Timothy M. Haffey

Subglottic stenosis: A ten‐year review of treatment outcomes

To evaluate the endoscopic surgical management of adult subglottic stenosis and describe treatment outcomes.

Evaluation of unilateral sensorineural hearing loss in the pediatric patient.

OBJECTIVES This study is a review of our series of pediatric patients with unilateral sensorineural hearing loss (USNHL) to report abnormalities on imaging studies, review genetic and ophthalmologic results, and survey audiometric findings. METHODS This study is a retrospective chart review of all pediatric patients with USNHL seen between 1/1/03 and 12/31/08 at our institution. The study was approved by the institutional review board. RESULTS Eighty-nine cases were identified with audiometric findings confirming unilateral hearing thresholds greater than 20 dBHL with no conductive component. There were 48 males and 41 females. Average age of diagnosis was 7 years. One audiogram showed low-frequency loss, 17 mid-frequency, 29 high-frequency, and 32 flat. Ten patients were diagnosed by auditory brainstem response testing at another institution, with thresholds not available for review. Eleven percent of patients progressed to bilateral loss. Sixty-one patients underwent computed tomography of temporal bones (CTTB). Twenty of 61 scans identified 34 anomalies including 15 enlarged vestibular aqueducts (EVAs), 8 Mondini, and 3 superior semicircular canal dehiscences (SSCDs). Thirty-one of 89 patients underwent magnetic resonance imaging (MRI). Three of these 31 patients had positive findings including 1 EVA, 1 Mondini, and 1 asymmetric internal auditory canal. When CTTB was positive, no additional lesions were detected on MRI. When CTTB was negative and MRI was done in 20 patients, 2 additional lesions were detected by MRI. Fourteen patients had genetics evaluation of which 6 had positive findings, including CHARGE, VACTERL, Goldenhar, and 3 were heterozygous for a Connexin mutation. CONCLUSIONS CTTB is an effective diagnostic tool for USNHL. MRI should be considered in patients with negative CTTB. Genetics and ophthalmologic evaluations are recommended for patients with risk factors or an abnormal clinical examination. Close follow-up is essential due to high rate of hearing loss progression.

Minimizing Morbidity in Microvascular Surgery: Small-Caliber Anastomotic Vessels and Minimal Access Approaches

IMPORTANCE Minimizing morbidity when performing free flap reconstruction of the head and neck is important in the overall reconstructive paradigm. OBJECTIVE To examine the indications and success rates of free tissue transfer using small-caliber facial recipient vessels and minimal access incisions. DESIGN, SETTING, AND PARTICIPANTS Retrospective medical record review of patients with head and neck defects undergoing free tissue transfer from May 2010 to June 2013 at 2 tertiary care academic medical centers. INTERVENTIONS Free tissue transfer using small-caliber recipient vessels and minimal access approaches. MAIN OUTCOMES AND MEASURES Postoperative complications, including flap failure, requirement for revision surgery, and nerve dysfunction. RESULTS Eighty-nine flaps in 86 patients met inclusion criteria. Fifty flaps used the facial artery and vein distal to the facial notch, and 33 flaps used the superficial temporal vascular system. Six flaps used the angular artery and vein. A variety of flap donor sites were included. In most cases, free tissue transfer was indicated for the reconstruction of defects secondary to extirpation of malignant neoplasia. Overall success rate was 97.7% with 2 instances of total flap loss and 1 partial loss. One patient had transient nerve weakness (frontal branch), which resolved during a follow-up of 9 months. CONCLUSIONS AND RELEVANCE Free tissue reconstruction of head and neck defects can be safely and reliably accomplished using small-caliber recipient vessels, such as the superficial temporal, distal facial, and angular vessels. Minimal access approaches for microvascular anastomosis may be performed with excellent cosmesis and minimal morbidity. LEVEL OF EVIDENCE 4.

Anterolateral Thigh Adipofascial Flap in Mucosal Reconstruction

IMPORTANCE This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique. OBJECTIVE To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated. RESULTS Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was reconstructed with a contralateral adipofascial flap with excellent outcome. Three patients (10%) required minor flap revisions. There were no other complications. CONCLUSIONS AND RELEVANCE The ALTAF is a versatile flap easily harvested for use in several types of mucosal reconstructions.

Exploring the clinical value and implications of routine pathological examination of septoplasty specimens

During septoplasty, otherwise normal cartilage and bone are removed and routinely submitted for pathologic examination. According to the College of American Pathologists, however, the examination of bone and cartilage from septoplasty and rhinoplasty may be left to the pathologists discretion. We explored the processing of tissues removed during septoplasty, examining the clinical value and implications of current practices.

