Joshua D. Hornig

Thyroid disease and compressive symptoms

Compressive symptoms are common in thyroid disease, but few studies have focused on the presence, associated factors, and etiology of compressive symptoms.

Minimally invasive video-assisted thyroidectomy versus conventional thyroidectomy: A cost-effective analysis

OBJECTIVE: To compare the cost of minimally invasive video-assisted thyroidectomy (MIVAT) with conventional thyroidectomy. STUDY DESIGN: A cost-effectiveness study and chart review. SETTING: Academic university hospital. SUBJECTS AND METHODS: Pediatric and adult patients referred to the Department of Otolaryngology-Head and Neck Surgery for suspicious thyroid nodules, goiters, or known carcinomas. A tertiary care hospitals billing department was queried for all hemithyroidectomies and total thyroidectomies completed by the Department of Otolaryngology- Head and Neck Surgery between January 5, 2006, and November 1, 2007. The charges, including surgery, hospital, pathology, and anesthesia, for minimally invasive video-assisted thyroidectomy (MIVAT) and traditional or minimally invasive open thyroidectomies meeting MIVAT inclusion criteria were then reviewed retrospectively and compared statistically. RESULTS: A total of 185 thyroidectomies were performed, 50.3 percent of which met criteria for MIVAT. Length of stay (days) was significantly shorter for patients undergoing MIVAT hemithyroidectomy (mean difference −0.8; 95% confidence interval [95% CI] −1.08 to −0.52) and not significantly different between groups for total thyroidectomy (mean difference 0.1; 95% CI −0.36 to 0.56). Mean anesthesia cost (U.S.

Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer

) was similar between groups for hemi- and total thyroidectomies. MIVAT mean pathology cost was significantly less than open thyroidectomy for hemithyroidectomy (mean difference −89.9; 95% CI −179.01 to −0.79) and approached significance for total thyroidectomy. There was no significant difference in hospital cost and total cost for hemithyroidectomy and total thyroidectomy. CONCLUSION: In a group of matched cohorts, the cost of MIVAT appears to be equal to that of open thyroidectomy.

Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours

The purpose of this study was to determine the effect of algorithmic physiologic management on patients undergoing head and neck free tissue transfer and reconstruction.

Neural outcomes after plasma knife dissection: A pathologic study and clinical correlation

Importance Free flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. Despite experience and meticulous technique, there is a small but recognized risk of partial or total flap loss in the postoperative setting. Historically, most microvascular surgeons involve resident house staff in flap monitoring protocols, and programs relied heavily on in-house resident physicians to assure timely intervention for compromised flaps. In 2003, the Accreditation Council for Graduate Medical Education mandated the reduction in the hours a resident could work within a given week. At many institutions this new era of restricted resident duty hours reshaped the protocols used for flap monitoring to adapt to a system with reduced resident labor. Objectives To characterize various techniques and frequencies of free flap monitoring by nurses and resident physicians; and to determine if adapted resident monitoring frequency is associated with flap compromise and outcome. Design, Setting, and Participants This multi-institutional retrospective review included patients undergoing free flap reconstruction to the head and/or neck between January 2005 and January 2015. Consecutive patients were included from different academic institutions or tertiary referral centers to reflect evolving practices. Main Outcomes and Measures Technique, frequency, and personnel for flap monitoring; flap complications; and flap success. Results Overall, 1085 patients (343 women [32%] and 742 men [78%]) from 9 institutions were included. Most patients were placed in the intensive care unit postoperatively (n = 790 [73%]), while the remaining were placed in intermediate care (n = 201 [19%]) or in the surgical ward (n = 94 [7%]). Nurses monitored flaps every hour (q1h) for all patients. Frequency of resident monitoring varied, with 635 patients monitored every 4 hours (q4h), 146 monitored every 8 hours (q8h), and 304 monitored every 12 hours (q12h). Monitoring techniques included physical examination (n = 949 [87%]), handheld external Doppler sonography (n = 739 [68%]), implanted Doppler sonography (n = 333 [31%]), and needle stick (n = 349 [32%]); 105 patients (10%) demonstrated flap compromise, prompting return to the operating room in 96 patients. Of these 96 patients, 46 had complete flap salvage, 22 had partial loss, and 37 had complete loss. The frequency of resident flap checks did not affect the total flap loss rate (q4h, 25 patients [4%]; q8h, 8 patients [6%]; and q12h, 8 patients [3%]). Flap salvage rates for compromised flaps were not statistically different. Conclusions and Relevance Academic centers rely primarily on q1h flap checks by intensive care unit nurses using physical examination and Doppler sonography. Reduced resident monitoring frequency did not alter flap salvage nor flap outcome. These findings suggest that institutions may successfully monitor free flaps with decreased resident burden.

