Faculty Bibliography

Systemic bleomycin therapy is associated with pulmonary fibrosis and cutaneous side effects. While it is believed that there is little to no systemic distribution of bleomycin when utilized to treat vascular malformations (VMs), we present a case series in which cutaneous, adhesive-related hyperpigmentation suggests that there is systemic egress of bleomycin following direct puncture sclerotherapy (DPS). This risk of hyperpigmentation after intralesional bleomycin should be discussed with patients, and steps to minimize the chances of it occurring should be implemented.

OBJECTIVE:This study aims to refine Music Upper Limb Therapy - Integrated (MULT-I) to create a feasible enriched environment for stroke rehabilitation and compare its biological and behavioral effects to that of a home exercise program (HEP). DESIGN/METHODS:Randomized mixed-methods study of 30 adults with post-stroke hemiparesis. Serum brain derived neurotrophic factor (BDNF) and oxytocin levels measured biologic effects, and upper limb function, disability, quality of life and emotional well-being were assessed as behavioral outcomes. Participant experiences were explored using semi-structured interviews. RESULTS:MULT-I participants showed reduced depression from pre- to post- intervention as compared to HEP participants. BDNF levels significantly increased for MULT-I participants, but decreased for HEP participants, with a significant difference between groups after excluding those with post-stroke depression. MULT-I participants additionally improved quality of life and self-perceived physical strength, mobility, activity, participation, and recovery from pre- to post-intervention. HEP participants improved upper limb function. Qualitatively, MULT-I provided psychosocial support and enjoyment while HEP supported self-management of rehabilitation. CONCLUSIONS:Implementation of a music enriched environment is feasible, reduces post-stroke depression, and may enhance the neural environment for recovery via increases in BDNF levels. Self-management of rehabilitation through a home exercise program may further improve upper limb function.

BACKGROUND:Patients with head and neck cancer (HNC) treated with radiation therapy (RT) are at risk for jaw osteoradionecrosis (ORN), which is largely characterized by the presence of exposed necrotic bone. This report describes the incidence and clinical course of and risk factors for exposed intraoral bone in the multicenter Observational Study of Dental Outcomes in Head and Neck Cancer Patients (OraRad) cohort. METHODS:Participants were evaluated before RT and at 6, 12, 18, and 24 months after RT. Exposed bone was characterized by location, sequestrum formation, and other associated features. The radiation dose to the affected area was determined, and the history of treatment for exposed bone was recorded. RESULTS:The study enrolled 572 participants; 35 (6.1%) were diagnosed with incident exposed bone at 6 (47% of reports), 12 (24%), 18 (20%), and 24 months (8%), with 60% being sequestrum and with 7 cases (20%) persisting for >6 months. The average maximum RT dose to the affected area of exposed bone was 5456 cGy (SD, 1768 cGy); the most frequent associated primary RT sites were the oropharynx (42.9%) and oral cavity (31.4%), and 76% of episodes occurred in the mandible. The diagnosis of ORN was confirmed in 18 participants for an incidence rate of 3.1% (18 of 572). Risk factors included pre-RT extractions (P = .008), a higher RT dose (P = .039), and tobacco use (P = .048). CONCLUSIONS:The 2-year incidence of exposed bone in the OraRad cohort was 6.1%; the incidence of confirmed ORN was 3.1%. Exposed bone after RT for HNC is relatively uncommon and, in most cases, is a short-term complication, not a recurring or persistent one.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:Fibula flaps are routinely used for osseous reconstruction of head and neck defects. However, single-barrel fibula flaps may result in a height discrepancy between native mandible and grafted bone, limiting outcomes from both an aesthetic and dental standpoint. The double-barrel fibula flap aims to resolve this. We present our institution's outcomes comparing both flap designs. STUDY DESIGN/METHODS:Retrospective cohort study. METHODS:We conducted a retrospective review of all patients undergoing free fibula flap mandibular reconstruction at our institution between October 2008 and October 2020. Patients were grouped based on whether they underwent single-barrel or double-barrel reconstruction. Postoperative outcomes data were collected and compared between groups. Differences in categorical and continuous variables were assessed using a Chi-square test or Student's t-test, respectively. RESULTS:Out of 168 patients, 126 underwent single-barrel and 42 underwent double-barrel reconstruction. There was no significant difference in postoperative morbidity between approaches, including total complications (P = .37), flap-related complications (P = .62), takeback to the operating room (P = .75), flap salvage (P = .66), flap failure (P = .45), and mortality (P = .19). In addition, there was no significant difference in operative time (P = .86) or duration of hospital stay (P = .17). After adjusting for confounders, primary dental implantation was significantly higher in the double-barrel group (odds ratio, 3.02; 95% confidence interval, 1.2-7.6; P = .019). CONCLUSION/CONCLUSIONS:Double-barrel fibula flap mandibular reconstruction can be performed safely without increased postoperative morbidity or duration of hospital stay relative to single-barrel reconstruction. Moreover, the double-barrel approach is associated with higher odds of primary dental implantation and may warrant further consideration as part of an expanded toolkit for achieving early dental rehabilitation. LEVEL OF EVIDENCE/METHODS:III Laryngoscope, 2021.

