Chang, Brent A.

ABSTRACT This case highlights the diagnostic challenges posed by rare oropharyngeal neurofibromas, their potential to mimic other conditions, and the novel application of transoral robotic surgery (TORS) for the management of an oropharyngeal neurofibroma. A 47‐year‐old female presented with a 1‐year history of a left tonsillar mass. Clinical evaluation, imaging, and biopsy results were inconclusive but raised suspicion for a neoplasm. The patient underwent robotic‐assisted tonsillectomy and mass resection. Subsequent histopathological evaluation confirmed a benign spindle cell tumor consistent with neurofibroma. Oropharyngeal neurofibromas may present diagnostic challenges due to their resemblance to common tonsillar pathologies. Imaging and biopsies may not always provide definitive diagnoses, necessitating surgical excision for accurate characterization. This case demonstrates the utility of TORS, offering improved visualization and access while minimizing patient morbidity.

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 Objective Lymphoepithelial carcinoma of the salivary gland (LECSG) is a rare malignancy. The purpose of this study is to evaluate the clinical features of LECSG with a focus on the role of Epstein‐Barr virus (EBV). Data Sources PubMed, Embase, Web of Science, institutional pathology Natural Language search tool. Review Methods Retrospective review of patients diagnosed with LECSG at a single institution and a systematic literature review. Full text articles in English were included. Results 285 cases of LECSG identified via literature review and an additional 10 within our institution. Most tumors were in the parotid gland (70.5%). Lymph node metastasis was observed in 28%. Most cases were in Asian or Inuit patients (70.5%). EBV association was positive in 52%, and 87.6% of these were in endemic populations. Treatment primarily involved surgical resection (65.8%), often combined with adjuvant therapy (50.2%). No significant differences in disease‐free survival (DFS) or disease‐specific survival (DSS) were observed by EBV status. Advanced tumor stage was associated with worse DFS ( P < .0001) and worse DSS ( P < .0001). Lymph node metastasis was also associated with reduced DSS ( P = .04). Independent predictors of poorer DFS and DSS included late tumor and endemic region of origin. Conclusion This comprehensive analysis of 295 salivary gland LEC cases provides valuable insights into the clinical behavior, pathological features, and treatment outcomes of this rare malignancy. The study highlights the potential role of EBV in tumor pathogenesis, particularly in endemic populations, and emphasizes the need for further research to establish optimal management strategies.

Abstract Objective Intraoperative parathyroid hormone (ioPTH) monitoring is crucial during parathyroid surgery to ensure chemical cure. However, delays in processing can prolong operative times. This study evaluates the effectiveness of a checklist to expedite ioPTH assay processes. Methods A multidisciplinary checklist was developed to standardize ioPTH collection and workflow. Thirty patients treated with use of the checklist were prospectively studied, while 30 patients treated without use of the checklist were retrospectively reviewed. Time intervals for post–15‐minute ioPTH assay results were compared. Results Thirty age‐ and sex‐matched patients were included in each group (n = 60) involving 5 surgeons. The intervention and control group had a mean baseline PTH of 140.9 and 130.3 pg/mL and a post–15‐minute ioPTH of 69.6 and 52.0 pg/mL, respectively. The mean time from sample collection to the post–15‐minute ioPTH assay result was significantly reduced in the intervention as compared to the control group (22.2 vs 33.3 minutes; P < .01). The proportional operative time spent awaiting ioPTH assay results was also reduced (24.4 vs 34.1%; P < .01). In subgroup analysis, a significant difference in the total operative time was found in adenomatous disease (68.0 vs 92.2 minutes, P < .05) but not four‐gland hyperplasia (119.3 vs 142.3 minutes). Discussion The implementation of a simple intraoperative checklist effectively reduces the overall ioPTH assay processing time, creating a more efficient surgical workflow. It is low‐cost and requires minimal additional resources. Implications for Practice This quality improvement intervention holds promise for broader adoption in parathyroid surgery to reduce delays and optimize patient care.

