Chang, Brent A

ABSTRACT Background Predictors of complications and length of stay (LOS) in patients requiring brief inpatient stays after total thyroidectomy remain poorly understood. We identify preoperative risk factors for complications, differentiate predictors of overnight versus two‐day stays and estimate associated hospital costs. Methods The National Inpatient Sample for 2016–2021 was used to analyse adult patients undergoing total thyroidectomy with LOS = 1 or 2 days. Multivariate regressions identified predictors of complications and LOS. Costs were transformed logarithmically. Results Of 26 560 patients, 70% had an overnight stay. Two‐day stays were associated with higher complication rates, comorbidity index, neck dissection and increased cost. Hispanic and Asian or Pacific Islander race, comorbidity and surgery in a rural hospital increased the risk of any thyroidectomy‐specific complication. Two‐day stays had a 29% higher cost than overnight stays. Conclusions Preoperative characteristics can help predict complications and LOS following total thyroidectomy. Risk stratification supports cost‐effective, patient‐centred care planning.

ABSTRACT Objectives To characterize practice patterns and outcomes in the management of low‐ and intermediate‐grade salivary gland carcinoma prior to the existence of treatment guidelines. Methods Analysis of a registry of patients who underwent parotid and submandibular gland resections for low‐and intermediate‐grade carcinomas between 2010 and 2019. Results Of all 786 patients included in the study, 726 (92%) had preoperative imaging and 653 (83%) had preoperative biopsy. Of the 729 patients with parotid gland cancer, the majority underwent superficial ( n = 384, 53%) or total ( n = 254, 35%) parotidectomy. In patients with facial nerve preservation, total parotidectomy was associated with a significant increase in transient facial weakness (72/177 (41%) vs. 82/311 (26%), RR 0.65, 95% CI 0.50–0.84, p < 0.05) and permanent facial nerve weakness (23/176 (13%) vs. 16/301 (5%), RR 0.41, 95% CI 0.22–0.75, p < 0.05) compared to superficial parotidectomy. Adjuvant radiation therapy ( RT ) was delivered to 285 (36%) patients. The proportion of patients receiving adjuvant RT declined significantly over the time period from 2015 to 2019 compared to 2010 to 2014 at 162/504 (32%) and 123/282 (44%), respectively ( RR 0.74, 95% CI 0.61–0.89, p < 0.05). When comparing the time periods from 2015 to 2019 and 2010 to 2014, there was no significant difference in local control rates ( RR 0.52, 95% CI 0.26–1.04, p = 0.06) or regional control rates ( RR 0.75, 95% CI 0.26–2.13, p = 0.58). Conclusions Management of low‐ and intermediate‐grade salivary cancer from 2010 to 2019 was variable, which is expected given the rarity and heterogeneity of the disease and the lack of treatment guidelines prior to 2021. Most patients with parotid malignancies underwent superficial or total parotidectomy. The extent of parotidectomy had an impact on facial nerve function outcomes. Delivery of adjuvant radiation trended down with time. The data presented here will support dissemination of the guidelines and provide data that could inform future trials. Level of Evidence 2b.

ABSTRACT Objective Total laryngectomy (TL) represents a major operation often performed on medically complex patients. The impact of blood transfusion in TL patients is not well defined. Here, we utilize a national database to characterize these patients and further investigate a potential dose‐dependent relationship between transfusion and postoperative outcomes. Methods The National Surgical Quality Program (NSQIP) was queried for patients who underwent TL with/without neck dissection (CPT 31360, 31365) between 2014 and 2022. Total units of transfused blood were only available for patients between 2020 and 2023. Statistical analysis involved hypothesis testing, multivariate logistic regression, and receiver operating characteristic (ROC) analysis. Results Among 2311 patients, 413 (17.9%) received transfusions. Non‐White race, ASA Class ≥ 3, hypertension, cancer with distant metastases, bleeding disorders, and elevated BUN, WBC, and INR were associated with transfusion ( p < 0.05). Multivariate analysis identified hypertension (OR 1.81), bleeding disorders (OR 2.64), ASA ≥ 3 (OR 2.40), concurrent free flap (OR 3.75) and lower hematocrit (OR 0.85) as predictors. Transfused patients had longer hospital stays (12 vs. 9 days), increased complications (e.g., stroke, DVT), higher reoperation (23.2% vs. 13.9%) and mortality (2.7% vs. 0.8%) ( p < 0.05). ROC analysis suggested transfusion > 2.5 units was associated with adverse outcomes. Conclusion TL remains a major surgical endeavor that can be associated with lengthy and complicated hospital courses. We show that perioperative transfusion may be associated with increased hospital stay, reoperation, and mortality in TL patients, with a potential dose‐dependent effect. Our study reinforces the risks associated with blood transfusion and further supports the thoughtful utilization of blood products in TL patients. Level of Evidence 3.

We present an interesting case of a 74‐year‐old female who presented with spinal accessory neuropathy following an ipsilateral right‐sided carotid endarterectomy 6 months after the initial injury. Subsequent surgical exploration revealed a surgical clip that had been placed directly across the spinal accessory nerve. Clip removal and neurolysis was subsequently performed, leaving the nerve intact. After surgical intervention, she immediately demonstrated increased bilateral shoulder shrug motion and continues to improve her function with physical therapy. This case demonstrates a fascinating case of cranial nerve recovery after delayed intervention in the context of existing literature. Laryngoscope, 135:2073–2075, 2025

An extended orbital exenteration defect in a male in his mid-80s was successfully reconstructed with a medial sural artery perforator flap. To our knowledge, this flap has not been described in the literature for such defects until now. While it may require meticulous intramuscular perforator dissection, it provides several advantages; it is thin, pliable, has a long pedicle of large calibre facilitating microanastomosis and provides adequate coverage where the amount of chimeric muscle can easily be tailored to the defect’s surface area and volume. In addition, its robust vascular supply can withstand volume changes post radiation therapy. Two years after surgery, the patient has healed well with an excellent functional outcome.