Minimally-invasive submandibular transfer (MIST) for prevention of radiation-induced xerostomia.

The initial aim was to determine the rate of pathologic tissue damage when dissecting the rat sciatic nerve with either bipolar forceps or low‐temperature tripolar plasma knife. The second aim was to determine the safety and effectiveness of the plasma knife during parotid surgery.

Fibrin sealant use in thyroidectomy: A prospective, randomized, placebo-controlled double blind trial using EVICEL

OBJECTIVE To develop a minimally invasive intraoral technique to transfer the submandibular gland into the submental space. STUDY DESIGN Experimental cadaver study. METHODS Five cephalus specimen, a total of 10 submandibular glands, underwent this intraoral approach. Primary outcome measures included operative time, length of gland transfer, adequate ligation of facial vessels, and preservation of lingual nerve, hypoglossal nerve, and submandibular duct. RESULTS All glands were successfully transferred. Operative times ranged from 60 to 120 minutes, mean time= 77 minutes. Length of gland repositioning ranged from 2.5 to 4 cm, mean length= 3.35 cm. Both nerves and the submandibular duct remained intact. Facial vessels were adequately visualized and ligated successfully if necessary for gland repositioning. CONCLUSIONS The submandibular gland can be transferred to the submental space through an intraoral incision without damaging the duct or neighboring nerves. The major advantage of this approach is the avoidance of an external neck scar and more rapid wound healing.

A Double-Blind, Randomized, Placebo-Controlled Clinical Trial Evaluating Fibrin Sealant in Thyroidectomy Closure

Objectives: To evaluate EVICEL fibrin sealant used in thyroid surgery closure. Primary endpoints were post-operative drain output, time to drain removal, length of admission and adverse events. Study design: A prospective, randomized, double-blind, placebo-controlled study. Settings: Subjects seen in the ENT Clinic at the Medical University of South Carolina. Subjects and methods: From June 2010 to January 2014, an IRB-approved prospective, randomized, double-blind study of EVICEL versus a saline control was conducted on 70 subjects receiving total thyroidectomy or hemithyroidectomy. 28 received Evicel and 27 received saline; data from fifteen subjects were eliminated due to protocol violations. The mean age was 50.3 (range 21 to 73). Results: There was no significant difference in drain output between Evicel (median[interquartile range]: 96.3 mL [73.3-139.3 mL]) and placebo (120.0 mL [68.8161.5 mL], p=0.334). Drain time (37.9 hrs [25.2-48.7 hrs] vs. 43.6 hrs [37.6-58.1 hrs]) and hospital stay (45.5 hrs[33.4-53.8 hrs] vs. 50.9 hrs[44.1-69.4 hrs]) were also shorter for Evicel, but again these differences were not significant (p=0.101 and 0.526 respectively). For total thyroidectomy subgroup there was a significant reduction in drain output (103.5 mL [80.0-138.6 mL] vs. 150.0 mL[120.0-188.5 mL], p=0.035) and drain time (40.3 hrs [26.2-49.1 hrs] vs. 47.1 hrs [42.0-67.8], p=0.035) with Evicel. Hospital stay in this subgroup was shorter with Evicel (50.3 hrs [43.6-54.9 hrs] vs. 59.4hrs [48.4-70.6 hrs]), but this result was not significant (p=0.246). No outcomes were significant in the hemithryoidectomy subgroup. Nine adverse events occurred in the Evicel group compared to three for placebo (p=0.101). Conclusion: Evicel sealant appears to be a safe, effective method to reduce serous drain output following total thyroidectomy, but has a limited role in hemithyroidectomy due to low levels of baseline drain output. Correspondence to: Dr. Shaun A. Nguyen, Associate ProfessorDirector of Clinical Research, Department of Otolaryngology-Head and Neck Surgery, Charleston, SC, USA, Tel: 843-792-1356; Fax: 843-792-0546, E-mail: nguyensh@musc.edu

