Kelly M. Malloy

Autograft versus allograft in degenerative cervical disease

Cervical spondylosis, common among people older than 50 years, may produce symptoms of cervical radiculopathy, myelopathy, or both. When patients with degenerative cervical disease require surgery, an anterior decompression of the neural elements and reconstruction of the anterior column with allograft or autograft is common. Allograft incorporates more slowly and less completely than autogenous bone graft, although harvest of autograft from the anterior iliac crest or the middle ⅓ of the fibula may be associated with postoperative morbidity. Overall, higher rates of fusion have been reported with autograft than allograft. However, similar fusion rates have been reported among nonsmokers having single-level anterior cervical interbody fusions. For patients requiring multilevel reconstruction surgery, fusion rates of approximately 100% have been achieved using autogenous strut grafts from the iliac crest and fibula, with a lower rate of incorporation for fibula allograft. The potential for a patient with a nonunion requiring additional operative treatment must be weighed against the potential for graft-related complications when choosing between autograft and allograft for anterior cervical reconstruction.

Transoral Robotic Surgery Alone for Oropharyngeal Cancer: An Analysis of Local Control

OBJECTIVE To evaluate local control following transoral robotic surgery (TORS) with the da Vinci Surgical System (Intuitive Surgical Inc) as a single treatment modality for oropharyngeal squamous cell carcinoma (OSCC). DESIGN Prospective, single-center, observational study. SETTING Academic university health system and tertiary referral center. PATIENTS Thirty adults with previously untreated OSCC. INTERVENTION Transoral robotic surgery with staged neck dissection as indicated. MAIN OUTCOME MEASURES Local control and margin status. RESULTS Thirty patients were enrolled with previously untreated OSCC and no prior head and neck radiation therapy. Follow-up duration was at least 18 months. At the time of diagnosis, 9 tumors were T1 (30%); 16 were T2 (53%); 4 were T3 (13%); and 1 was T4a (3%). The anatomic sites of these primary tumors were tonsil in 14 (47%), tongue base in 9 (30%), glossotonsillar sulcus in 3 (10%), soft palate in 3 (10%), and oropharyngeal wall in 1 (3%). There was only 1 patient (3%) who had a positive margin after primary resection; further resection achieved a final negative margin. Perineural invasion was noted in 3 tumors (10%). No patient received postoperative adjuvant therapy. At a mean follow-up of 2.7 years (range, 1.5-5.1 years), there was 1 patient with local failure (3%). CONCLUSION As the only modality used for treatment of pathologically low-risk OSCCs, TORS provides high local control and is associated with low surgical morbidity.

A critical analysis of the literature regarding surgical approach and outcome for adult low-grade isthmic spondylolisthesis

Objective: A systematic review of the radiographic and clinical outcomes of adult patients undergoing surgery for low-grade isthmic spondylolisthesis was performed to determine whether conclusions could be made regarding the optimal choice of surgically managing adult low-grade isthmic spondylolisthesis. Methods: We tabulated the radiographic and clinical outcomes of patients who underwent a posterior procedure alone, an anterior procedure alone, or a combined anterior and posterior procedure. We also evaluated the influence of covariates such as laminectomy, spinal internal fixation, smoking, and secondary gain issues on these outcomes. Patients were pooled, and a χ2 analysis was performed to determine the relationship between surgical approach and patient outcome. A covariate analysis was performed to determine the influence of a laminectomy, spinal fixation, smoking, and secondary gain issues on these outcomes. Results: The available literature consisted primarily of retrospective case series, with only 4 of 34 reports being prospective randomized controlled studies. Patients with combined anterior and posterior procedures were most likely to achieve a solid fusion and a successful clinical outcome. The use of spinal fixation also increased the chance of fusion and successful clinical outcome. Conclusions: A pooling of the surgical literature on adult low-grade spondylolisthesis indicates that a combined anterior and posterior procedure most reliably achieves fusion and a successful clinical outcome. The literature, however, is primarily retrospective and heterogeneous with respect to indications for surgery and methods of evaluating outcome, providing a compelling rationale for a prospective randomized controlled trial of the various surgical approaches to this problem.

Thoracodorsal artery scapular tip autogenous transplant: vascularized bone with a long pedicle and flexible soft tissue.

