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Objective Standard techniques for primary dural repair following lateral skull base surgery are both technically challenging and time consuming without the potential for primary dural repair. Inadequate closure may result in postoperative cerebrospinal fluid (CSF) leak infectious sequalae. Traditional methods of dural repair rely on secondary obliteration of the CSF fistula. We hypothesized that the use of nonpenetrating titanium microclips may serve as a useful adjunct in primary dural repair or the establishment of an immobile repair layer following lateral skull base surgery. Methods Here, we report a novel technique for primary dural repair using nonpenetrating titanium microclips as an adjunct to standard techniques in a series of six patients with lateral skull base pathologies. Results A total of six consecutive lateral skull base tumor patients with titanium microclip dural reconstruction were included in our case series. Lateral skull base pathologies represented in this group included two jugular foramen schwannomas, one vestibular schwannoma, one petroclival meningioma, one glomus jugulare paraganglioma, and one jugular foramen chordoid meningioma. Conclusion To our knowledge, this is the first report on the use of microclips in repairing dural defects following lateral skull base surgery. Surgical outcomes for this small case series suggest that dural repair of the later skull base with nonpenetrating titanium microclips is a useful adjunct in dural repair following lateral skull base surgery.

Anterior cervical discectomy and fusion (ACDF) is the most common surgical procedure utilized for degenerative diseases of the cervical spine. The authors present the case of a 64-year-old man who underwent an ACDF for degenerative changes causing cervical stenosis with myelopathy. The patient’s symptoms consisted of pain and weakness of the bilateral upper extremities that slowly progressed over 1.5 years. During the procedure, the superior horn of the thyroid cartilage impeded proper retraction, preventing adequate visualization due to its prominent size. At this point, otorhinolaryngology was consulted, which allowed for safe resection of this portion of the thyroid cartilage while preserving nearby critical structures. With the frequent usage of this surgical approach for various etiologies, the importance of proper recognition and consultation is paramount. Encountering prominent thyroid cartilage resulting in surgical obstruction has not been described in the literature and this report represents a paradigm for the proper course of action.

Objectives/Hypothesis This study compares the overall durability, phonation effort, and speech quality achieved by the Blom-Singer Dual Valve prosthesis to the same characteristics achieved by the single-valve prosthesis used in a select population of total laryngectomy patients who have demonstrated single-valve prosthesis failure within 3 months of placement. Study Design Prospective phase IV study. Methods Fourteen patients who had previously experienced early valve failure using a single-valve prosthesis had a Dual Valve placed by a speech language pathologist. A total of seventeen Dual Valves were inserted during routine clinical visits for valve replacement. Time intervals from insertion to replacement of the Dual Valve, as well as the average lifespan of patients’ three previous single valves were collected. Subjective, categorical responses to speech quality and phonation effort for the Dual Valve compared to the single valve were collected on a questionnaire upon failure of the device. Results The mean duration of the single valve was 60 days, with a median of 51 days, whereas the mean duration of the Dual Valve was 164 days, with a median duration of 84 days. Both sets of data were statistically significant, with a P value of .0131. Valve life was increased in 86% of patients, with 43% experiencing greater than 150 days improvement in valve duration when using the Dual Valve. Phonation effort was increased in 14% of patients, and speech quality was not significantly affected in any patients. Conclusions In this select population, the Dual Valve offers improved durability over the single valve without sacrificing speech quality, making it a preferred prosthesis option for patients experiencing single-valve failure in less than 3 months. Level of Evidence 4. Laryngoscope, 128:422–426, 2018

Here we present the case of a 36-year-old man who was found to have a symptomatic malignant neural sheath tumor growing from the C2 nerve root following a period of progressively worsening headaches. The patient was successfully treated with surgical resection resulting in resolution of cranial nerve deficits. Though uncommon, malignant peripheral nerve sheath tumor must be considered in the differential diagnosis of tumors involving the cervical nerve roots and carotid space.

