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Objective: To determine differences in post-treatment QoL across treatment settings in patients receiving adjuvant radiation therapy for head and neck squamous cell carcinoma (HNSCC)., Methods: This was a prospective observational cohort study of patients with HNSCC initially evaluated in a head and neck surgical oncologic and reconstructive clinic at an academic medical center (AMC). Participants were enrolled prior to treatment in a prospective registry collecting demographic, social, and clinical data. Physical and social-emotional QoL (phys-QoL and soc-QoL, respectively) was measured using the University of Washington-QoL questionnaire at pre-treatment and post-treatment visits., Results: A cohort of 177 patients, primarily male and White with an average age of 61.2 ± 11.2 years, met inclusion criteria. Most patients presented with oral cavity tumors (n = 132, 74.6%), had non-HPV-mediated disease (n = 97, 61.8%), and were classified as Stage IVa (n = 72, 42.8%). After controlling for covariates, patients treated at community medical centers (CMCs) reported a 7.15-point lower phys-QoL compared with those treated at AMCs (95% CI: -13.96 to -0.35, p = 0.040) up to 12 months post-treatment. Additionally, patients who were treated at CMCs had a 5.77-point (-11.86-0.31, p = 0.063) lower soc-QoL score compared with those treated at an AMC, which was not statistically significant., Conclusion: This study revealed that HNSCC patients treated with radiation at AMCs reported significantly greater phys-QoL in their first-year post-treatment compared to those treated at CMCs, but soc-QoL did not differ significantly. Further observational studies are needed to explore potential factors, including treatment planning and cancer resource engagement, behind disparities between AMCs and CMCs., Level of Evidence: 3 Laryngoscope, 134:3645-3655, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluate the potential use of artificial intelligence (AI) chatbots, such as ChatGPT, in preoperative counseling for patients undergoing head and neck cancer surgery., Study Design: Cross-Sectional Survey Study., Setting: Single institution tertiary care center., Methods: ChatGPT was used to generate presurgical educational information including indications, risks, and recovery time for five common head and neck surgeries. Chatbot-generated information was compared with information gathered from a simple browser search (first publicly available website excluding scholarly articles). The accuracy of the information, readability, thoroughness, and number of errors were compared by five experienced head and neck surgeons in a blinded fashion. Each surgeon then chose a preference between the two information sources for each surgery., Results: With the exception of total word count, ChatGPT-generated pre-surgical information has similar readability, content of knowledge, accuracy, thoroughness, and numbers of medical errors when compared to publicly available websites. Additionally, ChatGPT was preferred 48% of the time by experienced head and neck surgeons., Conclusion: Head and neck surgeons rated ChatGPT-generated and readily available online educational materials similarly. Further refinement in AI technology may soon open more avenues for patient counseling. Future investigations into the medical safety of AI counseling and exploring patients' perspectives would be of strong interest., Level of Evidence: N/A. Laryngoscope, 134:2757-2761, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective(s): To evaluate the impact of consistent surgical teams on procedure duration in head and neck free tissue transfer, and to evaluate the length of stay and readmission rates with consistent teams., Methods: A retrospective chart review of head and neck microvascular reconstruction by a single surgeon between August 2017 and November 2021 was performed. Procedure duration, wound complications, length of stay, and 30-day readmissions were analyzed. One circulating nurse (CN) and surgical technologist (ST) were considered "consistent" due to their prior work with the primary surgeon. All others were considered "ad hoc." Teams were "Consistent CN + ST," "Consistent ST," "Consistent CN," or "Ad hoc." Procedure duration between groups was compared via analysis of variance. Multivariate linear regression was performed to predict procedure duration., Results: A total of 135 patients were included. Age, sex, and American Society of Anesthesiologists status did not significantly differ across groups (p = 0.963; p = 0.467; p = 0.908, respectively). The mean procedure duration was 339.3 min and differed significantly across all groups (p = 0.006, Cohen d = 0.32). Compared to the Ad hoc group, consistent teams demonstrated significant reductions in mean procedure duration (Consistent CN + ST: 58.4 min, p = 0.001, Cohen d = 0.67; Consistent ST: 51.6 min, p = 0.013, Cohen d = 0.61; Consistent CN: 44.5 min, p = 0.031, Cohen d = 0.52). Controlling for other factors, the ad hoc team predicted increased procedure duration on multivariate analysis ( β 57.38, 19.92-94.85, p < 0.003). Wound complications, length of stay, and readmission rates did not differ significantly across groups (p = 0.940; p = 0.174; p = 0.935, respectively)., Conclusion: Consistent CN and ST improve operative efficiency in head and neck-free tissue transfer. Future studies may evaluate the impact of team consistency on complications, physician burnout, and health systems costs., Level of Evidence: 3 Laryngoscope, 133:2154-2159, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries., Methods: Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids., Results: Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054). RCT: Interim analysis for safety and futility was planned during trial's design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p < 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p > 0.05). Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2., Conclusion: Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery., Level of Evidence: 1, Randomized Clinical Trial Laryngoscope, 133:S1-S11, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Educational Objective: Assess outcomes of pediatric facial reconstruction with fibula free flaps., Objectives: Free flap reconstruction of complex maxillofacial defects in pediatric patients is rare. Post-operative complications, donor site morbidity, impact on craniofacial growth, and oro-dental rehabilitation are unknown. Our study assesses the outcomes of pediatric maxillofacial reconstruction with composite fibula free flaps., Study Design: Retrospective chart review., Methods: Multi-institutional retrospective chart review from 2000 to 2020 on pediatric patients undergoing maxillomandibular reconstruction with fibula free flaps., Results: Eighty-seven patients underwent 89 surgeries; 5 maxillary and 84 mandibular defects. Median age: 12 years. Defects were acquired following resection of sarcoma/carcinoma 44% or benign tumors 50%. 73% of cases had immediate free flap reconstruction. Closing osteotomies were reported in 74%; 1 in 40%, 2 in 27%, and more than 2 in 6.7%. Hardware was used in 98% and removed in 25%. 9.2% demonstrated long-term hardware exposure, greater than 3 months following reconstruction. Short-term complications: wound infection 6.7%, flap salvage/failure 2.2%, fistula 1.1%, and compromised craniofacial growth: 23%. Two patients developed trismus. Long-term fibula donor site complications: hypertrophic scarring: 3.4%, dysesthesia: 1.1%, and long-term gait abnormality: 1.1%. Dental rehabilitation was performed in 33%. Post-operative speech outcomes showed 94% with fully intelligible speech., Conclusion: Pediatric maxillary and mandible defects repaired with fibula free flaps demonstrated complication rates comparable to the adult free flap population. Long-term follow-up did not demonstrate adverse outcomes for craniofacial growth. Hardware for flap retention was utilized and remained in place with minimal exposure. Post-operative gait abnormality is rare., Level of Evidence: 3 Laryngoscope, 133:302-306, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: New advances in osseous microvascular mandibular rigid fixation are being employed at many institutions. These include standardized prebent/preformed reconstruction plates as well as computer-aided design/computer-aided manufacturing (CAD/CAM) custom plates that are patient specific. Our goal was to assess and compare the outcomes of both of these new technologies when utilized for mandibular microvascular reconstruction., Study Design: Retrospective chart review., Methods: Subjects were categorized into two groups according to their mandibular rigid fixation technique: group 1 = prebent/preformed plates and group 2 = CAD/CAM custom plates. Primary outcome measures were 1) perioperative complications (defined as deep tissue infection, wound dehiscence resulting in bone exposure, and/or plate exposure) and 2) reoperation rates for mandibular hardware failure/explantation. Statistical analysis consisted of χ 2 , Fisher exact test, and multivariable regression models., Results: A total of 142 subjects underwent microvascular mandibular reconstruction in a 6-year period. Eighty-nine subjects utilized prebent/preformed plates, and 53 employed CAD/CAM custom plates. Perioperative complications occurred in 32 of 89 (35.9%) subjects with prebent/preformed plates and 11 of 53 (20.7%) subjects using CAD/CAM custom plates. Reoperation requiring hardware explantation occurred in 18 of 89 (20.2%) subjects and three of 53 (5.6%) using CAD/CAM custom plates. Statistical comparison of perioperative complications between the two groups approached significance (P = .0556), and the rate of reoperation was significant favoring CAD/CAM implants (P = .0180)., Conclusions: In our experience, CAD/CAM custom plates utilized for rigid fixation during microvascular mandibular reconstruction demonstrated fewer complications and statistically lower reoperation rates when compared with prebent/preformed plates., Level of Evidence: 2c Laryngoscope, 129:1081-1086, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To compare free flap reconstructive cases from 1999 and 2009 with respect to patient characteristics, surgical characteristics, outcomes, and complications; and to discuss the evolution in free flap reconstruction at a single institution during this time period., Study Design: Retrospective cohort comparison., Methods: Free flap reconstruction cases from 1999 and 2009 were collected into two cohorts. Retrospective chart review was performed to extract patient characteristics, surgical characteristics, and outcomes. Cohorts were compared with respect to extracted data with statistical significance set at P < .05., Results: There were 39 free flap reconstructions performed in 1999 and 81 performed in 2009. Patients in the 2009 cohort had higher American Society of Anesthesiologists scores and incidence of cardiovascular disease (P = .009 and .0045, respectively). Median operative time decreased from 12 hours in 1999 to 9 hours in 2009 (P < .0001). Median