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Introduction Invasive fungal sinusitis (IFS) is a rare but deadly clinical entity that occurs in immunocompromised patients. Diagnosis in children typically requires operative biopsies under general anesthesia, which has associated risks. Findings on bedside nasal endoscopy (BNE) can be used with history, exam, and imaging to determine the need for surgery, however, the accuracy of this tool has not been established among pediatric patients. Methods Patients who underwent BNE for evaluation of IFS from 2008 to 2016 at the Children's Hospital of Philadelphia were identified using Current Procedural Terminology (CPT) codes. Retrospective chart analysis was performed and included underlying diagnoses, presenting signs and symptoms, imaging findings, endoscopic findings and outcomes. Results Nineteen patients were identified who underwent evaluation for IFS using BNE during the period studied. Eight patients had exam findings that were concerning for IFS, including debris or crusting, darkened or pale mucosa, or copious, thick and/or purulent secretions. Immediate operative biopsies and debridement revealed IFS in six of eight patients. Eleven patients had exam findings deemed not concerning for IFS including mucosal edema, mucous without purulence, or normal findings. Six of eleven patients underwent operative biopsy despite negative endoscopy, and five were observed clinically. None of the 11 patients with negative bedside endoscopy developed IFS. Conclusions All patients with IFS had concerning exam findings on endoscopy and were treated with immediate biopsies and debridement. No patient with normal or non-concerning findings on BNE progressed to have invasive fungal sinusitis. While suspicion for IFS in immunocompromised children must remain high, BNE is feasible and useful in its assessment.

Objective To determine which complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, correlate with 30-day mortality in surgery for malignancies of the head and neck. Study Design Retrospective review of prospectively collected national database. Setting NSQIP. Subjects and Methods NSQIP data from 2005 to 2014 were queried for ICD-9 codes head and neck malignancies. Multivariate logistic regression was used to examine the correlation of individual complications with 30-day mortality. Results In total, 15,410 cases met criteria with 3499 complications in 2235 cases. After controlling for patient and surgical variables, postoperative pneumonia ( P = .02; odds ratio [OR], 2.39; 95% confidence interval [CI], 1.15-4.72), progressive renal insufficiency ( P < .001; OR, 21.28; 95% CI, 4.22-87.94), bleeding requiring transfusion ( P = .02; OR, 2.10; 95% CI, 1.12-3.84), sepsis ( P = .02; OR, 2.86; 95% CI, 1.15-6.46), septic shock ( P = .045; OR, 2.87; 95% CI, 0.98-7.81), stroke ( P < .001; OR, 19.81; 95% CI, 6.23-56.03), and cardiac arrest ( P < .001; OR, 135.59; 95% CI, 65.00-286.48) were independently associated with increased odds of 30-day mortality. Conclusion The NSQIP database has been extensively validated and used to examine surgical complications, yet there is little analysis on which complications are associated with death. This study identified complications associated with increased risk of 30-day mortality following head and neck cancer surgery. These associations may be used as a measure of complication severity and should be considered when using the NSQIP database to evaluate outcomes in head and neck surgery.

The microbiology of pediatric complicated acute rhinosinusitis (ARS) has evolved, and our current understanding of pathogenic organisms is limited. The objectives of this study are to describe the incidence of pathogens causing complicated ARS requiring surgical intervention at our institution over a 10-year period as well as their associated treatment outcomes.Retrospective cohort study.A single tertiary care children's hospital.Data were reviewed from all patients who underwent surgery for complicated ARS and had positive culture data from 2006 to 2016. Associations among pathogens, complications, and outcomes were analyzed with Pearson χEighty-nine patients met criteria. Complications included orbital infections (78%), intracranial infections (48%), Pott's puffy tumor (13%), and cavernous sinus thrombosis (9.0%). Bacterial isolates were majority polymicrobial (55%) and included Streptococcus species (58%), Staphylococcus species (49%; including methicillin-resistant S aureus [MRSA], 11%), and anaerobic bacteria (35%). S pneumoniae (9.0%), Haemophilus species (4.5%), and Moraxella catarrhalis (1.1%) were relatively uncommon. Bacterial isolates were similar among patients with all types of complications.Among a large cohort of pediatric patients with complicated ARS, most bacterial isolates were polymicrobial, with Streptococcus and Staphylococcus species contributing to the majority of cases. S aureus species, including MRSA and anaerobic pathogens, were common. The pattern of bacterial isolates was similar among patients with all types of complications of ARS. We suggest treatment for complicated ARS with broad-spectrum antibiotics with coverage for Streptococcus species, Staphylococcus species including MRSA, and anaerobic bacteria.

