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Objectives: The medial sural artery (MSA) perforator flap is a versatile free flap. However, the cutaneous perforators are not well characterized. The objectives of this pilot anatomical study were to: (1) visualize in three‐dimensions, as in‐situ, the origin, course, and distribution of the cutaneous perforators, (2) characterize the number and frequency of the perforators, and (3) quantify mean pedicle length. Methods: Thirteen cadaveric specimens were dissected, digitized, and modeled in 3D. Three‐dimensional models and dissection photographs were used to determine the origin, course, number, distribution, and pedicle length of MSA perforators. Results: The most common pattern consisted of three perforators (39% of specimens). The maximum number of perforators identified was four (23%). The majority of specimens (92%) had a cutaneous perforator originating from the lateral branch of the MSA and coursed most frequently in the second (43%) and third (37%) quartiles of the length of the tibia. Mean pedicle length was 19.1 ± 6.9 cm. Perforators originating from the medial branch of the MSA were significantly (p < 0.05) shorter than those from the lateral branch and were found to course only in the first quartile. Conclusion: The 3D models constructed in this study provide a comprehensive overview of the location and course of the perforators, enabling measurement of parameters in 3D‐space. Anatomical characterization of the MSA perforator flap using 3D analysis can assist reconstructive surgeons in understanding the relevant anatomy and optimizing the surgical technique for flap harvest. Level of Evidence: N/A Laryngoscope, 134:4298–4303, 2024 [ABSTRACT FROM AUTHOR]

Objective: To identify the most frequently asked questions regarding "laryngectomy" through an assessment of online search data. Methods: Google Search data based on the search term "laryngectomy" were analyzed using Google Trends and Search Response. The most common People Also Ask (PAA) questions were identified and classified by the concept. Each website linked to its respective PAA question was rated for understandability, ease of reading, and reading grade level. Results: Search popularity for the term "laryngectomy" remained stable between 2017 and 2022. The most popular PAA themes were post‐laryngectomy speech, laryngectomy comparison to tracheostomy, stoma and stoma care, survival/recurrence, and post‐laryngectomy eating. Of the 32 websites linked to the top 50 PAA's, eleven (34%) were at or below an 8th grade reading level. Conclusion: Post‐laryngectomy speech, eating, survival, the stoma, and the difference between laryngectomy and tracheostomy are the most common topics searched online in relation to "laryngectomy." These are important areas for both patient and healthcare provider education. Level of Evidence: N/A Laryngoscope, 133:2971–2976, 2023 [ABSTRACT FROM AUTHOR]

Objective/Hypothesis: Pain management following transoral robotic surgery (TORS) varies widely. We aim to quantify opioid usage following TORS for oropharyngeal squamous cell carcinoma (OPSCC) and identify prescribing predictors. Study Design: Retrospective cohort study. Methods: A consecutive series of 138 patients undergoing TORS for OPSCC were reviewed from 2016 to 2019. Opioid usage (standardized to morphine milligram equivalents [MME]) was gathered for 12 months post‐surgery via prescribing record cross‐check with the Massachusetts Prescription Awareness Tool. Results: Of 138 OPSCC TORS patients, 92.8% were human papillomavirus (HPV) positive. Adjuvant therapy included radiation (XRT;67.4%) and chemoradiation (cXRT;6.5%). Total MME usage from start of treatment averaged 1395.7 MMEs with 76.4% receiving three prescriptions or less. Categorical analysis showed age <65, male sex, overweight BMI, lower frailty, former smokers, HPV+, higher T stage, and BOT subsite to be associated with increased MMEs. Adjuvant therapy significantly increased MMEs (TORS+XRT:1646.2; TORS+cXRT:2385.0; TORS alone:554.7 [P <.001]) and 12‐month opioid prescription totals (TORS+XRT:3.2; TORS+cXRT:5.5; TORS alone:1.6 [P <.001]). Adjuvant therapy increased time to taper (total MME in TORS alone versus TORS+XRT/cXRT: 0 to 3 months:428.2 versus 845.5, 4 to 6 months:46.8 versus 541.8, 7 to 9 months:12.4 versus 178.6, 10 to 12 months:11.0 versus 4.4,[P <.001]). Positive predictors of opioid prescribing at the 4‐ to 6‐month and 4‐ to 12‐month intervals included adjuvant therapy (odds ratio [OR]:5.56 and 4.51) and mFI‐5 score ≥3 (OR:36.67 and 31.94). Following TORS at 6‐, 9‐, and 12‐month, 15.7%, 6.6%, and 4.1% were still using opioids. Conclusions: In OPSCC treated with TORS, opioid use tapers faster for surgery alone versus with adjuvant therapy. Opioid prescribing risks include adjuvant therapy and higher frailty index. Level of Evidence: 4 Laryngoscope, 131:E1888–E1894, 2021 [ABSTRACT FROM AUTHOR]

