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Objectives/Hypothesis To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option. Study Design Retrospective chart review. Methods A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed. Results Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2–3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified. Conclusion In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates. Level of Evidence 4. Laryngoscope, 126:2679–2683, 2016

Objective In certain cases, the recurrent laryngeal nerve (RLN) has to be sacrificed. This often results in an inadequate length of residual RLN to be used in a reinnervation procedure. We investigated the length of the distal stump of the RLN from the inferior border of the inferior pharyngeal constrictor muscle (IPCM), where it is frequently compromised, to its entrance into the larynx. Our objective was to determine whether this residual nerve stock was sufficient for margin clearance and neurorrhaphy. Study design Cadaveric study Methods Recurrent laryngeal nerves were identified in fresh frozen cadavers. The IPCM was divided, revealing the distal stump of the RLN, which was measured. Results Dissection was performed in 20 cadavers (40 nerves). The average length of the right RLN and the left RLN from the IPCM until it entered the larynx was 15 mm and 14 mm, respectively. All residual RLN remnants were of sufficient length for neurorrhaphy. Conclusion Concomitant RLN reinnervation procedures in the setting of nerve sacrifice are not well described. A barrier to reinnervation in this setting may be insufficient residual nerve length for a neurorrhaphy. Often, when the RLN is sacrificed intraoperatively either iatrogenically or due to tumor invasion, it is close to the cricoarytenoid joint, at the inferior border of the IPCM. This study demonstrates that by splitting the IPCM, sufficient length can be obtained for neurorrhaphy.

Introduction The purpose of our study was to describe a novel technique for reconstruction of orbital defects after maxillectomy using a non-anatomic titanium mesh suspension of orbital contents for both support and volume correction. This construct is then articulated with a layered fibula osteocutaneous free flap that restores orbital rim, zygoma, and maxillary alveolus. We herein present our application of this technique, including refinements over time and long-term outcomes. Methods A retrospective review was performed on 12 patients who underwent reconstruction of Brown class III orbitopalatomaxillary defects with extensive orbital involvement (at minimum complete orbital floor and rim absent) with titanium mesh sling and a layered fibula free flap. Results Primary reconstruction was accomplished in all 12 patients. The mean postoperative length of stay was 8 days (6-14 days). There were no free flap failures or perioperative re-explorations. Patients were routinely extubated on postoperative day #1 and began oral intake by postoperative day #3. At a mean follow-up length of 48 months, unrestricted eye function was accomplished in all patients. Midfacial symmetry was accomplished in 10 of 12 patients; 2 patients had moderate asymmetry due to extirpation of facial musculature and/or soft tissue. Minor revisions were necessary for lower lid ectropion and exposure of the titanium plate. Two patients required adipofascial free flap coverage of exposed intraoral bone after radiation therapy. Conclusions This technique provides excellent restoration of eye position and function and also allows for implant-based prosthetic rehabilitation. It has become our procedure of choice for orbitomaxillary reconstruction.

The angular artery, its perforating branches, and their zones of tissue perfusion have been described extensively for facial reconstruction. Various cutaneous and mucosal flaps with either anterograde or retrograde perfusion play an important role in facial and oral reconstruction. However, these flaps share the limitations of pedicled nature and donor-site intolerance. Free-tissue transfer (FTT) has transformed capabilities and outcomes in head and neck reconstruction. While less constrained by tissue volume and subtype, FTT has its own limitations, including pedicle reach for anastomosis to inflow and outflow vasculature in upper face reconstruction. The angular vessels, owing to their relatively high central location and accessibility via a camouflaged nasolabial fold incision, may have value in midface and nasal reconstruction.To detail a technique for consistently locating the angular vessels while preserving the integrity of adjacent neuromuscular structures and to evaluate the caliber and consistency of the angular artery and vein for their usability in microvascular anastomosis.We conducted a PubMed literature search for the terms angular artery, melolabial flap, nasolabial flap, retroangular flap, and any associations with FTT. We also performed 26 anatomic cadaveric dissections on 13 fresh cadavers to evaluate the angular arteries and veins.Vessel caliber, length, and variability were analyzed and utility for use in FTT was assessed. A total of 26 angular arteries and 26 angular veins were included in the analysis. Anatomic relationships were used to develop a surgical schema for dissection and isolation of the angular vessels specifically for FTT.The angular vessels have consistent anatomic relationships facilitating localization and have a consistent caliber amenable to use in microvascular FTT. The mean (SD) artery diameter was 2.34 (0.67) mm prior to dilation and 3.21 (0.87) mm after dilation. The diameters of the vein before and after dilation were 3.57 (0.53) mm and 6.40 (0.81) mm, respectively. There was no statistical difference between the vessels on the right and left sides.We describe for the first time the anatomic cadaveric dissection and analysis of the angular arteries and veins specifically to determine compatibility with regard to FTT. We found good FTT compatibility.NA.

