Christopher J. Britt

Preliminary Evaluation of Functional Swallow After Total Laryngectomy Using High-Resolution Manometry

Introduction: Understanding of swallowing pressures after total laryngectomy (TL) and what constitutes a “functional” swallow are limited. Mobile structures are altered or removed after TL, with consequent effects on pressure profiles. High-resolution manometry (HRM) can characterize these pressures. Methods: Six TL subjects without dysphagia and 6 controls underwent pharyngeal HRM. Timing and pressure variables for the velopharynx, mesopharynx, and upper esophageal sphincter (UES) were compared. Changes in variables due to bolus volume were evaluated in TL subjects. Results: The TL subjects had increased duration of velopharyngeal pressure (P = .012). Maximum mesopharyngeal pressure was lower versus controls (P = .003). Maximal and total pre-opening (P = .002, P = .002) and post-closure (P = .001, P = .002) UES pressures were lower. Maximum mesopharyngeal pressure (P = .032) decreased with increasing bolus volume. Conclusions: Increased velopharyngeal pressure duration and total swallow duration reflect separation of the pharynx into distinct conduits for air and food, thus ensuring successful bolus passage without the need for respiration. Decreased UES pressure highlights the effects of disrupting the cricopharyngeal and rostral esophageal muscle fibers from their attachments to the larynx and performing a cricopharyngeal myotomy. Additional studies including subjects with dysphagia could further characterize the functional TL swallow and identify aspects susceptible to dysfunction.

Energy-Based Facial Rejuvenation: Advances in Diagnosis and Treatment

Importance The market for nonsurgical, energy-based facial rejuvenation techniques has increased exponentially since lasers were first used for skin rejuvenation in 1983. Advances in this area have led to a wide range of products that require the modern facial plastic surgeon to have a large repertoire of knowledge. Objective To serve as a guide for current trends in the development of technology, applications, and outcomes of laser and laser-related technology over the past 5 years. Evidence Review We performed a review of PubMed from January 1, 2011, to March 1, 2016, and focused on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines including case control, case studies and case reports when necessary, and included 14 articles we deemed landmark articles before 2011. Findings Three broad categories of technology are leading non–energy-based rejuvenation technology: lasers, light therapy, and non–laser-based thermal tightening devices. Laser light therapy has continued to diversify with the use of ablative and nonablative resurfacing technologies, fractionated lasers, and their combined use. Light therapy has developed for use in combination with other technologies or stand alone. Finally, thermally based nonlaser skin-tightening devices, such as radiofrequency (RF) and intense focused ultrasonography (IFUS), are evolving technologies that have changed rapidly over the past 5 years. Conclusions and Relevance Improvements in safety and efficacy for energy-based treatment have expanded the patient base considering these therapies viable options. With a wide variety of options, the modern facial plastic surgeon can have a frank discussion with the patient regarding nonsurgical techniques that were never before available. Many of these patients can now derive benefit from treatments requiring significantly less downtime than before while the clinician can augment the treatment to maximize benefit to fit the patient’s time schedule.

Factors influencing sialocele or salivary fistula formation postparotidectomy

Does the extent of parotidectomy or other patient or tumor characteristics influence the rate of sialocele/salivary fistula formation?

Incidental Parotid Neoplasms Pathology and Prevalence

Objective To better characterize parotid masses incidentally identified on imaging. Study Design Case series with chart review. Setting Academic medical center. Subjects and Methods Medical records were reviewed for 771 patients who underwent parotidectomy at the University of Wisconsin from 1994 to 2013. Patients were stratified into 2 groups: those with tumors identified solely on imaging (parotid incidentalomas [PIs]) and those with palpable masses, pain, facial nerve dysfunction, or other reasons their mass was identified (nonincidentals [NIs]). A χ2 test was employed to compare the prevalence of malignancy in PIs compared with NIs. Trend analysis was performed to determine the prevalence of PIs over the 20-year period. Results Of the 771 patients, 67 (8.7%) had their mass discovered incidentally on imaging (PIs). There was a significant difference in the rate of malignancy in the NI (32.7%) compared with the PI group (6.0%) (P < .01). During the 1994 to 2003 time period, 4.0% of all parotoidectomies performed were for PIs, while during the second decade (2004-2013), this proportion increased to 10.2%. This represents a 155.0% increase in the percentage of parotidectomies carried out for PIs between these 2 periods. Conclusion In this study, the rate of malignancy in PIs was significantly lower than the rate of malignancy in patients with NIs. The occurrence of PIs has increased over time and now represents greater than 10.0% of all parotidectomies performed at the University of Wisconsin. This information is important to consider when consenting a patient for resection of a PI.