Thyroidectomy remains the gold standard treatment for benign, symptomatic, or enlarging thyroid nodules, malignant nodules, and metastatic lymph node disease. However, in the past 2 decades, image-guided interventional techniques have emerged as promising alternative treatments for these conditions. Percutaneous ethanol ablation is now an accepted first-line treatment for recurring cystic thyroid nodules. Thermal ablation techniques such as high-intensity focused ultrasound, laser ablation, radiofrequency ablation, and microwave ablation have shown efficacy in producing a nodular volume reduction of greater than 50% that is maintained for several years with resolution of local compressive symptoms. There is also increasing evidence that these techniques can effectively treat papillary thyroid microcarcinomas and recurrent metastatic lymph node disease. Because these interventional ablation techniques are performed safely in an outpatient setting, are well tolerated, and the risk for needing thyroid hormone supplementation is negligible, they are becoming a popular alternative treatment to surgical resection. In this comprehensive review, we discuss each of these percutaneous interventions: the devices and techniques, the advantages and disadvantages of each energy, and summarize the outcomes published in the literature.

BACKGROUND:Transoral robotic surgery (TORS) was approved by the Food and Drug Administration in 2009 for the treatment of oropharyngeal cancers (oropharyngeal squamous cell carcinoma [OPSCC]). This study investigated the adoption and safety of TORS. METHODS:All patients who underwent TORS for OPSCC in the National Cancer Data Base from 2010 to 2016 were selected. Trends in the positive margin rate (PMR), 30-day unplanned readmission, and early postoperative mortality were evaluated. Outcomes after TORS, nonrobotic surgery (NRS), and nonsurgical treatment were compared with matched-pair survival analyses. RESULTS:From 2010 to 2016, among 73,661 patients with OPSCC, 50,643 were treated nonsurgically, 18,024 were treated with NRS, and 4994 were treated with TORS. TORS utilization increased every year from 2010 (n = 363; 4.2%) to 2016 (n = 994; 8.3%). The TORS PMR for base of tongue malignancies decreased significantly over the study period (21.6% in 2010-2011 vs 15.8% in 2015-2016; P = .03). The TORS PMR at high-volume centers (≥10 cases per year; 11.2%) was almost half that of low-volume centers (<10 cases per year; 19.3%; P < .001). The rates of 30-day unplanned readmission (4.1%) and 30-day postoperative mortality (1.0%) after TORS were low and did not vary over time. High-volume TORS centers had significantly lower rates of 30-day postoperative mortality than low-volume centers (0.5% vs 1.5%; P = .006). In matched-pair analyses controlling for clinicopathologic cofactors, 30-, 60-, and 90-day posttreatment mortality did not vary among patients with OPSCC treated with TORS, NRS, or nonsurgical treatment. CONCLUSIONS:TORS has become widely adopted and remains safe across the country with a very low risk of severe complications comparable to the risk with NRS. Although safety is excellent nationally, high-volume TORS centers have superior outcomes with lower rates of positive margins and early postoperative mortality.

Rhinoplasty is widely regarded as one of the more technically challenging surgeries, owing in part to the many possible short- and long-term complications that can arise. Although severe complications are uncommon, unforeseen complications can lead to esthetic and functional compromise, patient dissatisfaction, and need for revision surgery. The rhinoplasty surgeon must be prepared to counsel patients and identify and manage the range of complications that may result from this procedure. This article reviews some of the most frequently encountered complications related to rhinoplasty and their management approaches.