length of stay decreased from 14 to 9 days (P = .0006). The rate of perioperative return to the operating room to manage complications decreased from 30% to 17% (P = .103). There were five unsalvaged flap failures in 1999 (12.8%) compared to two failures in 2009 (2.5%) (P = .036)., Conclusions: Patients undergoing free flap reconstruction are increasingly older and have more medical comorbidities. Despite these challenges, increased efficiency and teamwork stemming from accumulated institutional experience have led to decreased operative times, length of stay, and complication rates and increased overall success rates., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: The objectives were to describe our experience with a bolsterless technique for the management of auricular hematomata and discuss the management options for auricular hematomata and the comparative benefits of the bolsterless technique., Study Design: Retrospective case series., Methods: Patients presented with recurrent auricular hematomata following traditional treatment with incision and drainage and bolster placement. Revision incision and drainage were performed, and then auricular skin was stabilized using through-and-through absorbable horizontal mattress sutures. Patients were seen in follow-up to evaluate for recurrence and assess cosmetic results., Results: Twenty-eight patients were treated for recurrent auricular hematomata using the bolsterless technique. There were no recurrences in follow-up, and cosmetic results were judged to be excellent by both patient and surgeon., Conclusions: Bolsterless management for auricular hematomata using absorbable mattress sutures has been described intermittently in the otolaryngology literature since 1991 but is not widely utilized. In this series, patients presenting with recurrent auricular hematomata following failure of traditional bolster management were effectively managed with the bolsterless technique. This technique is well tolerated by patients and allows for early return to athletic activity., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: To validate the sheep model for endoscopic nasal surgery, and to utilize this model to compare the immediate and early postoperative histopathologic effects of four electrosurgical turbinate reduction techniques., Study Design: Pilot comparative study of electrosurgical devices for inferior turbinate reduction using a sheep model., Methods: Three radiofrequency devices (one monopolar and two bipolar) were compared to monopolar electrosurgery in a sheep model of inferior turbinate reduction. Procedures were performed according to device manufacturer guidelines using standard endoscopic instruments. Normative acoustic rhinometry data were obtained for the sheep model. Histopathologic analysis of turbinate specimens was performed at postoperative day 0 and 21., Results: Turbinate reduction was performed on seven sheep, one procedure on each side, yielding 14 turbinate specimens. Acoustic rhinometry was validated in the sheep model and demonstrated increased nasal volumes following decongestion and turbinate reduction. Submucosal destruction of glands and venous sinusoids and replacement with fibrosis were demonstrated as a common mechanism of action for all four electrosurgical devices. Epithelial disruption was seen with all devices on postoperative day 0. Squamous metaplasia and normal respiratory epithelial regeneration were documented variably between devices at postoperative day 21., Conclusions: The sheep model is useful for study of both the anatomic and histopathologic effects of endonasal procedures. Standard endoscopic instruments and acoustic rhinometry can be used in this model with reproducible results. In this pilot animal study, radiofrequency devices for inferior turbinate reduction demonstrated greater preservation of normal nasal mucosal respiratory epithelium when compared to monopolar electrosurgery., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Educational Objective: At the conclusion of this presentation, the participants should be familiar with the clinical and pathologic features of collision tumors in the head and neck., Objectives: Present a case of collision tumor of the head and neck consisting of metastatic squamous cell carcinoma and B-cell lymphoma. Review the literature on collision tumors of the head and neck., Study Design: Case report., Methods: Retrospective case review including a review of the relevant literature., Results: The case of a 73 year-old-man with collision tumor of the cervical lymph nodes is presented. He had a history of resection of a squamous cell carcinoma of the nasal ala seven years prior to presentation with a neck mass. Fine needle aspiration of the mass was consistent with squamous cell carcinoma and he underwent neck dissection. Pathology revealed both squamous cell carcinoma and low grade B cell lymphoma in the same cervical lymph nodes. The patient underwent post-operative concurrent chemotherapy and radiotherapy directed at the squamous cell carcinoma. Subsequently, he initiated chemotherapy directed at the lymphoma., Conclusions: Collision tumors are rare entities that consist of two neoplasms of distinct origin found in a single anatomic location. In the head and neck, collision tumors often involve an incidental well-differentiated thyroid malignancy. Collision tumor involving metastatic squamous cell carcinoma and lymphoma is an exceedingly rare finding. A multidisciplinary team approach is required to optimize and coordinate management of these synchronous malignancies.