Objectives/Hypothesis Salvage laryngectomy after failed organ preservation often has a high complication rate, pharyngocutaneous fistulas being the most common. These fistulas increase morbidity, prolong hospitalization, and potentially delay adjuvant treatment. Fistula rates in the literature range from 3% to 65%. Use of the pectoralis flap to prevent fistula formation has been adopted as a common practice at our institution. A review of our experience using the overlay myofascial showed a higher than desired complication rate. The aim of this study is to assess whether the use of integrated myocutaneous flap results in a lower fistula rate. Study Design A retrospective review of 30 patients followed by a pilot study of 10 patients. All underwent salvage laryngectomy after failed organ preservation. Methods The operation notes of 40 laryngectomy patients were analyzed. The patient/tumor characteristics, pretreatment, neck dissection, flap type, and fistula rate were documented. Results The patient sample was 25% female. All patients received prior radiotherapy, but only 37.5% received prior chemoradiation. Neck dissections were performed in 80% of these patients, 76% of the myocutaneous group, and 84% of the myofascial group. Advanced tumor stage was found in 42% of the myofascial group and 52% of the myocutaneous group. Five of the 19 myofascial patients developed a fistula, whereas seven of the 21 myocutaneous patients developed a fistula. Conclusions The use of the pectoralis myocutaneous flap (PMCF) in this pilot series did not show a lower rate of fistula; other alternatives should be pursued to decrease this complication. Evidence Level 4. Laryngoscope, 124:1615–1617, 2014

Background. Our aim was to determine the feasibility and safety of initiating early oral feeding in patients who underwent salvage laryngectomy on postoperative day 5 and to review the rate of pharyngocutaneous fistula formation. Methods. A retrospective review of 29 patients who underwent salvage laryngectomy was completed. Patients included in the study had radiation therapy ± chemotherapy for laryngeal squamous cell carcinoma with subsequent total laryngectomy. Patients were excluded from analysis if they were reliant on a gastrostomy tube preoperatively, had a concurrent complete glossectomy, or developed a fistula before beginning oral feedings. Early oral feeding was initiated on postoperative day 5. Results. Twenty patients met complete inclusion criteria. Pharyngocutaneous fistula occurred in 10% (2/20) of the patients. Patients without postoperative complications on an average remained in the hospital for 7 days. Conclusions. The risk of fistula formation is not increased and the duration of hospital stay may be shortened in patients who were given early postoperative feeds. © 2009 Wiley Periodicals, Inc. Head Neck, 2009

Objectives/Hypothesis: To assess the efficacy of paclitaxel, ifosfamide, and cisplatinum induction chemotherapy plus concurrent chemoradiation in the treatment of stage III and IV base of tongue cancer. Study Design: Subgroup analysis of patients with base of tongue cancer enrolled in a single-institution prospective phase II trial, evaluating an organ-preservation approach in the treatment of locally advanced head and neck cancer. Methods: Eighteen patients with tumors ranging from stage T2–T4, any N, or M0 were treated with a protocol of induction chemotherapy, with Taxol, ifosfamide, cisplatin every 21 days for up to three cycles. If the primary tumor exhibited a complete or partial response, patients were treated with radiation and weekly taxol and carboplatin for 7 weeks. Surgery was used for those with less than partial response or disease progression. Neck dissection was performed in cases with clinical or radiological evidence of persistent disease in the neck 6 to 8 weeks after completion of treatment. Results: Sixteen patients were male and two were female; the average age was 55 years (range, 43–65). Fifteen patients had stage IV disease and three had stage III disease. Of the 18 patients initially enrolled, 17 patients had a complete response. All 17 patients had no evidence of loco-regional disease at a median follow-up of 29.6 months. Only 1 of them developed distant metastases 30 months after completion of treatment. Three patients required permanent percutaneous endoscopic gastrostomy tubes because of severe dysphagia associated with concurrent chemoradiation. Conclusions: The treatment regimen studied is remarkably effective in stage III and IV base of tongue cancer with 100% of patients completing the protocol alive to date. Although some patients required persistent percutaneous endoscopic gastrostomy use, no patient experienced significant enough toxicity during the protocol to delay or withdraw from treatment.