OBJECTIVE:Perfusion imaging identifies anterior circulation stroke patients who respond favorably to endovascular thrombectomy (ET), but its role in basilar occlusion (BAO) is unknown. We hypothesized that BAO patients with limited regions of severe hypoperfusion (Time-to-maximum [Tmax] delay >10 seconds) would have a favorable response to ET compared to patients with more extensive regions involved. METHODS:We performed a multicenter retrospective cohort study of BAO patients with perfusion imaging prior to ET. We pre-specified a Critical Area Perfusion Score (CAPS; 0-6 points), which quantified severe hypoperfusion (Tmax >10s) in cerebellum (1 point/hemisphere), pons (2 points), midbrain and/or thalamus (2 points). Patients were dichotomized into favorable (CAPS≤3) and unfavorable (CAPS>3) groups. The primary outcome was a favorable functional outcome 90-days after ET (modified Rankin Scale [mRS] 0-3). RESULTS:103 patients were included. CAPS≤3 patients (87%) had a lower median NIHSS (12.5 [IQR 7-22]) compared to CAPS>3 patients (13%) (23 [IQR 19-36]; p=0.01). Reperfusion was achieved in 84% of all patients with no difference between CAPS groups (p=0.42). 64% of reperfused CAPS≤3 patients had a favorable outcome compared to 8% of non-reperfused CAPS≤3 patients (OR=21.0 [95% CI 2.6-170]; p<0.001). No CAPS>3 patients had a favorable outcome, regardless of reperfusion. In a multivariable regression analysis, CAPS≤3 was a robust independent predictor of favorable outcome after adjustment for reperfusion, age, and pre-ET NIHSS (OR 39.25 [95% CI 1.34->999)]; p=0.04). INTERPRETATION/CONCLUSIONS:BAO patients with limited regions of severe hypoperfusion had a favorable response to reperfusion following ET. However, patients with more extensive regions of hypoperfusion in critical brain regions did not benefit from endovascular reperfusion. This article is protected by copyright. All rights reserved.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:The aim of this study was to obtain a reliable estimate of single-sided deafness (SSD) prevalence in the adult U.S. POPULATION/METHODS/: METHODS:A cross-sectional national epidemiologic study was performed. Participants were included from the National Health and Nutrition Examination Survey (NHANES). Each cohort includes a nationally representative sample of approximately 5,000 noninstitutionalized civilians. Subjects 20 years old and over with audiometric testing were included. SSD was defined as normal hearing (pure-tone average [PTA] of ≤25 dB) in one ear and severe or worse hearing (PTA > 70 dB) in the other, using both three- and four-frequency PTA definition. Prevalence was measured as a raw number (n) and percentage (%) of the sample. Weighted estimates of prevalence were calculated based on the 2019 U.S. population census. RESULTS:An estimated 345,064 Americans (estimated prevalence of 0.14%, 95% confidence interval = 0.08-0.24) had SSD. SSD was more prevalent in individuals 60 to 79 years of age (estimated 155,917 U.S. adults, prevalence of 0.25%). A higher prevalence of SSD was noted among women compared to men (215,430 U.S. adult women, prevalence of 0.17% vs. 131,726 U.S. adult men, prevalence of 0.11%). Using a three-frequency PTA definition resulted in an estimated prevalence of 0.11%. Finally, 27% of adults with SSD reported having "good" or "excellent" hearing despite their hearing loss. CONCLUSIONS:The prevalence of SSD in the United States is estimated at 0.11%-0.14% (271,122 to 345,064 adults), depending on PTA definition used. These individuals could potentially benefit from auditory rehabilitation, including cochlear implantation. LEVEL OF EVIDENCE/METHODS:2 Laryngoscope, 2021.

OBJECTIVE:To present a rare case of a middle ear capillary hemangioma in an adult. PATIENT/METHODS:A 31-year-old woman with a 6-month history of left ear fullness, pressure, tinnitus, and progressive hearing loss. INTERVENTION/METHODS:Endoscopic laser-assisted resection. MAIN OUTCOME MEASURES/METHODS:Clinical, radiographic, and histopathological findings of a capillary hemangioma. RESULTS:Otoscopy revealed an erythematous and slightly pulsating multilobulated middle ear retrotympanic mass. Her audiogram demonstrated a left-sided mixed hearing loss with air-conduction thresholds in the severe-to-profound range. Computed tomography (CT) imaging was significant for total opacification of the left middle ear and mastoid air cells. She underwent a combined endoscopic transcanal and transmastoid excision of the mass with ossicular chain reconstruction. A KTP laser was used to ablate and shrink down the periphery of the lesion. Pathology of the specimen was consistent with a capillary hemangioma. The patient's pulsatile tinnitus and spontaneous vertigo resolved postoperatively. CONCLUSIONS:Capillary hemangiomas are an uncommon cause of vascular middle ear lesions in adults and typically present with symptoms of aural fullness, pulsatile tinnitus, conductive hearing loss, otalgia, and vertigo. Surgery resection provides definitive treatment and the use of laser ablation techniques can allow for hemostasis and excellent visualization.