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The primary aim of this study is to evaluate the safety, efficacy, and execution of major open laryngotracheal operations for patients in the advanced decades.Case series with chart review.Multidisciplinary clinic at a tertiary care academic hospital.Patient characteristics, operative course, and postoperative outcomes were retrospectively recorded for all airway reconstruction operations performed between 1999 and 2016 on patients aged ≥60 years Long-term success was defined as prosthesis-free survival at last follow-up. Descriptive statistics were performed.Twenty-nine patients met inclusion criteria, and the median age was 71 years (interquartile range, 63-74). Tracheal resection was the most common procedure (13 patients), followed by laryngotracheal reconstruction (7 patients). Fifteen patients began their operation with a tracheostomy, 6 of whom underwent decannulation prior to leaving the operating room. Three additional patients underwent decannulation at follow-up appointments and were prosthesis-free at most recent follow-up. The mean time to decannulation among these patients was 3 months. Of the 14 patients beginning their procedure without a tracheostomy, only 2 required permanent airway prosthesis. The overall long-term rate of prosthesis-free survival was 72.4% (21 of 29 patients). Factors suggestive of long-term success include lower McCaffrey grade and lack of pulmonary disease, hypertension, or diabetes, as well as decreased red blood cell distribution width on preoperative complete blood count.Through careful patient selection, preoperative workup, and meticulous postoperative care, airway reconstruction procedures in patients aged ≥60 years are reasonably successful. Of 29 patients, 21 (72.4%) were successfully breathing long-term without airway prosthesis.

Objective To characterize and identify risk factors for 30-day surgical site infections (SSIs) in patients with head and neck cancer who underwent microvascular reconstruction. Study Design Cross-sectional study with nested case-control design. Setting Nine American tertiary care centers. Subjects and Methods Hospitalized patients were included if they underwent head and neck cancer microvascular reconstruction from January 2003 to March 2016. Cases were defined as patients who developed 30-day SSI; controls were patients without SSI at 30 days. Postoperative antibiotic prophylaxis (POABP) regimens were categorized by Gram-negative (GN) spectrum: no GN coverage, enteric GN coverage, and enteric with antipseudomonal GN coverage. All POABP regimens retained activity against anaerobes and Gram-positive bacteria. Thirty-day prevalence of and risk factors for SSI were evaluated. Results A total of 1307 patients were included. Thirty-day SSI occurred in 189 (15%) patients; median time to SSI was 11.5 days (interquartile range, 7-17). Organisms were isolated in 59% of SSI; methicillin-resistant Staphylococcus aureus (6%) and Pseudomonas aeruginosa (9%) were uncommon. A total of 1003 (77%) patients had POABP data: no GN (17%), enteric GN (52%), and antipseudomonal GN (31%). Variables independently associated with 30-day SSI were as follows: female sex (adjusted odds ratio [aOR], 1.6; 95% CI, 1.1-2.2), no GN POABP (aOR, 2.2; 95% CI, 1.5-3.3), and surgical duration ≥11.8 hours (aOR, 1.9; 95% CI, 1.3-2.7). Longer POABP durations (≥6 days) or antipseudomonal POABP had no association with SSI. Conclusions POABP without GN coverage was significantly associated with SSI and should be avoided. Antipseudomonal POABP or longer prophylaxis durations (≥6 days) were not protective against SSI. Antimicrobial stewardship interventions should be made to limit unnecessary antibiotic exposures, prevent the emergence of resistant organisms, and improve patient outcomes.