Background Substantial health care resources are used on aggressive end-of-life care, despite an increasing recognition that palliative care improves quality of life and reduces health care costs. We examined the incidence of palliative care encounters in in-patients with incurable head and neck cancer and associations with in-hospital mortality, length of hospitalization, and costs. Methods Data from the Nationwide Inpatient Sample (NIS) for 80,514 head and neck cancer patients with distant metastatic disease in 2001 to 2010 was analyzed using cross-tabulations and multivariate regressions. Results Palliative care encounters occurred in 4029 cases (5%) and were significantly associated with age ≥80 years, female sex, self-pay payor status, and prior radiation. Palliative care was significantly associated with increased in-hospital mortality and reduced hospital-related costs. Conclusion Inpatient palliative care consultation in terminal head and neck cancer is associated with reduced hospital-related costs, but appears to be underutilized and restricted to the elderly, uninsured, and patients with an increased risk of mortality. © 2015 Wiley Periodicals, Inc. Head Neck 38: 355–363, 2016

To investigate the relationship between hospital volume and mortality, complications, and failure-to-rescue rates among patients undergoing head and neck cancer (HNCA) surgery.Cross-sectional analysis.Nationwide Inpatient Sample.Discharge data for 159,301 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2001 to 2010 were analyzed using cross-tabulations and multivariate regression modeling. Failure to rescue was defined as death after a major complication, including acute myocardial infarction, acute renal failure, venous thromboembolism, pneumonia, gastrointestinal bleed, pulmonary failure, hemorrhage, or surgical site infection. We compared the incidence of mortality, major complications, and failure-to-rescue rates across hospital volume tertiles.The majority of hospitals performing HNCA surgery were low-volume hospitals, which performed a mean of 6 HNCA cases per year (n = 7635). Intermediate-volume hospitals performed a mean of 37 cases per year (n = 729), and high-volume hospitals performed a mean of 131 cases (n = 207). High-volume hospital care was associated with significantly decreased odds of death (odds ratio, 0.56; 95% confidence interval, 0.46-0.86) and failure to rescue (odds ratio, 0.56; 95% confidence interval, 0.33-0.97) compared to low-volume hospital care. However, there was no significant difference in major complication rates between patients undergoing HNCA surgery at high-volume hospitals and those at low-volume hospitals.Patients with HNCA who receive care at high-volume hospitals compared with low-volume hospitals have a 44% lower odds of mortality, which appears to be associated with differences in the response to and management of complications rather than differences in complication rates.

Objective To determine which complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, correlate with 30-day mortality in surgery for malignancies of the head and neck. Study Design Retrospective review of prospectively collected national database. Setting NSQIP. Subjects and Methods NSQIP data from 2005 to 2014 were queried for ICD-9 codes head and neck malignancies. Multivariate logistic regression was used to examine the correlation of individual complications with 30-day mortality. Results In total, 15,410 cases met criteria with 3499 complications in 2235 cases. After controlling for patient and surgical variables, postoperative pneumonia ( P = .02; odds ratio [OR], 2.39; 95% confidence interval [CI], 1.15-4.72), progressive renal insufficiency ( P.001; OR, 21.28; 95% CI, 4.22-87.94), bleeding requiring transfusion ( P = .02; OR, 2.10; 95% CI, 1.12-3.84), sepsis ( P = .02; OR, 2.86; 95% CI, 1.15-6.46), septic shock ( P = .045; OR, 2.87; 95% CI, 0.98-7.81), stroke ( P.001; OR, 19.81; 95% CI, 6.23-56.03), and cardiac arrest ( P.001; OR, 135.59; 95% CI, 65.00-286.48) were independently associated with increased odds of 30-day mortality. Conclusion The NSQIP database has been extensively validated and used to examine surgical complications, yet there is little analysis on which complications are associated with death. This study identified complications associated with increased risk of 30-day mortality following head and neck cancer surgery. These associations may be used as a measure of complication severity and should be considered when using the NSQIP database to evaluate outcomes in head and neck surgery.