Objective: The objective of this study was to report the long-term efficacy of radiofrequency volumetric tissue reduction (RFVTR) and to compare this with other accepted surgical treatments of inferior turbinate hypertrophy. Study Design and Setting: Prospective, 2-year follow-up of 19 patients originally enrolled in a prospective, randomized, single blinded, placebo controlled trial for treatment of inferior turbinate hypertrophy with RFVTR. Patients evaluated their severity of obstruction, frequency of obstruction, and overall ability to breathe by way of a 10 cm visual analogue scale. Results: RFVTR for inferior turbinate hypertrophy showed continued benefit at 2 years posttreatment, with no indication of increasing symptomatology. The benefit demonstrated in frequency of obstruction, severity of obstruction, and overall ability to breathe (P < .05) was maintained at 2 years. No complications occurred. Review of the literature shows lower short- and long-term complications for RFVTR compared with other surgical methods Conclusion: RFVTR is effective in treating inferior turbinate hypertrophy with sustained benefit at 2 years follow-up while resulting in fewer complications than other surgical methods. Significance: RFVTR is a relatively new procedure, and therefore there are few long-term evaluations of its effectiveness; this is the first prospective study to document successful outcomes at 2 years follow-up.

The role of the surgeon in the management of hyperparathyroidism has changed substantially over the last several decades. Previously, most referrals to surgeons came from endocrinologists. These patients were generally thoroughly evaluated and usually were ready to be scheduled for surgical exploration. In recent years, the addition of serum calcium measurement during routine blood chemistries for adults has led to the identification of numerous patients with asymptomatic hypercalcemia. These patients are being referred in increasing numbers to surgeons. This change in referral patterns requires the appropriate preoperative evaluation by the surgeon to identify those patients who would be best treated by parathyroidectomy. There have been numerous technological advances in preoperative and intraoperative identification of parathyroid adenomas. These, combined with the availability of rapid intraoperative parathyroid hormone measurements have allowed the introduction of minimally invasive techniques for parathyroid exploration. This article reviews the appropriate preoperative assessment of patients with hypercalcemia, and the indications for surgical management of hyperparathyroidism.

Osteonecrosis of the jaw is an uncommon consequence of biphosphonate therapy. This has most commonly been a bone complication with little if any soft tissue involvement. An unusual case of necrotizing fasciitis with extensive soft tissue infection stemming from a prolonged case of osteonecrosis of the jaw presented. The management of this patient (aggressive surgical debridement and prolonged wound care) is reviewed as well as the review of the underlying processes.

Background Giant cell granuloma is rare in the head and neck region and most commonly affects the maxilla and mandible. Although it is a benign disease process, it may be locally destructive. Surgery is the treatment currently recommended. Because of the location of the disease, surgery may be disfiguring. Because it is a benign process, less radical nonsurgical treatment alternatives are desirable. Methods A case report of a giant cell granuloma treated with steroid injections. Results After six weekly intralesional steroid injections, a giant cell granuloma of the maxilla became calcified and smaller. After a follow-up period of 2 years, there was no evidence of regrowth, and the bony osteolytic lesion had filled with bone. A review of the literature revealed two case reports of successful steroid injections with similar response. Conclusions Steroid injections are a viable alternative in the treatment of giant cell granuloma, which may avoid surgery. © 2000 John Wiley & Sons, Inc. Head Neck 22: 822–825, 2000.

Objective We report a series of patients treated for carcinoma of the tonsil who either presented with bilateral carcinomas or later developed a second primary carcinoma of the contralateral tonsil. This report raises awareness of this occurrence. Study design Case series. Methods Four cases have been identified of either concomitant or subsequent carcinoma of the contralateral tonsil inpatients treated for tonsillar carcinoma from the practices of 3 head and neck surgeons in a single demographic area over a 35 year span. Results Four patients were identified who were treated for tonsillar carcinoma with concomitant or subsequent carcinoma of the contralateral tonsil: One patient with bilateral metastatic carcinoma in cervical lymph nodes was found to have bilateral occult tonsillar primaries.Three patients who were treated for tonsillar primary carcinomas subsequently developed carcinoma of the contralateral tonsil. Conclusions A small population of patients with unilateral tonsil carcinoma will developed a second in the contralateral tonsil. This raises the question of whether removal of the contralateral tonsil at the time of initial treatment might have spared the morbidity/mortality of the subsequent contralateral tonsil cancer.