OBJECTIVE To demonstrate that the 3 reconstructive advantages of the thoracodorsal artery scapular tip transplant (Tdast), a long pedicle, independently mobile tissue components, and the 3-dimensional nature of the scapular tip, will improve the quality and success of complex reconstructions by avoiding vein grafting, preventing the need for 2 separate transplants, and facilitating bony inset. DESIGN Prospective case series. SETTING Tertiary care academic medical center. PATIENTS Twenty-one patients (male to female ratio, 16:5; mean age, 52 years) underwent reconstruction of the upper, middle, and lower face from 2001 through 2006. Indications for reconstruction were tumor ablation in 11 patients, secondary reconstruction in 4 patients, osteoradionecrosis in 4, and posttraumatic reconstruction in 2. Seventeen patients underwent radiation. INTERVENTIONS All patients underwent harvest of an autogenous transplant of scapular tip bone and latissimus dorsi soft tissue based on the thoracodorsal artery. The mean bone length was 5.2 cm (range, 2.5-9.0 cm), and the mean cutaneous surface area was 68 cm² (range, 20-250 cm²). MAIN OUTCOME MEASURES Reduction of vein grafting, avoidance of 2 transplants, use of the triangular shape of the scapular tip in reconstruction, complications, and shoulder function. RESULTS The success rate of transplantation was 100%. The use of this transplant avoided vein grafting in 16 patients and the need for 2 separate transplants in 11 patients, and the 3-dimensional nature of the scapular tip facilitated inset in 13 patients. In 14 patients, more than 1 of these reconstructive advantages was achieved. In 6 patients, all 3 were accomplished. Eleven patients experienced a complication. The major complication rate was 33%, and the minor complication rate was 33%. The mean Constant-Murley test of shoulder function score was 87 of 100 (range, 74-100). CONCLUSIONS The Tdast is an excellent choice for reconstruction in the head and neck as an alternative to procedures requiring vein grafting and multiple free tissue transplants, or in which the 3-dimensional contour of the scapular tip aids in reconstruction. The complication rate should be assessed in the context of the risk factors of the patient population and the outcome with respect to stable employment, increasing body mass index, and maintenance of shoulder function.

Photodynamic therapy in the management of pre-malignant head and neck mucosal dysplasia and microinvasive carcinoma

The management of head and neck mucosal dysplasia and microinvasive carcinoma is an appealing strategy to prevent the development of invasive carcinomas. While surgery remains the standard of care, photodynamic therapy (PDT) offers several advantages including the ability to provide superficial yet wide field mucosal ablative treatment. This is particularly attractive where defining the extent of the dysplasia can be difficult. PDT can also retreat the mucosa without any cumulative fibrotic complications affecting function. To date, clinical experience suggests that this treatment approach can be effective in obtaining a complete response for the treated lesion but long term follow-up is limited. Further research efforts are needed to define not only the risk of malignant transformation with PDT but also to develop site specific treatment recommendations that include the fluence, fluence rate and light delivery technique.

Ultrasound-guided contrast-enhanced sentinel node biopsy of the head and neck in a porcine model

Objective To test the feasibility of contrast-enhanced ultrasound (CEUS)–guided sentinel lymph node biopsy (SNB) of the head and neck in a porcine model. Study Design and Setting In this prospective, non-randomized study, methylene blue and Sonazoid were injected into the lateral tongue or floor of mouth (FOM) of four swine. Real-time CEUS was used to identify contrast in the lymphatic channels flowing to the sentinel lymph node (SLN). Endoscopic or open SNB was performed. Neck dissection was then performed, and the residual nodal packet was examined for remaining contrast-enhancing or blue dye–stained nodes. Results In all eight procedures, the SLN was visualized with ultrasound and blue dye. Seven procedures identified a single SLN, and one identified two SLNs. Subsequent neck dissections revealed no other nodes containing methylene blue or contrast in the nodal specimen or operative bed. Conclusion/Significance CEUS-guided SNB of the head and neck in swine is feasible, with success comparable to blue dye–guided SNB. This technique may offer several advantages over traditional techniques, and warrants further study.

Management of aerodigestive tract foreign bodies: innovative teaching concepts.

Objectives: We discuss a method to provide medical education in bronchoesophagology by using high-fidelity patient simulation manikins. Methods: A sophisticated, life-sized infant manikin with realistic anatomic, physiologic, and hemodynamic responses to interventions was programmed to simulate endobronchial foreign body lodgment by blocking ventilation of one lung and manifesting audible stridor, asymmetric chest wall motion, and decreased oxygen saturation. Results: Otolaryngology residents participated in simulation exercises incorporating the cognitive and technical skills necessary for successful airway endoscopy, including technical proficiency and teamwork, to learn to coordinate endoscopy and ventilation and manage laryngospasm. Rather than relying on instructor description, the participants responded directly to the manikin. This sense of realism stimulated participants to rehearse to improve provider performance and patient safety. Simulation provided an agenda determined by the needs of the learners, exploration without direct risk to patients, immediate feedback, and objective documentation. Conclusions: Rapidly evolving medical simulation technologies support activated, effective adult learning; they will play an increasing role in medical education.

Simulation-based otorhinolaryngology emergencies boot camp: Part 1: Curriculum design and airway skills.

Laryngoscope, 124:1562–1565, 2014

Simulation-based otorhinolaryngology emergencies boot camp: Part 2: Special skills using task trainers.

Laryngoscope, 124:1566–1569, 2014

Simulation-based otorhinolaryngology emergencies boot camp: Part 3: Complex teamwork scenarios and conclusions

Laryngoscope, 124:1570–1572, 2014