Upper airway manifestations of Crohn's disease are rare with the most common being tracheobronchitis. We present a case report of a 12-year-old male with suspected Crohn's disease who presented with progressive symptoms of upper airway obstruction. Biopsies of thickened, pale, fibrotic supraglottic tissues were consistent with supraglottic involvement of Crohn's disease. He was treated with intralesional steroid injection with resolution of symptoms, obviating the need for systemic steroid treatment, which has been described in cases of Crohn's disease involving the airway.

Reconstruction with autologous tissue remains a sound option for many women following mastectomy.1,2 Among the strengths of autologous reconstruction is achievement of a natural consistency and pleasing aesthetic outcome. However, the main limitation can be donor site morbidity following flap harvest.3 Modifications in surgical technique and flap design using the muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) flap and the deep inferior epigastric perforator (DIEP) flap have decreased donor site morbidity.4–8 However, advancements in preserving the integrity of the rectus muscle in the abdominal wall, that is, by focusing on single perforator dissection, may result in compromised flap vascularity and an increase in perfusion-related flap complications.5,9 Fat necrosis is a consequence of either inadequate arterial inflow or relatively poor venous outflow in a DIEP flap. Development of fat necrosis requiring reoperation can result in significant aesthetic deformity and emotional and financial costs: treatment often requires breast imaging studies, tissue biopsy, and/or excision and may cause significant anxiety in patients with a history of breast cancer. Rates of fat necrosis documented in the literature range widely, from 2% to 62.5%.4,5,9–12 The roles of flap type, perforator number, donor site location, and flap size on the development of fat necrosis and complications continue to be debated in the literature. To our knowledge, no previous study has analyzed the interaction of perforator number and flap weight and their combined effect on fat necrosis in breast reconstruction with abdominal perforator-based free flaps. We hypothesized that increasing flap weight results in increased risk of fat necrosis. We also hypothesized that flaps with larger weights require more perforators to optimize vascular perfusion and that inclusion of more than one perforator may protect larger flaps from fat necrosis. Therefore, we retrospectively reviewed our patients to investigate the associations between flap weight and number of perforators with rates of fat necrosis and other associated complications in DIEP and MS-TRAM free flaps.

Previous studies have shown that exposure to a hypoxic in vitro environment increases the secretion of pro-angiogenic growth factors by human adipose-derived stromal cells (hASCs) [Cao Y, et al., Biochem Biophys Res Commun 332: 370–379, 2005; Kokai LE, et al., Plast Reconstr Surg 116: 1453–1460, 2005; Park BS, et al., Biomed Res (Tokyo) 31: 27–34, 2010; Rasmussen JG, et al., Cytotherapy 13: 318–328, 2010; Rehman J, et al., Circulation 109: 1292–1298, 2004]. Previously, it has been demonstrated that hASCs can differentiate into pericytes and promote microvascular stability and maintenance during angiogenesis in vivo (Amos PJ, et al., Stem Cells 26: 2682–2690, 2008; Traktuev DO, et al., Circ Res 102: 77–85, 2008). In this study, we tested the hypotheses that angiogenic induction can be increased and pericyte differentiation decreased by pretreatment of hASCs with hypoxic culture and that hASCs are similar to human bone marrow-derived stromal cells (hBMSCs) in these regards. Our data confirms previous studies showing that hASCs: 1) secrete pro-angiogenic proteins, which are upregulated following culture in hypoxia, and 2) migrate up gradients of PDGF-BB in vitro, while showing for the first time that a rat mesenteric model of angiogenesis induced by 48/80 increases the propensity of both hASCs and hBMSCs to assume perivascular phenotypes following injection. Moreover, culture of both cell types in hypoxia before injection results in a biphasic vascular length density response in this model of inflammation-induced angiogenesis. The effects of hypoxia and inflammation on the phenotype of adult progenitor cells impacts both the therapeutic and the basic science applications of the cell types, as hypoxia and inflammation are common features of natural and pathological vascular compartments in vivo.