Objectives The objective was to review the clinicopathologic features of carotid blowout syndrome (CBS) in patients with head and neck cancer (HNC) and present a management algorithm. Methods We reviewed all HNC patients with a diagnosis of CBS seen at our tertiary cancer hospital from 1994 to 2009 and performed a retrospective review of all English-language studies documenting CBS cases within the past 15 years. Results Eight patients with HNC developed CBS at our institution, and another 132 HNC patients were presented in 21 studies. Patients with CBS typically have a history of radiotherapy (89%), nodal metastasis (69%), and neck dissection (63%). This disease usually occurs proximal to the carotid bifurcation and is commonly associated with soft tissue necrosis in the neck (55%) and mucocutaneous fistulas (40%). Half of CBS patients present with sentinel bleeding, but 60% of patients will develop a life-threatening hemorrhage requiring emergent intervention. Over 90% of patients with CBS were treated with endovascular therapy, and surgical ligation was rarely indicated. The morbidity and mortality rates of patients with CBS are significant; only 23% have survived without evidence of disease. Conclusions Carotid blowout syndrome is uncommon and can be rapidly fatal without prompt diagnosis and intervention. Although endovascular treatment within the carotid system can have a significant risk of mortality and neurologic morbidity, it has become the treatment of choice for CBS.

To determine the rate of use and non-use of prophylactic percutaneous endoscopic gastrostomy (PEG) tubes among patients with head and neck cancer (HNC) patients.All patients with HNC undergoing PEG between January 1, 2004 and June 30, 2006 were identified. Patients (or their next-of-kin) were surveyed by phone and all available medical records and cancer registry data were reviewed. Prophylactic PEG was defined as placement in the absence of dysphagia and prior to radiation or chemoradiation. Each patient with a prophylactic PEG was assessed for cancer diagnosis, type of therapy, PEG use, and complications related to PEG.One hundred and three patients had PEG tubes placed for HNC. Thirty four patients (33%) could not be contacted for follow-up. Of the 23 (22.3%) patients with prophylactic PEG tubes, 11/23 (47.8%) either never used the PEG or used it for less than 2 wk. No association with PEG use vs non-use was observed for cancer diagnosis, stage, or specific cancer treatment. Non-use or limited use was observed in 3/6 (50%) treated with radiation alone vs 8/17 (47.1%) treated with chemoradiation (P = 1.0), and 3 of 10 (30%) treated with surgery vs 8 of 13 (62%) not treated with surgery (P = 0.21). Minor complications were reported in 5/23 (21.7%). One (4.3%) major complication was reported.There is a high rate of unnecessary PEG placement when done prophylactically in patients with head and neck cancer.

Tracheostomy tube fracture resulting in airway obstruction is a relatively rare but serious complication. We report the case of a 48-year-old man whose tracheostomy tube fractured and became lodged in the right primary bronchus. Recommendations are made for tracheostomy care to help prevent similar complications in patients with an indwelling tracheostomy tube.

Objectives1) To describe a case of ectopic intratracheal thyroid cancer. 2) To review the literature describing ectopic intratracheal thyroid tissue.MethodsEctopic thyroid tissue is periodically encountered and can sometimes be malignant. The most common locations for ectopic thyroid tissue to be found are the tongue and along the tract of descent of the thyroid gland into the neck. We describe a case of ectopic intratracheal thyroid cancer and review the literature for similar cases. We also discuss possible explanations for this phenomenon.ResultsA total thyroidectomy with tracheal resection was performed. The patient received postoperative I131 therapy and has no detectable serum thyroglobulin to date. There is a small number of cases that report ectopic thyroid tissue found in the trachea. 3 of these were malignant. Including the current case, 26% of ectopic intratracheal tissue is malignant.ConclusionsEctopic intratracheal thyroid tissue is rare. Since 26% of reported cases have been malignant, we su...