Patient and tumor characteristics predictive of primary parotid gland malignancy: A 20-year experience at the University of Wisconsin☆☆☆

PURPOSE To identify patient and tumor characteristics predictive of primary parotid malignancy. MATERIALS AND METHODS Records were reviewed for patients who underwent parotidectomy at the University of Wisconsin from 1994 to 2013. Patients with primary parotid neoplasms were separated into benign or malignant subgroups. A multivariate logistic regression model was employed to compare categorical (gender, lesion side, nature of presentation, recurrence) and numerical variables (age, tumor size) between the benign and malignant groups. Mean BMI was compared between the groups by univariate analysis. RESULTS 771 patients underwent parotidectomy from 1994 to 2013, and 474 had a primary parotid neoplasm. No relationship existed between malignancy and gender (p=0.610), lesion side (p=0.110), or BMI (p=0.196). Mean age (p=0.015) and tumor size (p=0.011) were significantly different between the benign and malignant groups. Patient presentation was classified into three categories: symptomatic (n=109), palpable and asymptomatic (n=303), and incidentally noted on imaging (n=57). From all patients with symptomatic, asymptomatic or incidentally noted masses, 41.3%, 10.6% and 5.3%, respectively, were diagnosed with malignant disease. There was a significant relationship between the patients initial presentation and malignancy (p<0.001), and patients with facial nerve dysfunction or skin involvement had the greatest likelihood of malignancy. Finally, there was a significant association between malignancy and recurrence (p=0.001). CONCLUSIONS In this study, age, tumor size, and nature of presentation were all associated with primary parotid malignancy. Understanding the impact of these features on the probability of malignancy is valuable in decision making and counseling of patients presenting with a newly diagnosed parotid neoplasm.

Secondary tracheoesophageal puncture in-office using Seldinger technique.

Objective Evaluate the safety and efficacy of in-office secondary tracheoesophageal puncture (TEP) technique using transnasal esophagoscopy (TNE) and the Seldinger technique in conjunction with a cricothyroidotomy kit for placement. Study Design Case series with chart review. Setting Academic medical center. Subject and Methods A retrospective chart review was performed on 83 subjects who underwent in-office secondary TEP. Variables that were examined included disease site, staging, histologic diagnosis, extent of resection and reconstruction, chemoradiation, functional voice status (as assessed by speech pathologist in most recent note), and complications directly related to the procedure. Results Eighty-three individuals from our institution met our criteria for in-office secondary TEP from 2005 to August 2012. Of these, 97.6% (81/83) had no complications of TEP. The overall complication rate was 2.4% (2/83). Complications included bleeding from puncture site and closure of puncture site after dislodgement of prosthesis at the time of puncture. Fluent conversational speech was achieved in 69.9% of all patients (58/83), and an additional 19.3% (16/83) achieved functional/intelligible speech; of those, 3.6% (3/83) were unable to achieve fluent conversational speech due to anatomic defects from previous surgery. Conclusion An in-office TEP can be safely performed using the Seldinger technique with direct visualization using TNE, despite the extent of resection or reconstruction, with functional speech outcomes comparable to other studies available in the literature.

Chondroradionecrosis of the larynx: 24-year University of Wisconsin experience

Chondroradionecrosis (CRN) is an uncommon but significant complication of laryngeal radiotherapy that presents a diagnostic challenge to clinicians through its similarity in presentation to cancer recurrence.

Tracheal exposure: Anticipatory management of the difficult airway

When a patient cannot be intubated or ventilated, cricothyrotomy is indicated. Risks associated with emergent cricothyrotomy are significant, and this procedure typically requires revision. Additional options for establishing an emergent airway are limited. Thus, elective tracheotomy to ensure a safe airway after procedures involving the upper aerodigestive tract is common. Although safe and effective overall, this procedure is not without additional risks, added resources, complex cares, and extended hospitalizations.

A novel technique for tracheal reconstruction using a resorbable synthetic mesh: Tracheal Reconstruction With Resorbable Mesh

INTRODUCTION Surgical reconstruction of the trachea may be necessary following the resection of congenital, traumatic, or neoplastic airway lesions. Smaller defects up to 2 cm may be closed primarily. However, larger defects may require more extensive reconstruction with autologous tissue transfer and/or alloplastic grafts. Such reconstruction is guided by several key requirements, including an epithelialized surface to line the luminal side of the defect, lateral rigidity to prevent airway collapse, and longitudinal flexibility to allow for neck flexion and extension. A number of reconstructive materials and techniques have been developed to this end, including microvascular free tissue transfer. However, in patients with extensive comorbidities or limited recipient vessels in the neck due to prior surgery, free tissue transfer may not be a feasible option. Here, we present a novel technique for the repair of an anterior tracheal defect using a moldable, resorbable synthetic mesh inserted into a pedicled myocutaneous pectoralis major flap.

p16 Immunohistochemistry Is a Useful Diagnostic Adjunct in Cases of Metastatic Cervical Carcinoma of Unknown Origin

PURPOSE Metastatic cervical carcinoma of unknown primary (MCCUP) is increasing in frequency owing in part to rising human papillomavirus (HPV)-driven oropharyngeal carcinoma. Identifying the primary site is valuable, because it is associated with increased survival and decreased morbidity. HPV-positive cervical nodal disease focuses attention on the oropharynx for directed biopsy examinations, including tonsillectomy. When the primary is small, carcinoma might not be apparent by traditional hematoxylin and eosin (H&E) staining alone. MATERIALS AND METHODS This report describes 2 cases of p16-positive MCCUP in which a small primary carcinoma was not readily identified in surgical specimens using H&E staining. RESULTS Additional evaluation of the specimens with p16 immunohistochemistry (IHC) showed carcinoma in these 2 cases. CONCLUSIONS When H&E staining does not show carcinoma in cases of MCCUP, p16 IHC should be considered given the high prevalence of HPV-positive MCCUP and the potential for identification of a small primary tumor that might otherwise be missed with H&E staining.