Sternohyoid Flap for Facial Reanimation: A Comprehensive Preclinical Evaluation of a Novel Technique

IMPORTANCE Neuromuscular reanimation of the face provides the correct specific neural functional input and thereby prevents synkinesis. Unfortunately, this ideal situation is rarely encountered in the clinical setting. OBJECTIVES To assess the technical feasibility of and define the surgical procedure for harvesting the sternohyoid muscle as a novel free flap for use in facial reanimation indications. DESIGN, SETTING, AND PARTICIPANTS Fresh, postmortem, nonfixed cadavers were used to define the anatomy and perform the flap harvest procedures. Twenty-four flap harvests were performed. Angiography was performed on the pedicle of the harvested flaps to assess potential flap perfusion. Adenosine triphosphatase staining was performed on the muscle specimens to establish fiber type. MAIN OUTCOME MEASURES The harvest technique, pedicle (arterial or venous), nerve length, and flap geometry parameters were characterized. RESULTS The sternohyoid muscle was found to be reliably vascularized by the superior thyroid artery in all cases with an appropriate arterial and venous pedicle for vascular anastomosis. The mean arterial (5.5 cm) and venous (5.9 cm) pedicle lengths are comparable with gracilis flaps. The mean motor nerve length was 10.7 cm. The inclusion of the hyoid bone allows rigid fixation, and the muscle size, fiber type, and volume profiles all compare favorably to the gracilis flap for use in the indication of facial reanimation. Mock surgical procedures were performed to define inset parameters. This flap potentially allows single-stage cross-facial neurorrhaphies to be performed. CONCLUSIONS AND RELEVANCE This is the first article, to our knowledge, of the sternohyoid muscle as a potential donor site for free-tissue transfer. This muscle has a predictable vascular pedicle and neural innervation along with size and fiber type parameters that make it an ideal potential free flap for facial reanimation. LEVEL OF EVIDENCE NA.

Paranasal sinus exostoses: an unusual complication of topical drug delivery using cold nasal irrigations.

The use of topical drug delivery through nasal irrigations can minimize systemic side effects and deliver higher concentrations of drugs directly to diseased sinus mucosa. Complications related to this popular method of treatment are not well described. We present our experience with paranasal sinus exostosis (PSE), a new diagnostic entity that appears to be a complication of cold nasal irrigations.

Short-stay hospital admission after free tissue transfer for head and neck reconstruction.

To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option.

Pathological Review of Turbinate Tissue from Functional Nasal Surgery: Incurring Costs without Adding Quality

Objective Inferior turbinate surgery for nasal obstruction can be performed in a variety of ways. Only a few of these methods produce tissue that can be sent for pathologic analysis. According to the College of American Pathologists, turbinate tissues are not exempt from requisite pathologic evaluation. Our objectives were to evaluate the clinical value and cost implications of routine pathological examination of turbinate specimens. Study Design Case series with chart review. Setting Academic tertiary care medical center. Subjects and Methods Charts of patients who underwent an inferior turbinate procedure for nasal obstruction between January 2008 and August 2011 were reviewed. Results Thirteen hundred consecutive cases from 17 surgeons were identified. Among these patients, 223 (17%) underwent an isolated turbinate reduction procedure and 779 (59%) underwent a reduction procedure in conjunction with a septoplasty. The remaining patients had a turbinate procedure in addition to another head and neck procedure. Only 591 (45%) turbinate reduction procedures were performed by methods that were tissue producing, and of these, 137 (23%) were sent for pathologic analysis. All submitted specimens received a gross examination and 123 (90%) also underwent histologic analysis. No abnormalities were reported. Conclusion At our institution, most surgeons did not submit turbinate tissues for pathologic examination even when a specimen was produced. Of the specimens sent, no abnormal pathologic results were identified. Our results suggest that routine pathologic evaluation of inferior turbinate specimens may not contribute to patient care and perhaps represents an unnecessary cost.

Auto Flow-Through Technique for Anterolateral Thigh Flaps

IMPORTANCE The vascular supply of anterolateral thigh (ALT) free flaps is variable, and the pedicle length and ability to capture perforators to the flap may be limited by the anatomic configuration. We describe the reasoning behind performing the auto flow-through procedure, as well as the steps to carry this procedure out. OBSERVATIONS A retrospective medical chart review was performed within our health care system database to identify patients in whom the auto flow-through technique was used during reconstruction with an ALT free flap. The auto flow-through technique was applied to 3 separate ALT free flaps to incorporate perforators from 2 separate vascular systems. This technique allowed for more robust vascularity of the flap and/or optimized pedicle length that would have otherwise necessitated vein grafts. All patients had successful ALT free flap reconstruction and went on to have good functional results. CONCLUSIONS AND RELEVANCE The auto flow-through technique is an adaptation of the flow-through flap, which allows for capture of vascular perforators from separate sources when this configuration is present in the ALT free flap. This technique is especially useful when operating in a vessel-depleted neck or when maximizing pedicle reach is necessary. This technique allows the ALT to be used in challenging reconstruction cases regardless of the vascular branching pattern of the pedicle. LEVEL OF EVIDENCE 4.