AbstractObjectiveThe profunda artery perforator (PAP) flap has gained popularity in head and neck reconstruction with a favorable donor site providing a relatively hidden scar and the ability to harvest a large amount of pliable tissue with consistent vascular anatomy. The primary aim of this study is to evaluate the safety and efficacy of this PAP flap in head and neck reconstruction.Data SourcesPUBMED, EMBASE, Web of Science, Google Scholar (January 1948‐February 2022).Review MethodsA systematic review of the English language literature was conducted for studies with at least 3 patients 18 years or older undergoing head and neck reconstruction utilizing the PAP. Study quality and risk of bias were evaluated using the MINORS scoring system. Main analysis endpoints were flap failure rate, donor site morbidity, and complication rate.ResultsNine articles and 206 total PAP flaps were included. The rate of flap‐related and medical complications was 33%, with only 2 (0.97%) instances of complete flap failure. Other complications included partial flap failure (10, 4.86%) and donor site wound complications (12, 5.83%). A total of 16 flaps (7.77%) required subsequent revision in the operating room. Average MINORS score of the studies suggested a moderate to high risk of bias.ConclusionBased on limited quality evidence, this review suggests that the PAP flap is a safe and feasible tool for head and neck reconstruction, with comparable complication and success rates as other free flaps. Further large‐scale studies are warranted.

ObjectivesMicrovascular free tissue transfer is routinely used for reconstructing midface defects in patients with malignancy, however, studies regarding reconstructive outcomes in invasive fungal sinusitis (IFS) are lacking. We aim to describe outcomes of free flap reconstruction for IFS defects, determine the optimal time to perform reconstruction, and if anti‐fungal medications or other risk factors of an immunocompromised patient population affect reconstructive outcomes.MethodsRetrospective review of reconstruction for IFS (2010–2022). Age, BMI, hemoglobin A1c, number of surgical debridements, and interval from the last debridement to reconstruction were compared between patients with delayed wound healing versus those without. Predictor variables for delayed wound healing and the effect of time on free flap reconstruction were analyzed.ResultsTwenty‐seven patients underwent free flap reconstruction for IFS. Three patients were immunocompromised from leukemia and 21 had diabetes mellitus (DM). Patients underwent an average of four surgical debridements for treatment of IFS. The interval from the last IFS debridement to flap reconstruction was 5.58 months (±5.5). Seven flaps (25.9%) had delayed wound healing. A shorter interval of less than 2 months between the last debridement for IFS and reconstructive free flap procedure was associated with delayed wound healing (Fisher Exact Test p = 0.0062). Other factors including DM, BMI, HgA1c, and bone reconstruction were not associated with delayed wound healing.ConclusionPatients with maxillectomy defects from IFS can undergo microvascular‐free flap reconstruction with good outcomes while on anti‐fungal medication. Early reconstruction in the first 2 months after the last IFS debridement is associated with delayed wound healing.Level of Evidence4 Laryngoscope, 134:1642–1647, 2024

ObjectiveThis study describes the prevalence of pathogenic germline variants (PGVs) in head and neck cancer patients, the incremental yield compared to a guideline‐based approach to genetic evaluation, and the uptake of family variant testing.Study DesignProspective cohort study.SettingThree tertiary academic medical centers.MethodsGermline sequencing using an 84‐gene screening platform among unselected head and neck cancer patients who received care at Mayo Clinic Cancer Centers between April 2018 and March 2020.ResultsAmongst 200 patients, the median age was 62.0 years (Q1, Q3: 55, 71), 23.0% were female, 89.0% white/non‐Hispanic, 5.0% Hispanic/Latinx, 6% of another race, and 42.0% had prognostic stage IV disease. The most common subsites were the oropharyngeal (45.0%) and salivary glands (12.0%). The most common histology was squamous cell carcinoma (74.5%). Twenty‐one patients (10.5%) had a total of 22 PGVs; 20 of the 21 patients (95.2%) did not meet criteria for testing by current guidelines. Regarding penetrance of the 22 PGVs, 11 were high or moderate (most commonPMS2orHOXB13), and 11 were low or recessive (most commonMUTYH,WNR, orRECQL4). One patient had a change in care based on an identified PGV. Family variant testing was completed at a rate of 4.8%.ConclusionsUniversal gene panel testing identified a PGV in 10.5% of head and neck cancer patients; almost all would have been missed by current guideline‐based testing. One of 21 patients had a treatment change due to their PGV, indicating that head and neck cancer treatment decisions are not yet widely informed by germline alterations.Level of Evidence3Laryngoscope, 133:3378–3388, 2023

AbstractObjectivesThe objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting.MethodsRelevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options.ResultsSpecific regional pedicled flap options are presented including the pectoralis major flap, deltopectoral flap, supraclavicular flap, submental flap, latissimus flap, and trapezius flap.ConclusionsRegional pedicled flaps are useful options in a salvage setting even for large defects and should be in the armamentarium of any reconstructive head and neck surgeon. Each flap option carries specific characteristics and considerations.