To explore the potential of tumor-specific DNA as a biomarker for head and neck squamous cell carcinomas (HNSCC), we queried DNA from saliva or plasma of 93 HNSCC patients. We searched for somatic mutations or human papillomavirus genes, collectively referred to as tumor DNA. When both plasma and saliva were tested, tumor DNA was detected in 96% of 47 patients. The fractions of patients with detectable tumor DNA in early- and late-stage disease were 100% (n = 10) and 95% (n = 37), respectively. When segregated by site, tumor DNA was detected in 100% (n = 15), 91% (n = 22), 100% (n = 7), and 100% (n = 3) of patients with tumors of the oral cavity, oropharynx, larynx, and hypopharynx, respectively. In saliva, tumor DNA was found in 100% of patients with oral cavity cancers and in 47 to 70% of patients with cancers of the other sites. In plasma, tumor DNA was found in 80% of patients with oral cavity cancers, and in 86 to 100% of patients with cancers of the other sites. Thus, saliva is preferentially enriched for tumor DNA from the oral cavity, whereas plasma is preferentially enriched for tumor DNA from the other sites. Tumor DNA in saliva was found postsurgically in three patients before clinical diagnosis of recurrence, but in none of the five patients without recurrence. Tumor DNA in the saliva and plasma appears to be a potentially valuable biomarker for detection of HNSCC.

Substantial health care resources are used on aggressive end-of-life care, despite an increasing recognition that palliative care improves quality of life and reduces health care costs. We examined the incidence of palliative care encounters in in-patients with incurable head and neck cancer and associations with in-hospital mortality, length of hospitalization, and costs.Data from the Nationwide Inpatient Sample (NIS) for 80,514 head and neck cancer patients with distant metastatic disease in 2001 to 2010 was analyzed using cross-tabulations and multivariate regressions.Palliative care encounters occurred in 4029 cases (5%) and were significantly associated with age ≥80 years, female sex, self-pay payor status, and prior radiation. Palliative care was significantly associated with increased in-hospital mortality and reduced hospital-related costs.Inpatient palliative care consultation in terminal head and neck cancer is associated with reduced hospital-related costs, but appears to be underutilized and restricted to the elderly, uninsured, and patients with an increased risk of mortality.

Background Measures that can reduce the incidence of venous thromboembolism (VTE) are of great clinical importance. In addition to the use of sequential compression devices (SCDs), chemoprophylaxis with low-molecular-weight heparin (LMWH) has been recommended by the American College of Chest Physicians for major general surgery procedures. There remains inconclusive evidence to support guidelines for the plastic surgery population, and some surgeons hesitate to use anticoagulation due to concerns about bleeding in broad planes of dissection. The purpose of this study was to evaluate the risk of postoperative complications secondary to chemical thromboprophylaxis in massive weight loss patients. Methods Five hundred forty-six surgical cases were enrolled in an institutional review board-approved prospective clinical database in the 2 years before and after routine LMWH use was initiated. Inclusion required weight loss of greater than 50 lb. Group 1 had SCDs only (n = 334), whereas group 2 had SCDs and LMWH 6 hours postoperatively (n = 212). Risk of VTE was calculated and complications of LMWH administration were analyzed. Results The overall risk of deep venous thrombosis and pulmonary embolism was 0.18%. There was no statistical difference between the groups (P > 0.05). Overall risk of hematoma was 5.4%, in concordance with the literature. There was no difference in hematoma risk between the groups (4.6% before and 6.6% after LMWH; P = 0.3). The transfusion rate was 8.5% before use of LMWH (group 1) and 7.6% after (group 2; P = 0.7). Conclusions Strategies to reduce VTE rates remain important in all areas of plastic surgery. We have demonstrated no increased risk of transfusion or hematoma and a low overall incidence of VTE after implementing a chemoprophylaxis regimen. Postoperative LMWH can provide an excellent balance between VTE prophylaxis and the risk of bleeding complications.