Objective: To investigate intraoperative nerve monitoring (IONM) use among thyroid surgeons.Methods: A 25-question survey was used to assess attitudes regarding IONM use. Surveys were sent to surgeons registered to the American Academy of Otolaryngology-Head and Neck Surgery, International Association of Endocrine Surgeons, and American Head and Neck Society.Results: Among 1,015 respondents, 83% reported using IONM (65.1% always using IONM and 18.1% reporting selective use). For selective users, a majority reported using IONM for reoperative cases (95.1%) and in cases with preoperative vocal cord paralysis (59.8%). When comparing location, there was a significant difference in IONM implementation (P < 0.001), with 70.4% of North American responders using it ubiquitously compared to 27.4% of non-North American responders. Preoperative laryngeal exam was performed more universally by North American surgeons and more selectively by non-North American surgeons (P < 0.001). Other attitudes toward their implementation and the postoperative laryngeal exam were similar. Surgeons ≤45 years of age and those with ≤15 years of practice used IONM more than their peers (P < 0.001). Thyroid surgery volume, fellowship training, and type of practice had no bearing on IONM use.Conclusion: The prevalence of IONM in thyroid and parathyroid surgeries has increased significantly over the past decade, with 83% of surgeons using IONM in some or all cases. Although IONM use may be more ubiquitous in North America, attitudes toward its implementation and pre- and postoperative laryngeal exams are fairly uniform. IONM use is more prevalent among younger surgeons, whereas its use has no correlation with thyroid surgery volume or type of practice.Level Of Evidence: 4 Laryngoscope, 130:1097-1104, 2020. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To determine the relationship between force metrics measured by the laryngeal force sensor (LFS) during suspension microlaryngoscopy (SML) and perioperative narcotic requirements.Study Design: Prospective observational study.Methods: Compressive tissue forces were recorded during SML using the LFS and correlated with postoperative narcotic requirements in the postanesthesia care unit (PACU) at an academic tertiary center. Patients were prospectively enrolled and had force metrics recorded throughout each procedure including maximum force, average force, suspension time, and total impulse. Narcotic administration in the intraoperative period and PACU were also recorded and converted into intravenous morphine equivalents (ME). Surgeons were blinded to the force recordings during surgery to prevent operator bias.Results: Eighty-two patients completed the study. Of these patients, the mean perioperative ME requirement was 16.96 mg (range, 0.15-79.82 mg). Univariate analysis demonstrated a positive correlation between perioperative narcotic requirements and total suspension time (P < .001) as well as total impulse (P = .007). A positive correlation was also seen with maximum force, although not significantly. On multiple linear regression, total suspension time was a significant predictive variable for perioperative narcotic use, with a marginal incremental increase of 0.273 mg of ME per minute of total suspension time (0.273 mg/min, 95% confidence interval: 0.040-0.507 mg/min, P = .022).Conclusions: Intraoperative force metrics including total suspension time are predictive of increased perioperative narcotic requirement after SML. Total impulse during SML may also correlate with increased perioperative narcotic requirements.Level Of Evidence: 2 Laryngoscope, 129:2563-2567, 2019. [ABSTRACT FROM AUTHOR]