Inferior turbinate surgery for nasal obstruction can be performed in a variety of ways. Only a few of these methods produce tissue that can be sent for pathologic analysis. According to the College of American Pathologists, turbinate tissues are not exempt from requisite pathologic evaluation. Our objectives were to evaluate the clinical value and cost implications of routine pathological examination of turbinate specimens.Case series with chart review.Academic tertiary care medical center.Charts of patients who underwent an inferior turbinate procedure for nasal obstruction between January 2008 and August 2011 were reviewed.Thirteen hundred consecutive cases from 17 surgeons were identified. Among these patients, 223 (17%) underwent an isolated turbinate reduction procedure and 779 (59%) underwent a reduction procedure in conjunction with a septoplasty. The remaining patients had a turbinate procedure in addition to another head and neck procedure. Only 591 (45%) turbinate reduction procedures were performed by methods that were tissue producing, and of these, 137 (23%) were sent for pathologic analysis. All submitted specimens received a gross examination and 123 (90%) also underwent histologic analysis. No abnormalities were reported.At our institution, most surgeons did not submit turbinate tissues for pathologic examination even when a specimen was produced. Of the specimens sent, no abnormal pathologic results were identified. Our results suggest that routine pathologic evaluation of inferior turbinate specimens may not contribute to patient care and perhaps represents an unnecessary cost.

Objectives/Hypothesis To evaluate the endoscopic surgical management of adult subglottic stenosis and describe treatment outcomes. Study Design Retrospective review. Methods Ten-year review of adult patients with subglottic stenosis. Results Ninety-two adults (23 male, 69 female) with subglottic stenosis underwent 247 endoscopic dilations between 2001 and 2010. The mean age was 48 years at time of first surgery. Etiology was GPA (granulomatosis with polyangiitis, formerly Wegener's granulomatosis) (45%), intubation (25%), or idiopathic (33%). Forty-one patients (45%) underwent a single procedure; 51 patients (55%) required multiple surgeries. The average interval for patients requiring a subsequent procedure was 13.7 months. Variations in surgical technique did not show differences in time to next procedure, and the use of mitomycin-C did not result in longer intervals between procedures. No significant complications were encountered after dilation. Conclusions Subglottic stenosis remains a treatment challenge. Although patients are often symptomatically improved after endoscopic dilation, recurrence rates remain high. Level of Evidence 4. Laryngoscope, 124:736–741, 2014

This review describes a general approach and philosophy in the management of massive facial trauma with extensive tissue loss, with particular highlight on the role of free tissue transfer.

Objective The best imaging study for evaluation of pediatric hearing loss is debated and it is well known magnetic resonance imaging is more costly than computed tomography. The objective of this study is to evaluate charges of computed tomography temporal bone (CTTB) versus magnetic resonance imaging brain, internal auditory canal/cerebellopontine angle (MRI IAC/CPA), with and without sedation in the pediatric population in order to assess to what extent the charges for the procedure are increased. In addition, differences in need for sedation and duration of sedation will be evaluated. Methods All patients, 0–18 years that underwent CTTB or MRI IAC/CPA, between January 2013 through December 2014 within department of otolaryngology. Results 120 CTTBs (118 non-sedated and 2 sedated) and 51 MRI IAC/CPAs (32 non-sedated and 19 sedated) were performed. Average charge for non-sedated CTTB was $1856. CTTB scan under sedation incurred total additional charges of $2385. Average charges for non-sedated MRI IAC/CPA was $3770. Technical charges for sedated MRI IAC/CPA was $151 lower ($2858) but had additional sedation charges of $2256, a recovery room charge of $250, and additional professional fees of $1496 for total charges of $7621. 37% of MRI IAC/CPAs needed sedation to be completed in comparison to 1.6% of CTTB. Conclusion MRI IAC/CPAs are, on average, twice as costly as CTTBs. Almost 40% of patients need sedation to complete MRI IAC/CPA. These considerations may factor into decision making when choosing imaging modality in evaluation of pediatric hearing loss.