Objective To analyze patients with “normal” baseline quick intraoperative parathyroid hormone (QPTH) levels during parathyroidectomy and to determine the prevalence of this finding, the usefulness of the assay in this situation, and to explain the possible causes for this phenomenon. Study design and setting Patients who underwent parathyroidectomy using QPTH in a tertiary hospital. Methods Retrospective analysis of 39 patients treated surgically for primary hyperparathyroidism using QPTH. Results Of the patients, 14 (36%) had normal baseline QPTH. 8 patients with localizing sestamibi scans had a single adenoma, and excision resulted in a mean decrease of 85.4% in QPTH. Six patients had nonlocalizing sestamibi scans, 1 patient had an 84% drop in QPTH level after removal of a single adenoma, and 5 patients had hyperplasia requiring ≥3 glands excision. At 11.36 months' mean follow-up, 13 patients (93%) were normocalcemic. Conclusions A “normal” baseline QPTH level was found in 36% of patients. A 50% decrease in QPTH remains predictive of biochemical cures in patients with localizing sestamibi scans. The likely explanation for this variability in “normal” levels between different assays is the variability in detection of the 7-84 PTH fragment, which results in an overestimation of the PTH level. Assays such as the QPTH, which are more sensitive for the biologically active PTH molecule [(1-84) PTH] than other laboratory PTH assays will tend to have lower PTH levels that can be within the normal range. EBM rating: B-3.

We sought to evaluate the short-term efficacy of radiofrequency volumetric tissue reduction (RFVTR) in treating nasal obstruction in subjects with inferior turbinate hypertrophy.We conducted a prospective, randomized, single-blinded, placebo-controlled trial with crossover option, involving 32 patients and performed in a clinical office setting at the University of Oklahoma Medical Center.The outcomes were measured using 10-cm visual analog scales (VASs) before treatment and at 8 weeks and 6 months posttreatment. Improvement was shown in frequency of obstruction, severity of obstruction, and overall ability to breathe for both the placebo and RFVTR treatment arms at 8 weeks (P0.05). The amount of improvement, however, was significantly better in the treatment arm compared with placebo for the severity of obstruction and overall ability-to-breathe categories. At 6 months, the mean improvement scores were significantly better than the pretreatment scores for all 3 categories.RFVTR is an effective alternative for the treatment of patients with nasal obstruction due to inferior turbinate hypertrophy.This is the first randomized trial that demonstrates that RFVTR is significantly better than placebo in treating nasal obstruction due to inferior turbinate hypertrophy.

The recent advance of intraoperative PTH monitoring combined with preoperative localization techniques allow for minimally invasive parathyroid surgery in 75% to 85% of cases. In cases where a single adenoma is identified, minimally invasive techniques should result in a need for repeat surgery in only 2% of cases. The cost of intraoperative PTH assays of localization and gamma probes limits their availability. Complications of parathyroidectomy are uncommon, but appropriate management is important, particularly for patients with hypocalcemia.

The purpose of this study was to determine if use of an intranasal vasoconstrictor (oxymetazoline) could be used to effectively treat epistaxis, avoiding nasal packing. The charts of 60 patients who presented to the emergency room with the diagnosis of epistaxis and who required medical management were reviewed. Sixty-five percent of these patients were successfully managed with oxymetazoline as their sole therapy. An additional 18% were managed successfully with silver nitrate cautery in combination with oxymetazoline. In only 17% of patients was it necessary to use nasal packing as treatment for epistaxis after an initial attempt with oxymetazoline alone or in combination with silver nitrate failed. These data suggest that pharmacologic management may be adequate in the majority of patients with epistaxis, thus avoiding the need for nasal packing with its associated complications.