ABSTRACT Background Medial sural artery perforator (MSAP) flaps are favored in head and neck reconstruction for skin paddle pliability, pedicle length, and low donor site morbidity. We sought to characterize MSA vascular branching patterns based on the Dusseldorp et al. classification system using pre‐operative lower extremity computed tomography angiogram (CTA). Methods We conducted a retrospective review of 153 scans from 78 patients who underwent CTA prior to head and neck reconstruction at our institution. Primary data points included MSA branching pattern, branch dominance, and vessel depth. Results The type IIa branching type was most prevalent and the MSA lateral branch most frequently dominant, and they were significantly related to one another. There was no significant difference in depth between branching patterns. Conclusions Lower extremity CTA provides valuable insight to vascular anatomy for MSAP flap harvest. The type IIa and IIb types may be associated with lateral and medial MSA dominance, respectively.

Additive manufacturing (AM) of polyetheretherketone (PEEK) offers a promising route for producing lightweight, biocompatible, and patient-specific medical implants with complex geometries. This study investigates and optimizes fused deposition modeling (FDM) parameters for fabricating small-scale PEEK medical components with improved dimensional accuracy and surface quality. PEEK’s high processing temperature and thermal contraction make precision printing of fine features challenging. A Taguchi design of experiments (L9 orthogonal array) was employed to assess the effects of nozzle temperature, layer height, printing speed, and extrusion width on dimensional deviation and surface roughness using 5 × 5 × 5 mm cube specimens. Dimensional accuracy was quantified along the horizontal and vertical axes, and surface roughness was measured using a stylus profilometer. Statistical analysis showed layer height was the most significant factor affecting horizontal accuracy (p = 0.0225), while printing speed most strongly influenced vertical deviation. The optimal parameters, 450 °C nozzle temperature, 0.06 mm layer height, 7.5 mm/s printing speed, and 0.4 mm extrusion width, achieved mean deviations of 0.013 mm (horizontal) and 0.049 mm (vertical) with a surface roughness of 4.01 µm. Validation using a benchmark model and micro-computed tomography confirmed improved reproduction of small features under these conditions. The results demonstrate that precise control of FDM parameters enables accurate fabrication of sub-millimeter PEEK structures suitable for medical device applications.

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.

Background: Postoperative failure to wean from ventilator support is associated with poor outcomes. This study characterizes patients requiring prolonged ventilation after head-and-neck reconstructive surgery and their outcomes. Methods : Patients who underwent head-and-neck reconstructive surgery were identified in the National Surgical Quality Improvement Program (NSQIP) database using CPT codes, ICD-10 codes, and free-text search. Hypothesis testing and regression analysis was utilized to compare patient characteristics and peri/postoperative complication rates between those with and without extended ventilation. Results : NSQIP contained 4661 patients who underwent free flap surgery; 180 experienced prolonged ventilation. Patients with primary oral cavity/sinonasal malignancy, preoperative ventilator dependence, and preoperative open wound/wound infection were more likely to experience prolonged ventilation. Prolonged ventilation patients experienced double the overall hospital stay, and increased rates of wound disruption, reoperation, and mortality. (p<0.05). Conclusion : Prolonged mechanical ventilation can significantly affect outcomes of free flap patients, including longer hospital stays, and higher 30-day mortality.

Objective: Airway management in patients with severely-narrowed tracheal lumens presents significant challenges, especially when traditional intubation methods are not feasible. In such cases, failed intubation attempts can worsen airway compromise and cause life-threatening complications. Extracorporeal membrane oxygenation (ECMO) offers an alternative approach to ensure oxygenation and ventilation during complex airway surgeries. The objective of this study was to assess the safety and feasibility of using venovenous ECMO to ensure oxygenation before attempting intubation in patients with severely-narrowed tracheal lumens undergoing head and neck surgery. Methods: This is a retrospective case series of 3 adult patients who underwent venovenous ECMO-assisted intubation for head and neck surgeries at a single institution between 2010 and 2023. The primary outcome was the successful establishment of an airway and the avoidance of respiratory failure during the surgical procedure. Results: All 3 patients successfully underwent ECMO-assisted intubation. None of the patients experienced major complications directly attributable to ECMO, and all were extubated within 24 hours postoperatively. Conclusions: Venovenous ECMO provides an effective strategy for managing difficult airways in patients with severely-narrowed tracheas, enabling safe anesthesia induction. This technique may be crucial in preventing complications associated with traditional airway management methods.

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.