David W. J. Côté

Triamcinolone-impregnated nasal dressing following endoscopic sinus surgery: a randomized, double-blind, placebo-controlled study.

To evaluate the impact of steroid‐impregnated absorbable nasal dressing on wound healing and surgical outcomes after endoscopic sinus surgery (ESS).

The Implantable Cook-Swartz Doppler Probe for Postoperative Monitoring in Head and Neck Free Flap Reconstruction

OBJECTIVE To determine if the implantable Cook-Swartz Doppler Flow Monitoring System (Cook Vascular Inc, Vandergrift, Pennsylvania) improves surgical salvage rates for compromised free flaps. DESIGN Retrospective medical record review spanning 2002 to 2006 for a large head and neck oncology program. SETTING A tertiary care hospital. PATIENTS A consecutive series of 351 patients (244 men and 107 women; mean age, 58.63 years) who underwent free flap reconstruction of head and neck defects that were monitored using the implantable Doppler probe were included. RESULTS The most common indication for surgery was squamous cell carcinoma (81.0%), followed by functional reconstruction (4.3%). The most common free flap used was radial forearm (68.0%), followed by the fibular free flap (19.0%). With operative exploration used as the gold standard, the Cook-Swartz Doppler Flow Monitoring System had a sensitivity of 65.8% and specificity of 98.2% for the detection of flap compromise. For the detection of vascular compromise of the monitored vessel (excluding flap compromise cases whereby flow in the monitored vessel was not compromised on operative exploration, ie, venous obstruction, hematoma formation, and necrotizing fasciitis), the sensitivity increased to 100%. CONCLUSIONS This is the largest reported series, to our knowledge, of implantable Cook-Swartz Doppler use, and our experience would suggest that this is a reliable technique for postoperative monitoring in head and neck reconstruction. Our use of the implantable Doppler probe allowed us to recognize vascular compromise early, resulting in an overall flap success rate of 98.1%, with a 92.0% salvage rate of flaps that experienced vascular compromise of the monitored vessel.

Double Free-Flap Reconstruction Indications, Challenges, and Prospective Functional Outcomes

OBJECTIVE To investigate the increasing use of double free flaps in the reconstruction of large head and neck defects. DESIGN A 5-year retrospective medical record review in a large tertiary care head and neck oncology program. Prospectively collected functional data were also analyzed. SETTING Academic research. PATIENTS A consecutive series of 35 patients (24 men and 11 women; mean age, 57.7 years). MAIN OUTCOME MEASURES The use of double free flaps in the reconstruction of large head and neck defects and prospective functional outcomes. RESULTS The most common indication for surgery (n = 25 [71.4%]) was squamous cell carcinoma. The most common double free-flap combination (n = 22 [62.9%]) included an osteocutaneous fibular free flap with a fasciocutaneous radial forearm free flap. Objective evaluation by naive listeners demonstrated a mean single-word intelligibility score of 66.2% and a mean sentence intelligibility score of 84.8% in this group of patients. Modified barium swallow study results revealed no evidence of laryngeal penetration for swallowing liquid consistencies in 21 patients (60.0%), pudding consistencies in 30 patients (85.7%), and cookie consistencies in 32 patients (91.4%). CONCLUSIONS With proper patient selection and planning and the use of 2 surgical teams, the length of surgery and complication rates are not significantly increased in double free-flap reconstruction. Furthermore, by using 2 free flaps, the best osseous and soft-tissue elements may be independently selected, yielding appropriate tissue characteristics for ideal defect reconstruction.

Detection of human papillomavirus type 16 in oropharyngeal squamous cell carcinoma using droplet digital polymerase chain reaction.

The incidence of oropharyngeal squamous cell carcinoma caused by oncogenic HPV (HPV‐OPSCC) is rising worldwide. HPV‐OPSCC is commonly diagnosed by RT‐qPCR of HPV‐16 E6 and E7 oncoproteins or by cyclin‐dependent kinase inhibitor 2A, multiple tumor suppressor 1 (p16) immunohistochemistry (IHC). Droplet digital PCR (ddPCR) has been recently reported as ultra‐sensitive and highly precise method of nucleic acid quantification for biomarker analysis. We aimed to validate this method for the detection of HPV‐16 E6 and E7 in HPV‐OPSCC.

Role of primary surgery in the treatment of advanced oropharyngeal cancer

The purpose of this study was to compare survival outcomes of patients with advanced stage oropharyngeal squamous cell carcinoma (SCC) according to surgical and nonsurgical treatments, when stratified by smoking and p16 status.

Outcomes of free flap reconstruction in the elderly

The reconstructive surgeon is often faced with the dilemma of offering free flap reconstruction to the elderly after surgical extirpation in the head and neck due to the perception that this population tolerates these procedures poorly.

High definition video teaching module for learning neck dissection

IntroductionVideo teaching modules are proven effective tools for enhancing student competencies and technical skills in the operating room. Integration into post-graduate surgical curricula, however, continues to pose a challenge in modern surgical education. To date, video teaching modules for neck dissection have yet to be described in the literature.PurposeTo develop and validate an HD video-based teaching module (HDVM) to help instruct post-graduate otolaryngology trainees in performing neck dissection.MethodsThis prospective study included 6 intermediate to senior otolaryngology residents. All consented subjects first performed a control selective neck dissection. Subjects were then exposed to the video teaching module. Following a washout period, a repeat procedure was performed. Recordings of the both sets of neck dissections were de-identified and reviewed by an independent evaluator and scored using the Observational Clinical Human Reliability Assessment (OCHRA) system.ResultsIn total 91 surgical errors were made prior to the HDVM and 41 after exposure, representing a 55% decrease in error occurrence. The two groups were found to be significantly different. Similarly, 66 and 24 staff takeover events occurred pre and post HDVM exposure, respectively, representing a statistically significant 64% decrease.ConclusionHDVM is a useful adjunct to classical surgical training. Residents performed significantly less errors following exposure to the HD-video module. Similarly, significantly less staff takeover events occurred following exposure to the HDVM.

