 silastic capsules containing TP or controls receiving a blank capsule (untreated). Direct laryngoscopic assessment of vocal cord mobility was performed before, immediately following and 1, 2, 3, 4, 5 or 6 weeks post injury. RESULTS Treatment with TP enhanced the recovery of full VFM following crush injury of the RLN compared to controls. There was statistically significant improvement in VFM seen at the 1 and 2 week time points (p < 0.05). By 4 weeks TP-treated rats displayed a 100% recovery of VFM function, compared to only 50% by the control group. CONCLUSIONS TP enhances RLN functional recovery following a crush injury, which further supports its potential general applicability as a therapeutic agent in peripheral nerve injury.

Lateral Temporal Bone and Parotid Malignancy With Facial Nerve Involvement

Objectives. To review our institution’s experience and outcomes in the treatment of lateral temporal bone (LTB) and parotid malignancy with facial nerve (FN) involvement. To identify risk factors for treatment failures and to clarify previously established prognostic factors for this advanced-stage disease. Study Design. Case series with chart review. Setting. Tertiary care academic hospital. Subjects and Methods. A series of 26 patients treated operatively for malignancy of the LTB and parotid gland with FN involvement were reviewed retrospectively. All patients underwent sacrifice of the FN due to intraoperative determination of nerve invasion. Demographic, historical, intraoperative, pathologic, and follow-up data were collected and analyzed to determine survival outcomes and locoregional control. Risk factor analysis was performed. Results. The FN was found to be grossly involved by tumor at the stylomastoid foramen in 57.7% of patients, resulting in sacrifice more proximally in the vertical segment in 57.7%. Statistical analysis demonstrated a locoregional recurrence rate of 34.6%, with the majority of recurrence occurring within the first 2 years after surgery. The rate of distant failure was 15.4%. Kaplan-Meier and chi-square analysis showed an overall survival of 76.0%, 66.7%, 35.3%, 31.2%, and 28.6% at 1, 2, 3, 4, and 5 years, respectively. Advanced age, the presence of tumor of epithelial origin, and pathologically positive lymph nodes are significantly predictive of poor survival. Conclusion. Outcomes of malignancy of the LTB with FN involvement treated with primary surgical therapy compare favorably with previously published control rates, and overall prognosis for this condition is likely better than historically established.

A Rat Model for Intracranial Facial Nerve Crush Injuries

Objective. (1) Explain the need for an animal model to study intracranial injuries to the facial nerve. (2) Describe various techniques attempted to identify and crush the intracranial segment of the facial nerve in a rat model. (3) Describe in detail a successful rat model of intracranial facial nerve crush injury. Study Design. Randomized controlled animal study. Setting. Animal laboratory. Subjects and Methods. Multiple attempts at surgical approaches to the cerebellopontine angle were attempted on cadaveric rats. Once a successful approach was derived, this was used on 19 live rats under anesthesia. Fourteen rats had a 1-minute facial nerve crush performed, and 5 had a sham surgery with complete surgical exposure of the facial nerve but no crush. Rats were followed for a 12-week duration evaluating immediate postoperative facial nerve function, complications, and survival. Results. All 14 (100%) rats that underwent surgery with crush injury had complete facial paralysis postoperatively. Complete facial paralysis was defined as loss of eye-blink reflex, flat vibrissae, and lack of vibrissae movement. The 5 sham surgery rats had complete facial function postoperatively. Surgery was performed by 2 separate surgeons with no difference in outcome between the 2. Complications occurred in only 1 animal (1/19, 5.3%), which was a corneal abrasion requiring sacrifice. Conclusion. Our group describes a consistent method for performing an intracranial crush injury in the rat. This new model and its applications in translational facial nerve research are promising, particularly with tumors or lesions at the cerebellopontine angle.

Feasibility of desorption electrospray ionization mass spectrometry for diagnosis of oral tongue squamous cell carcinoma

RATIONALE Desorption electrospray ionization mass spectrometry (DESI-MS) has demonstrated utility in differentiating tumor from adjacent normal tissue in both urologic and neurosurgical specimens. We sought to evaluate if this technique had similar accuracy in differentiating oral tongue squamous cell carcinoma (SCC) from adjacent normal epithelium due to current issues with late diagnosis of SCC in advanced stages. METHODS Fresh frozen samples of SCC and adjacent normal tissue were obtained by surgical resection. Resections were analyzed using DESI-MS sometimes by a blinded technologist. Normative spectra were obtained for separate regions containing SCC or adjacent normal epithelium. Principal Component Analysis and Linear Discriminant Analysis (PCA-LDA) of spectra were used to predict SCC versus normal tongue epithelium. Predictions were compared with pathology to assess accuracy in differentiating oral SCC from adjacent normal tissue. RESULTS Initial PCA score and loading plots showed clear separation of SCC and normal epithelial tissue using DESI-MS. PCA-LDA resulted in accuracy rates of 95% for SCC versus normal and 93% for SCC, adjacent normal and normal. Additional samples were blindly analyzed with PCA-LDA pixel-by-pixel predicted classifications as SCC or normal tongue epithelial tissue and compared against histopathology. The m/z 700-900 prediction model showed a 91% accuracy rate. CONCLUSIONS DESI-MS accurately differentiated oral SCC from adjacent normal epithelium. Classification of all typical tissue types and pixel predictions with additional classifications should increase confidence in the validation model.