Multicenter Assessment of Antibiotic Prophylaxis Spectrum on Surgical Infections in Head and Neck Cancer Microvascular Reconstruction

Objectives: Evaluate the advantages and disadvantages of Evicel fibrin sealant when used in thyroid surgery closure, taking into account the following endpoints: postoperative drain output, time to drain removal, length of admission, and adverse events. Methods: From June 2010 to January 2014, an institutional review board–approved prospective, randomized, double-blind study of Evicel versus a saline control was conducted on 70 subjects receiving total thyroidectomy or hemithyroidectomy. Twenty-eight received Evicel and 27 received saline; data from 15 subjects were eliminated due to protocol violations. The mean age was 50.3 (range, 21 to 73). Results: Comparisons of baseline characteristics, including age, sex, and type of surgery, revealed successful subject randomization. There was no significant difference in drain output between Evicel (median [interquartile range]: 96.3 mL [73.3-139.3 mL]) and placebo (120.0 mL [68.8-161.5 mL], P = .334). Drain time (37.9 hours [25.2-48.7 hours] vs 43.6 hours [37.6-58.1 hours]) and hospital stay (45.5 hours [33.4-53.8 hours] vs 50.9 hours [44.1-69.4 hours]) were also shorter for Evicel, but again these differences were not significant (P = .101 and .526, respectively). For the subjects undergoing total thyroidectomy, there was a significant reduction in drain output (103.5 mL [80.0-138.6 mL] vs 150.0 mL [120.0-188.5 mL], P = .035) and drain time (40.3 hours [26.2-49.1 hours] vs 47.1 hours [42.0-67.8 hours], P = .035) with Evicel. Hospital stay in this subgroup was shorter with Evicel (50.3 hours [43.6-54.9 hours] vs 59.4 hours [48.4-70.6 hours]), but this result was not significant (P = .246). No outcomes were significant in the hemithryoidectomy subgroup. Nine adverse events occurred in the Evicel group compared to 3 for placebo (P = .101). Conclusions: Evicel sealant appears to be a safe, effective method to reduce serous drain output following total thyroidectomy but has a limited role in hemithyroidectomy due to low levels of baseline drain output.

Association of the Anterolateral Thigh Osteomyocutaneous Flap With Femur Structural Integrity and Assessment of Prophylactic Fixation

Objective To characterize and identify risk factors for 30-day surgical site infections (SSIs) in patients with head and neck cancer who underwent microvascular reconstruction. Study Design Cross-sectional study with nested case-control design. Setting Nine American tertiary care centers. Subjects and Methods Hospitalized patients were included if they underwent head and neck cancer microvascular reconstruction from January 2003 to March 2016. Cases were defined as patients who developed 30-day SSI; controls were patients without SSI at 30 days. Postoperative antibiotic prophylaxis (POABP) regimens were categorized by Gram-negative (GN) spectrum: no GN coverage, enteric GN coverage, and enteric with antipseudomonal GN coverage. All POABP regimens retained activity against anaerobes and Gram-positive bacteria. Thirty-day prevalence of and risk factors for SSI were evaluated. Results A total of 1307 patients were included. Thirty-day SSI occurred in 189 (15%) patients; median time to SSI was 11.5 days (interquartile range, 7-17). Organisms were isolated in 59% of SSI; methicillin-resistant Staphylococcus aureus (6%) and Pseudomonas aeruginosa (9%) were uncommon. A total of 1003 (77%) patients had POABP data: no GN (17%), enteric GN (52%), and antipseudomonal GN (31%). Variables independently associated with 30-day SSI were as follows: female sex (adjusted odds ratio [aOR], 1.6; 95% CI, 1.1-2.2), no GN POABP (aOR, 2.2; 95% CI, 1.5-3.3), and surgical duration ≥11.8 hours (aOR, 1.9; 95% CI, 1.3-2.7). Longer POABP durations (≥6 days) or antipseudomonal POABP had no association with SSI. Conclusions POABP without GN coverage was significantly associated with SSI and should be avoided. Antipseudomonal POABP or longer prophylaxis durations (≥6 days) were not protective against SSI. Antimicrobial stewardship interventions should be made to limit unnecessary antibiotic exposures, prevent the emergence of resistant organisms, and improve patient outcomes.