Educational Objective: At the conclusion of this presentation, the participants should be familiar with the management of serious head and neck infections occurring inpatients on biologic agents for rheumatoid arthritis., Objectives: Present a case of retropharyngeal abscess managed in a patient on abatacept, a T cell immune modulator, for rheumatoid arthritis. Review the literature on the relationship between biologic agents for rheumatoid arthritis and head and neck infections., Study Design: Case report., Methods: Retrospective case review including a review of the relevant literature., Results: The case of a 62-year-old woman with retropharyngeal abscess is presented. Her medical history was significant for rheumatoid arthritis treated with abatacept, a T-cell immune modulator. She presented with progressive odynophagia and neck pain, and a computed tomography scan revealed large retropharyngeal abscess extending to the superior mediastinum with bilateral pleural effusions. Transcervical incision and drainage was performed and infectious disease consultation was obtained. Full recovery was achieved after a month long course of intravenous antibiotics., Conclusions: Biologic agents that achieve selective immune modulation have revolutionized the treatment of rheumatoid arthritis. However, there is a small but significant risk of serious infection that accompanies these drugs. Otolaryngologists should be vigilant for signs and symptoms of serious head and neck infection in patients who are on biologic agents for rheumatoid arthritis. Management of these patients must account for their diminished immune response to infection.

Educational Objective: At the conclusion of this presentation, the participants should be able to describe the tissue effects of steel scalpel, monopolar electrosurgery, and ultrasonic scalpel glossectomy with respect to histopathologic margin assessment in a rat model., Objectives: Histopathologic margin assessment is important in guiding treatment and determining prognosis for squamous cell cancer of the oral tongue. Energy based devices for glossectomy produce varying degrees of tissue distortion and artifact that can influence margin assessment. The purpose of this study is to compare the tissue effects of three surgical methods of glossectomy with respect to margin assessment by a pathologist., Study Design: Blinded histopathologic study of three surgical techniques for glossectomy using a rat model., Methods: The anterior tongue of thirty Sprague-Dawley rats was excised using either steel scalpel, monopolar electrosurgery, or ultrasonic scalpel (three groups of ten). Specimens were fixed in formalin and serially sectioned, and hematoxylin and eosin stains were examined by a pathologist blinded to the surgical procedure. Comparison between surgical techniques with respect to effect on the tissue margin was carried out using a previously described grading system for margin assessment., Results: Minimal tissue disruption at the surgical margin was produced by the steel scalpel, in contrast to monopolar electrosurgery and harmonic scalpel, which both produced varying levels of tissue distortion. Margin fragmentation, cautery artifact, and artifact depth was greater with monopolar electrosurgery when compared to harmonic scalpel., Conclusions: Energy based devices cause tissue distortion which may in theory effect the ability to accurately assess surgical margins for tumor involvement on histopathology. In our rat model of glossectomy, the harmonic scalpel created less tissue distortion at the surgical margin than monopolar electrosurgery. Further study is required to determine the clinical relevance of these findings.