Objective: To investigate the frequency and outcomes of elective neck dissection (END) for adenoid cystic carcinoma (ACC) of the head and neck.Methods: The National Cancer Database was queried for a cohort study of patients with ACC of the major salivary glands, nasal cavity/nasopharynx, hard/soft palate, tongue, floor of mouth, larynx, and oral cavity who underwent primary surgical resection from 2004 to 2014. Multivariable logistic regression was used to identify predictors of END and occult nodal metastasis. Overall survival (OS) was estimated using the Kaplan-Meier method and modeled with Cox proportional hazards regression.Results: Among 2,807 patients with ACC treated surgically, 636 (22.7%) underwent END. Patients with ACC of the salivary glands and tongue most frequently underwent END; patients with hard/soft palate (odds ratio [OR] 0.06, P < 0.001) and nasal cavity/nasopharynx (OR 0.05, P < 0.001) ACC rarely underwent END compared to patients with major salivary gland cancer. Increasing tumor (T) stage (T4 vs. T1, OR 3.02, P < 0.001) was associated with END. Patients with advanced T3 to T4 ACC of the major salivary glands demonstrated extended OS associated with END (5-year OS 78.1% vs. 70.4%, P = 0.041) on Kaplan-Meier analysis and with END with adjuvant radiation therapy (hazard ratio 0.55, P = 0.027) using Cox proportional hazards regression. Elective neck dissection for T4 ACC of the salivary glands (21.3%) and tongue (25.5%) most consistently revealed occult nodal metastasis.Conclusion: Elective neck dissection for ACC of the major salivary glands or tongue is most likely to reveal occult nodal metastasis. Elective neck dissection is associated with extended OS for advanced-stage ACC of the major salivary glands.Level Of Evidence: NA Laryngoscope, 129:2094-2104, 2019. [ABSTRACT FROM AUTHOR]

Objective: Balloon dilation (BD) is a controversial alternative to conventional sinus surgery. The role of industry on practice patterns remains unknown. The aim of this study was to determine whether industry payments from BD manufacturers influence practice patterns for otolaryngologists and evaluate how these payments change over time.Methods: Retrospective cohort study using Medicare Provider Utilization and Payment (PUP) Data and Center for Medicare and Medicaid Services Open Payments (OP) general payment datasets. A total of 294 otolaryngologists identified in the PUP dataset who performed BD procedures from January 1, 2013, to December 31, 2015, were cross-referenced in the OP dataset from January 1, 2014, to December 31, 2016, for BD manufacturer payments. Payments to surgeons performing BD stratified by amount, type, and number of procedures performed were primary outcome measures.Results: Of the 294 otolaryngologists reporting BD procedures, 223 (76%) received payments from a company that manufactures BD devices. Receipt of $2,500 in BD payments was associated with performance of one additional BD procedure, and consulting fees were most positively associated with performing additional BD procedures (P = 0.006). The providers receiving the most in BD payments were more likely to continue to receive the most in payments, regardless of number of BD procedures performed. Performing more BD procedures did not correlate with decrease in other sinus procedures.Conclusion: Payments to otolaryngologists from manufacturers of sinus BD devices are associated with the performance of an increased number of such procedures. Surgeons should consider the impact of interactions with industry when evaluating patients for BD procedures.Level Of Evidence: 4. Laryngoscope, 128:1540-1545, 2018. [ABSTRACT FROM AUTHOR]

Objective: We sought to establish the significance of querying chronic rhinosinusitis (CRS) patients about their past CRS-related oral antibiotic and corticosteroid usage by determining the association between these metrics and patients' quality of life (QoL).Study Design: Cross-sectional study.Methods: A total of 157 patients with CRS were prospectively recruited. CRS-specific QoL was measured using the 22-item Sinonasal Outcome Test (SNOT-22). General health-related QoL was measured using the EuroQoL five-dimensional questionnaire visual analog scale. Associations were sought between these measures of QoL and frequency of CRS-related oral antibiotic and corticosteroid usage reported by the participants in the prior 3 and 12 months.Results: More frequent antibiotic and corticosteroid use was significantly associated with worse CRS-specific and general health-related QoL, whether querying medication use over the prior 3 months or over the prior 12 months (P < 0.001 in all cases). The effect size of CRS-related antibiotic use during the prior 3 months on CRS-specific QoL (SNOT-22 score) was significantly greater than for use during the prior 12 months. However, there was no other statistically significant difference in effect size for association between QoL and CRS-related antibiotic or corticosteroid use in the prior 3 months versus prior 12 months. These results were independent of the presence or absence of polyps.Conclusion: More frequent past CRS-related oral antibiotic and corticosteroid use, regardless of time period queried (3 months or 12 months) is associated with significant decrease in CRS-specific and general health-related QoL. CRS-related systemic medication use is an important indicator of CRS patients' QOL that easily can be queried and utilized in both clinical and research settings.Level Of Evidence: 2c. Laryngoscope, 128:37-42, 2018. [ABSTRACT FROM AUTHOR]