Objectives/Hypothesis: During septoplasty, otherwise normal cartilage and bone are removed and routinely submitted for pathologic examination. According to the College of American Pathologists, however, the examination of bone and cartilage from septoplasty and rhinoplasty may be left to the pathologist's discretion. We explored the processing of tissues removed during septoplasty, examining the clinical value and implications of current practices. Study Design: Retrospective chart review. Methods: Our database was searched for septoplasty (CPT code 30520) procedures performed specifically for the indication of nasal obstruction. Results: Five hundred sixteen consecutive cases from 15 surgeons spanning a 2-year period were identified. In the majority of cases, septal tissues removed during surgery were submitted to pathology. The majority of cases (>90%) involved septoplasty performed in conjunction with another procedure, most commonly addressing the inferior turbinates. All septal specimens received gross examination by a pathologist, and a smaller fraction were also examined histologically. Gross findings included the qualitative appearance of the specimen and dimensional measurements of bone and cartilage fragments. No abnormalities were identified (by gross or histologic examination) in any of the specimens. Associated costs included specimen handling, storage, and pathology fees. Conclusions: In our health care system, it is common practice to submit tissues removed during septoplasty for pathologic examination. This study demonstrates that routine evaluation of septal tissues following surgery for obstruction has no clinical value whatsoever, and is associated with direct and indirect costs. Given the current health care climate, this practice should be further scrutinized and reconsidered.

Objectives/Hypothesis: The use of topical drug delivery through nasal irrigations can minimize systemic side effects and deliver higher concentrations of drugs directly to diseased sinus mucosa. Complications related to this popular method of treatment are not well described. We present our experience with paranasal sinus exostosis (PSE), a new diagnostic entity that appears to be a complication of cold nasal irrigations. Study Design: Retrospective chart review. Methods: Retrospective chart reviews were performed on patients within the Cleveland Clinic Foundation from 2005 to 2011. Six patients were identified with sinus exostoses. A literature review for “sinonasal exostoses” and “paranasal sinus exostoses” was performed using PubMed. Results: Six patients with PSE were identified at the Cleveland Clinic Foundation between 2005 and 2011. All patients had undergone sinus surgery, and none had documented evidence of PSE prior to surgery. There was no evidence of worsening PSE once the cold irrigations were stopped. No patients showed any resolution of PSE over time. None of our patients has progressed to have disease burden significant enough to require intervention. Conclusions: PSE is a rare condition that mirrors a well-described otologic process; exostoses of the external auditory canal. PSE appears to be a complication of cold nasal irrigations. It does not resolve with the halting of cold irrigations, but does not appear to progress further after intervention. PSE only affects postoperative patients. With the evolving trend to treat postoperative sinus disease topically, the clinician should be aware of the dangers of cold irrigations, and patients should be counseled accordingly.

To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option.Retrospective chart review.A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed.Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2-3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified.In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates.4. Laryngoscope, 126:2679-2683, 2016.

Minimizing morbidity when performing free flap reconstruction of the head and neck is important in the overall reconstructive paradigm.To examine the indications and success rates of free tissue transfer using small-caliber facial recipient vessels and minimal access incisions.Retrospective medical record review of patients with head and neck defects undergoing free tissue transfer from May 2010 to June 2013 at 2 tertiary care academic medical centers.Free tissue transfer using small-caliber recipient vessels and minimal access approaches.Postoperative complications, including flap failure, requirement for revision surgery, and nerve dysfunction.Eighty-nine flaps in 86 patients met inclusion criteria. Fifty flaps used the facial artery and vein distal to the facial notch, and 33 flaps used the superficial temporal vascular system. Six flaps used the angular artery and vein. A variety of flap donor sites were included. In most cases, free tissue transfer was indicated for the reconstruction of defects secondary to extirpation of malignant neoplasia. Overall success rate was 97.7% with 2 instances of total flap loss and 1 partial loss. One patient had transient nerve weakness (frontal branch), which resolved during a follow-up of 9 months.Free tissue reconstruction of head and neck defects can be safely and reliably accomplished using small-caliber recipient vessels, such as the superficial temporal, distal facial, and angular vessels. Minimal access approaches for microvascular anastomosis may be performed with excellent cosmesis and minimal morbidity.4.