Molecular predictors of locoregional and distant metastases in oropharyngeal squamous cell carcinoma

BackgroundThe incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing due to fundamental changes in oncogenesis related to effects of the human papilomavirus (HPV). Virally-mediated tumours behave and respond to treatment differently than their classic, carcinogenically-mediated counterparts despite similar stage and grade of disease. This difference in behaviour has lead to investigation of etiologies of OPSCC at the molecular level.Molecular biomarkers offer potential insight into the behaviour of OPSCC. Identifying a subset of patients that are more likely to have recurrence and distant metastasis is valuable for prognostication and treatment planning. There is limited information regarding the profiles of these biomarkers in locoregional and distant metastases in OPSCC.ObjectiveThis study was designed to identify biomarker profiles predictive of locoregional and distant metastases and recurrence in OPSCC.MethodsCross-sectional study of a prospectively-collected oropharyngeal tumour database was undertaken. All patients with OPSCC presenting to the University of Alberta Hospital from 2002- 2009 were included in the study. Data collection from the Alberta Cancer Registry, including demographics, nodal status, distant metastases, treatment, recurrence, and survival, was undertaken. Tissue micro-arrays (TMAs) were constructed for each tumour specimen using triplicate cores (0.6mm) of formalin-fixed, paraffin-embedded (FFPE) pre-treatment tumour tissue. TMAs were processed using immunohistochemistry for p16, EGFR, Ki67, p53, and Bcl-XL. Positivity for each biomarker was determined using quantified AQUAnalysis ® scores on histoplots. Multivariate statistics were utilized to assess the relationship between each biomarker and locoregional and distant metastases, as well as recurrence-free survival (RFS).ResultsHigh expression of p16 (p=0.000) and Bcl-XL (p=0.039) independently demonstrated a significant association with nodal disease at presentation. Kaplan-Meier analysis demonstrated improved RFS in patients with high p16 and decreased RFS in patients with high p53 expression. Cox regression analysis supported p16 as an independent prognosticator for improved RFS. p53 demonstrated an association with recurrence, but when compared to p16 status, nodal status, and staging, was not an independent predictor of recurrence.ConclusionsBiomarker profiling using p16, Bcl-xL, and p53 may be useful in prognostication and treatment planning in patients with OPSCC.

Immunoglobulin G4-related diseases in the head and neck: a systematic review

BackgroundImmunoglobulin G4 related disease (IgG4-RD) is a poorly understood chronic inflammatory disorder affecting the middle-aged and elderly that can present to the otolaryngologist. We aim to summarize the current literature regarding the manifestations and management of IgG4-RD in the head and neck.MethodsPubmed and EMBASE were searched using the term relevant search algorithm utilizing keywords such as: IgG4 related disease, head and neck, orbit, salivary glands, sialadenitis, Kuttner, angiocentric eosinophilic fibrosis, submandibular, lacrimal, thyroid, dacryoadenitis, nasal, sinus, and Mikulicz’s. Reference lists were searched for identification of relevant studies.Case reports, original research and review articles published in English from 1964 to 2014 whose major topic was IgG4-RD affecting the head and neck were included. Data regarding patient demographics, presentation, histopathology, management and treatment outcomes of IgG4-RD were extracted. Level of evidence was also assessed and data were pooled where possible. Three independent reviewers screened eligible studies; extracted relevant data and discrepancies were resolved by consensus, where applicable. Descriptive and comparative statistics were performed.ResultsFourty-three articles met our inclusion criteria. IgG4-RD most often presents as a mass lesion in the head and neck region. Common diagnostic features include: 1) elevated serum IgG4 level, 2) marked infiltration of exocrine glands by IgG4-positive plasma cells with fibrosis, and 3) marked improvement with corticosteroid therapy and additional immunosuppressive therapy in corticosteroid refractory cases. Early diagnosis and involvement of rheumatology is important in management.ConclusionsIgG4-RD is a challenging non-surgical disease that has multiple manifestations in the head and neck. It must be distinguished from various mimics including malignancy, systemic diseases, and infectious. Otolaryngology-Head and Neck surgeons should be aware of this condition and its management.

Trends in Level of Evidence in Facial Plastic Surgery Research

Background: Evidence-based medicine has increasingly become an integral part of clinical research and practice. The purpose of this study was to assess the trends in the level of evidence in leading facial plastic surgery journals in recent years. Methods: All scientific articles within the field of facial plastic surgery published in The Laryngoscope, Archives of Facial Plastic Surgery, Otolaryngology-Head and Neck Surgery, Journal of Plastic Surgery, and Plastic and Reconstructive Surgery from 1999, 2002, 2005, and 2008 were rated for level of evidence. The presence of p values and confidence intervals was also noted. Results: Of 975 articles reviewed, 88 percent were clinical and 88 percent were therapy articles. Overall, there was an increase in the average level of evidence of articles published from 1999 to 2008. There was also a significant increase in the proportion of articles reporting p values and confidence intervals. However, the number of articles containing level 1 or 2 evidence remains low. Conclusions: With the increased demand for evidence-based medicine, facial plastic surgery literature has seen an overall increase in the quantity of higher level evidence research published. However, articles representing level 1 and 2 evidence remain rare.