Importance Unplanned hospital readmission is costly and in recent years has become a focus of health care legislation intended to reduce health care expenditures. Greater understanding of which perioperative complications are associated with hospital readmission after surgery for head and neck cancer is needed to reduce unplanned readmissions. Objective To determine which clinical risk factors and complications are associated with 30-day unplanned readmission after surgery for malignant neoplasms of the head and neck. Design, Setting, and Participants This retrospective longitudinal claims analysis included data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from January 1, 2012, to December 31, 2014. Patients undergoing surgery for malignant tumors of the head and neck were included; those with a primary diagnosis of thyroid malignant disease and those undergoing free autologous tissue transfer were excluded. Main Outcomes and Measures Clinical risk factors and complications were analyzed for association with unplanned hospital readmission using multivariable regression analysis. Statistical significance was determined using P Results A total of 7605 patients (5007 men [65.8%]; mean [SD] age, 64.2 [0.2] years) were identified and included for analysis. Overall, 1472 complications occurred in 912 cases. Three hundred eighty-eight patients (5.1%) had an unplanned readmission, which was lower than the previously published overall readmission rate for noncardiac surgical procedures in the NSQIP (6.8%). Clinical factors that were independently associated with unplanned readmission were age (adjusted odds ratio [AOR], 1.12; 95% CI, 1.03-1.22), diabetes (AOR, 1.60; 95% CI, 1.01-2.43), preoperative dyspnea at rest (AOR, 2.89; 95% CI, 1.40-5.55) and with moderate exertion (AOR, 1.48; 95% CI, 1.01-2.11), long-term use of corticosteroids (AOR, 2.45; 95% CI, 1.63-3.58), disseminated cancer (AOR, 1.57; 95% CI, 1.14-2.20), and a contaminated wound (AOR, 2.05; 95% CI, 1.05 - 3.7). When specific complications were examined, superficial incisional surgical site infection (SSI) (AOR, 2.02; 95% CI, 1.14-3.40), deep incisional SSI (AOR, 2.57; 95% CI, 1.26-5.03), organ or space SSI (AOR, 13.27; 95% CI, 6.57-26.61), wound disruption (AOR, 3.58; 95% CI, 1.95-6.31), pneumonia (AOR, 3.39; 95% CI, 1.88-5.96), deep vein thrombosis (AOR, 5.60; 95% CI, 1.90-15.25), pulmonary embolism (AOR, 20.72; 95% CI, 7.86-55.68), urinary tract infection (AOR, 2.66; 95% CI, 1.00-6.34), stroke (AOR, 12.42; 95% CI, 3.99-36.50), sepsis (AOR, 2.64; 95% CI, 1.27-5.30), and septic shock (AOR, 4.12; 95% CI, 1.10-15.81) were all associated with 30-day unplanned hospital readmission. Conclusions and Relevance This study evaluated clinical factors and postoperative complications to determine which ones were associated with 30-day unplanned hospital readmission among patients undergoing surgery for malignant tumors of the head and neck. Further understanding of which complications are associated with unplanned readmission after head and neck surgery will allow for improved risk stratification and development of postoperative care protocols to reduce unplanned hospital readmission.