Objective: The objective of this study is to determine the incidence, risk factors, and management of sialoceles and salivary fistula after parotidectomy. Methods: Single institution, multiple surgeon retrospective review of patients undergoing parotid surgery r over a three year period (2006-2009). Results: The incidence of sialocele and/or fistula in 65 patients was 21.4%. A salivary fistula was seen in 28% of patients that had a complete superficial parotidectomy, and 5% of patients that had a partial parotidectomy (p 1week) and/or is amylase positive. Factors that were examined included tumor pathology, type of parotidectomy performed (partial lobectomy, complete superficial parotidectomy, total parotidectomy, and radical parotidectomy), the type of drain placed, the duration of drain placement, the volume of the specimen, and the duration of the sialocele or fistula. Patients that required neck dissection, skin resection, regional or microvascular flap reconstruction, or temporal bone resection were excluded. Surgeries were classified as a partial lobectomy (dissection and removal of tissue over either the upper or lower division of the facial nerve), complete lateral lobectomy (dissection and removal of tissue over both the upper and lower division), deep lobe parotidectomy, radical parotidectomy. A students t-test and Fisher exact test were used to determine significance. The incidence of sialocele in this study was found to be 21%, which is consistent with what is reported in other studies. A myriad of factors were examined to determine if a correlation existed with sialocele formation, but the only factor that achieved statistical significance was the type of parotid surgery performed. Patients undergoing a complete dissection of the superficial lobe of the parotid had a significantly higher rate if salivary fistula formation. This finding is contrary to what has been reported in previous studies which showed a higher rate of sialocele with a partial lobectomy.4 Though the reason for the association with extent surgery is unclear, it is possible that as a larger surface area of the gland is exposed, there is a greater accumulation of saliva, leading to a higher propensity of sialocele formation. The higher rate of of sialocele formation in patients undergoing a deep lobe parotidectomy is also suggestive of this reasoning, but this did not approach statistical significance given the low number of patients undergoing this procedure. The type of treatment did not seem to hasten resolution of the sialocele, though the power of this portion of the study was low. A prosepctive study or larger sample size would be necessary to answer this question. Other limitations of this study are primarily due to its retrospective nature. In conclusion, sialoceles and salivary fistulas are a relatively common occurrence after parotid surgery. They appear to occur more frequently with removal of the entire superficial lobe of the parotid compared . Resolution tends occur in approximately one month. At present, no therapy has been shown to prevent their occurrence. Introduction Material and Methods Results Discussion/Conclusion Type of Surgery Sialocele Partial Lobectomy 5% Complete Lateral Lobectomy* 28% Deep Lobe Parotidectomy 50% Treatment Frequency Used Average Days to Resolution Aspiration 64% 26.3 Packing 7.1% 26 Pressure Dressing 35% 26.4 Scopolamine 42% 29.5 Drain 14% 27 TABLE 1 Incidence of Sialocele/Salivary Fistula Based on the type of Surgery Performed

S100P, and SAT remained elevated 2 weeks after surgery (P .05). Cytokeratin 14 (CK14) exhibited the greatest diminution in array expression pattern 2 weeks after surgery for OSCC and confirmed with qPCR. Using t test comparisons, postoperative CK14 gene expression was lower than before surgery (P .05) and no different vs control subjects. (P .05). Conclusions: While IL8, IL1B, DUSP1, HA3, OAZ1, S100P, and SAT hold promise for detecting OSCC in saliva, salivary CK14 mRNA can serve as a detection marker as well as a prognostic marker for therapeutic response to surgery in OSCC. Creating a saliva-based panel of these biomarkers could be used to diagnose and follow up patients with OSCC.

Objectives To evaluate the adequacy of as-needed (prn) dosing of narcotics during the acute postoperative period following laryngectomy and to evaluate the role of nurses' interpretation and implementation of narcotic orders in postoperative pain management. Study Design A retrospective review of the medical records of 37 patients who underwent laryngectomy at the University of Oklahoma. The postoperative care was standardized through a clinical pathway to provide a uniform level of care. Methods The parameters reviewed include (1) the type and dose of analgesic prescribed, (2) the quantity and frequency of analgesic administered to each patient, and (3) the adequacy of the initial pain-control prescription. Results All physician orders for narcotics were at or above the minimum dosing guidelines; 68% met a recommended adequate postoperative prescription for moderate pain. However, none of the patients actually received the intended dose during a 24-hour period while hospitalized. Physicians were contacted about 13 patients (35%) because of inadequate pain relief, but only 8 patients (22%) had their narcotic dose increased appropriately. Patients were dosed below the minimum prescribed dose 19 times (2.8%), and in 24 instances (3.6%) the backup analgesic, designated as "prn breakthrough pain," was given as the primary analgesic. Conclusions As-needed dosing of analgesia resulted in suboptimal pain control for at least 35% of patients undergoing laryngectomy. Inadequate prescription and variable implementation of prn orders contributed to this.