Importance Free flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. Despite experience and meticulous technique, there is a small but recognized risk of partial or total flap loss in the postoperative setting. Historically, most microvascular surgeons involve resident house staff in flap monitoring protocols, and programs relied heavily on in-house resident physicians to assure timely intervention for compromised flaps. In 2003, the Accreditation Council for Graduate Medical Education mandated the reduction in the hours a resident could work within a given week. At many institutions this new era of restricted resident duty hours reshaped the protocols used for flap monitoring to adapt to a system with reduced resident labor. Objectives To characterize various techniques and frequencies of free flap monitoring by nurses and resident physicians; and to determine if adapted resident monitoring frequency is associated with flap compromise and outcome. Design, Setting, and Participants This multi-institutional retrospective review included patients undergoing free flap reconstruction to the head and/or neck between January 2005 and January 2015. Consecutive patients were included from different academic institutions or tertiary referral centers to reflect evolving practices. Main Outcomes and Measures Technique, frequency, and personnel for flap monitoring; flap complications; and flap success. Results Overall, 1085 patients (343 women [32%] and 742 men [78%]) from 9 institutions were included. Most patients were placed in the intensive care unit postoperatively (n = 790 [73%]), while the remaining were placed in intermediate care (n = 201 [19%]) or in the surgical ward (n = 94 [7%]). Nurses monitored flaps every hour (q1h) for all patients. Frequency of resident monitoring varied, with 635 patients monitored every 4 hours (q4h), 146 monitored every 8 hours (q8h), and 304 monitored every 12 hours (q12h). Monitoring techniques included physical examination (n = 949 [87%]), handheld external Doppler sonography (n = 739 [68%]), implanted Doppler sonography (n = 333 [31%]), and needle stick (n = 349 [32%]); 105 patients (10%) demonstrated flap compromise, prompting return to the operating room in 96 patients. Of these 96 patients, 46 had complete flap salvage, 22 had partial loss, and 37 had complete loss. The frequency of resident flap checks did not affect the total flap loss rate (q4h, 25 patients [4%]; q8h, 8 patients [6%]; and q12h, 8 patients [3%]). Flap salvage rates for compromised flaps were not statistically different. Conclusions and Relevance Academic centers rely primarily on q1h flap checks by intensive care unit nurses using physical examination and Doppler sonography. Reduced resident monitoring frequency did not alter flap salvage nor flap outcome. These findings suggest that institutions may successfully monitor free flaps with decreased resident burden.

This chapter provides an overview of current techniques of robotic surgery in the larynx. The focus is primarily on supraglottic laryngectomy as it is the most widely accepted transoral robotic procedure performed at the level of the larynx. A brief historical overview is provided followed by a detailed description of the regional anatomy, preoperative evaluation, and intraoperative logistics. A step-by-step case presentation of a supraglottic laryngectomy is included as a guide to discuss procedural details. Perioperative management, expected outcomes, complications, and future directions in robotic laryngeal surgery are also discussed.

Purpose of review Chronic rhinosinusitis affected 12.5% of the general population in the United States, making it one of the most common causes for patients to seek medical care. Despite a lack of compelling evidence, antibiotics are the most frequently prescribed class of medications for the treatment of chronic sinusitis, demonstrating a deeply rooted belief that bacteria are in some way responsible for the disease. Recent findings Despite the high prevalence of sinusitis, the cause of chronic rhinosinusitis remains elusive despite multiple attempts to determine the underlying cause. Theories have come and gone throughout the years with fungi, bacteria, host immunological defects, allergy, structural and functional defects, gastroesophageal reflux disease, environmental chemicals, and bacterial biofilms being blamed for this chronic inflammatory state of the sinonasal mucosa. Recent literature has continued to explore these various theories. Summary To date, there is no high-quality evidence that antibiotic therapy has any effect on the long-term management of chronic rhinosinusitis. No randomized placebo-controlled studies evaluating the utility of antibiotics have as yet been conducted. There remains an urgent need for a high-quality, prospective clinical trial to determine the proper role of antibiotics in the treatment of chronic rhinosinusitis.

Objectives Our laboratory is developing a surgical robotic system to further improve dexterity and visualization that will allow for broader application of transnasal skull base surgery. To optimize this system, intraoperative force data are required. Using a modified curette, force data were recorded and analyzed during pituitary tumor excision. Design A neurosurgical curette was modified by the addition of a force sensor. The instrument was validated in an in vitro model to measure forces during simulated pituitary tumor excision. Following this, intraoperative force data from three patients during transnasal endoscopic excision of pituitary tumors was obtained. Setting Academic medical center. Main Outcome Measures Forces applied at the skull base during surgical excision of pituitary tumors. Results Average forces applied during in vitro testing ranged from 0.1 to 0.15 N. Average forces recorded during in vivo testing ranged from 0.1 to 0.5 N. Maximal forces occurred with collisions of the bony sella. The average maximal force was 1.61 N. There were no complications related to the use of the modified curette. Conclusions Forces to remove pituitary tumor are small and are similar between patients. The in vitro model presented here is adequate for further testing of a robotic skull base surgery system.