Cochlear implant extrusion secondary to keloid formation

Abstract Objective and importance The goal of this paper is to describe a previously unreported etiology for cochlear implant extrusion. A short literature review is included. This paper represents the first reported case of cochlear implant extrusion secondary to keloid formation. Clinical presentation We present the case of a 40-year-old male who underwent cochlear implant insertion approximately 5 years prior who later developed a 5 cm post-auricular soft tissue swelling and partial extrusion which interfered with implant function. Intervention He subsequently underwent wound debridement, cochlear implant removal, and rotational skin flap closure. Final pathology revealed keloid scar. Conclusion Cochlear implant extrusion is a rare complication which has been attributed to various causes. This report identifies keloid formation as another possible source.

Body Mass Index Predicts Risk for Complications from Transtemporal Cerebellopontine Angle Surgery

Objectives To determine the relationship between body mass index (BMI) and risk for specific complications from transtemporal cerebellopontine angle (CPA) surgery for nonmalignant disease. Study Design Case series with chart review. Setting Tertiary-care academic hospital. Subjects and Methods Retrospective review of 134 consecutive patients undergoing transtemporal cerebellopontine angle surgery for nonmalignant disease from 2009 to 2011. Data were collected regarding demographics, body mass index, intraoperative details, hospital stay, and complications including cerebrospinal fluid leak, wound complications, and brachial plexopathy. Results One hundred thirty-four patients were analyzed with a mean preoperative body mass index of 28.58. Statistical analysis demonstrated a significant difference in body mass index between patients with a postoperative cerebrospinal fluid leak and those without (P = .04), as well as a similar significant difference between those experiencing postoperative brachial plexopathy and those with no such complication (P = .03). Logistical regression analysis confirmed that body mass index is significant in predicting both postoperative cerebrospinal fluid leak (P = .004; odds ratio, 1.10) and brachial plexopathy (P = .04; odds ratio, 1.07). Elevated body mass index was not significant in predicting wound complications or increased hospital stay beyond postoperative day 3. Conclusion Risk of cerebrospinal fluid leak and brachial plexopathy is increased in patients with elevated body mass index undergoing surgery of the cerebellopontine angle. Consideration should be given to preoperative optimization via dietary and lifestyle modifications as well as intraoperative somatosensory evoked potential monitoring of the brachial plexus to decrease these risks.

Incidence of Occult Nodal Disease in Patients Treated with Salvage Laryngectomy with Radiologically Negative Neck

Objectives: The National Comprehensive Cancer Network guidelines address neck dissection in the setting of primary tumor treatment but do not provide a clear guideline for negative nodal disease in recurrent advanced laryngeal cancer. We often extrapolate the indication of neck dissection for recurrent disease based on the guidelines of primary disease. It is controversial whether there is a survival benefit for patients with clinically and radiologically negative (N0) necks to receive a neck dissection versus conservative management. This study aims to determine survival outcomes and incidence of post-operative complications in patients who underwent neck dissection at the time of salvage laryngectomy with clinically and radiologically negative neck. Methods: Single institution case series at a tertiary care university hospital. We identified 424 cases of total laryngectomy between 2000-2010.We reviewed the subset of N0 patients who had salvage laryngectomy and divided them into neck dissection versus conservative management. We reviewed demographic variables, final pathological stage of dissected neck specimen, and post-operative course and survival. Results: Patients who had a neck dissection at salvage laryngectomy with clinically N0 disease as compared to those treated conservatively may have no significant difference in survival; there may be a significant difference in the complication rate and perioperative mortality rate between the two groups. Conclusions: The data reviewed in this large series of patients will be useful for clinicians to determine the survival and complications that are frequently experienced by patients following neck dissection with salvage laryngectomy in the setting of previous radiation.

Risk for Complications from CPA Surgery due to BMI

Objective: To determine the relationship between body mass index (BMI) and risk for complications from transtemporal surgery for non-malignant disease processes of the cerebellopontine angle (CPA). To determine the threshold BMI above which risk is increased. Method: Retrospective review of 106 patients undergoing transtemporal CPA surgery for non-malignant disease processes from 2010 to 2011 (tertiary-care academic center). Preoperative BMI, approach, hospital stay, and complications including cerebrospinal fluid (CSF) leak, wound complications, and brachial plexopathy. Data were analyzed to determine whether BMI affects postoperative CSF leak, wound infection, or brachial plexopathy. Results: A total of 106 patients were included, with a mean BMI of 28.17. Statistical analysis demonstrated an increased incidence of CSF leak in patients with a preoperative minimum BMI of 31.4 (rpb = 0.216, df = 101, P < .05). There was no clear relationship between BMI and the development of postoperative wound complications. An increased risk for postoperative brachial plexopathy was found in patients with a BMI > 29.97. Conclusion: Risk of CSF leak and brachial plexopathy after transtemporal CPA surgery for non-malignant processes are increased in patients with an elevated BMI. Consideration should be given to preoperative dietary/lifestyle modifications and exercise programs and/or perioperative lumbar drain placement and intraoperative upper extremity evoked potential monitoring to decrease these risks.