Objective: Assess the feasibility of a novel robotic platform for use in microvascular surgery.Study Design: Prospective feasibility study.Setting: Robotics laboratory.Methods: The Robotic ENT (Ear, Nose, and Throat) Microsurgery System (REMS) (Galen Robotics, Inc., Sunnyvale, CA) is a robotic arm that stabilizes a surgeon's instrument, allowing precise, tremor-free movement. Six microvascular naïve medical students and one microvascular expert performed microvascular anastomosis of a chicken ischiatic artery, with and without the REMS. Trials were blindly graded by seven microvascular surgeons using a microvascular tremor scale (MTS) based on instrument tip movement as a function of vessel width. Time to completion (TTC) was measured, and an exit survey assessed participants' experience. The interrater reliability of the MTS was calculated.Results: For microvascular-naïve participants, the mean MTS score for REMS-assisted trials was 0.72 (95% confidence interval [CI] 0.64-1.07) and 2.40 (95% CI 2.12-2.69) for freehand (P < 0.001). The mean TTC was 1,265 seconds for REMS-assisted trials and 1,320 seconds for freehand (P > 0.05). For the microvascular expert, the mean REMS-assisted MTS score was 0.71 (95% CI 0.15-1.27) and 0.86 (95% CI 0.35-1.37) for freehand (P > 0.05). TTC was 353 seconds for the REMS-assisted trial and 299 seconds for freehand. All participants thought the REMS was more accurate and improved instrument handling and stability. The intraclass correlation coefficient for MTS ratings was 0.914 (95% CI 0.823-0.968) for consistency and 0.901 (95% CI 0.795-0.963) for absolute value.Conclusion: The REMS is a feasible adjunct for microvascular surgery and a potential teaching tool capable of reducing tremor in novice users. Furthermore, the MTS is a feasible grading system for assessing microvascular tremor.Level Of Evidence: NA. Laryngoscope, 127:2495-2500, 2017. [ABSTRACT FROM AUTHOR]

Head and neck cancers account for a significant proportion of reported malignancies in the United States; however, multiple concurrent primary malignancies from different sites are rare. We describe the case of a 44-year-old man simultaneously diagnosed with three independent head and neck malignancies (adenocarcinoma in minor salivary gland, papillary thyroid carcinoma, and acinic cell carcinoma) in the setting of Lynch syndrome. To our knowledge, this is the first case of multiple head and neck malignancies arising simultaneously from Lynch syndrome. This case highlights the need for diligent workup in patients with hereditary conditions that predispose to malignancies. Laryngoscope, 128:2759-2761, 2018. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis To investigate the use of an algorithm for rapid discharge after transoral robotic surgery (TORS) and its effect on postoperative complications. Study Design Retrospective cohort study. Methods A retrospective analysis of TORS cases from September 2009 to February 2013 was conducted. The effect of patient and tumor characteristics on postoperative length of stay (LOS) and complications were analyzed. Results A total of 91 patients were included; 79 underwent TORS for malignancy and 12 for a benign process. The mean LOS was 1.51 days (range, 1-5 days) with a median of 1 day. The mean time to initiation of oral diet was 1.26 days (range, 1-7 days) with a median of 1 day. Eleven (12%) patients experienced one or more complications during their postoperative course. Multivariate analysis demonstrated a significant association between patient and procedure variables and postoperative complications. TORS base of tongue reduction for obstructive sleep apnea (OSA) was associated with a significantly greater mean incremental time to initiation of oral diet (1.0 days, 95% confidence interval [CI]: 0.4 to 1.7, P < .001). A significantly greater mean incremental LOS was observed for patients with advanced comorbidity and a delay in initiation of oral diet beyond 24 hours. Conclusions Rapid initiation of oral diet and rapid discharge home is feasible and not associated with postoperative complications. Similarly, the performance of a concurrent neck dissection does not contribute to LOS or the development of postoperative complications. Patients undergoing TORS for OSA are at greater risk of delay in initiation of oral diet and increased LOS. Level of Evidence 4 Laryngoscope, 124:2518-2525, 2014 [ABSTRACT FROM AUTHOR]