Objectives:A wide array of surgical techniques has been developed to address internal nasal valve collapse. In particular, butterfly grafts and spreader grafts are used ubiquitously without any objective comparison being made on the efficacy of these approaches. The objective of this study was to quantitatively assess the effect that these techniques have on lateral nasal wall compliance.Methods:A total of 11 fresh nonfixed cadavers (22 valves) were utilized for this study. Baseline measurements of lateral wall compliance were performed using a tension gauge and a novel procedure (herein described), and each nasal valve was measured independently. The valves were augmented with butterfly graft, endonasal spreader graft, and open spreader graft. Lateral nasal wall compliance was measured after each technique, and statistical analysis was performed.Results:There was an increase in force required to displace the lateral nasal wall compared with baseline after butterfly and endonasal spreader techniques (P < ...

This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique.To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction.A retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated.Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was reconstructed with a contralateral adipofascial flap with excellent outcome. Three patients (10%) required minor flap revisions. There were no other complications.The ALTAF is a versatile flap easily harvested for use in several types of mucosal reconstructions.

Background A 10- to 15-mm L-strut in the dorsal and caudal areas of the nasal septum is preserved during septoplasty to maintain structural stability and prevent external deformity. However, during endoscopically performed septoplasty the surgeon has a very different perspective, which may create a more challenging situation to ensure adequate strut preservation. No reliable intranasal landmarks have been established. We establish intranasal landmarks that may be used during endoscopic septoplasty (ES) to safely maintain sufficient caudal and dorsal support. A cadaveric anatomic study was performed. Methods Measurements were made using calipers in 15 human cadavers (8 male and 7 female subjects), totaling 30 nasal passages. The caudal strut distance was measured from the inferior concha to the caudal aspect of the quadrangular cartilage. The dorsal strut height was measured from a line parallel to the nasal dorsum that extended from the middle turbinate (MT) axilla to the nasal vestibule (termed the “axillary line”). Results Using the inferior concha and the vertical MT attachment as endoscopic landmarks, the average caudal and dorsal struts measured 18.9 and 16.4 mm, respectively. Strut size was larger in male subjects than female subjects; however, dimensions remained >10 mm in all cadavers, establishing these landmarks as safe and effective for determining extent of cartilage resection. Conclusion The inferior turbinate and vertical MT attachment may be used to guide extent of cartilage resection during ES. Use of the described conchal and axillary lines as landmarks allow for preservation of an adequate L-strut during ES and may reduce support related complications.

IMPORTANCE The vascular supply of anterolateral thigh (ALT) free flaps is variable, and the pedicle length and ability to capture perforators to the flap may be limited by the anatomic configuration. We describe the reasoning behind performing the auto flow-through procedure, as well as the steps to carry this procedure out. OBSERVATIONS A retrospective medical chart review was performed within our health care system database to identify patients in whom the auto flow-through technique was used during reconstruction with an ALT free flap. The auto flow-through technique was applied to 3 separate ALT free flaps to incorporate perforators from 2 separate vascular systems. This technique allowed for more robust vascularity of the flap and/or optimized pedicle length that would have otherwise necessitated vein grafts. All patients had successful ALT free flap reconstruction and went on to have good functional results. CONCLUSIONS AND RELEVANCE The auto flow-through technique is an adaptation of the flow-through flap, which allows for capture of vascular perforators from separate sources when this configuration is present in the ALT free flap. This technique is especially useful when operating in a vessel-depleted neck or when maximizing pedicle reach is necessary. This technique allows the ALT to be used in challenging reconstruction cases regardless of the vascular branching pattern of the pedicle. LEVEL OF EVIDENCE 4.

Objectives:Inferior turbinate surgery for nasal obstruction can be performed in a variety of ways. Only a few of these methods produce tissue that can be sent for pathologic analysis. According to the College of American Pathologists (CAP), turbinate tissues are not exempt from pathology evaluation. Our objectives were to evaluate the clinical value and implications of routine pathological examination of turbinate specimens.Methods:A retrospective chart review was performed between January 2008 and August 2011 at a tertiary medical center for patients who underwent an inferior turbinate reduction procedure for nasal obstruction.Results:1,300 consecutive cases from 17 surgeons were identified. Among these patients, 223 (17%) underwent an isolated turbinate reduction procedure and 505 (39%) underwent a reduction procedure in conjunction with a septoplasty. The remaining had a turbinate reduction procedure in addition to another head and neck procedure. 591 (45%) of the turbinate reduction procedures were pe...

Objectives This study is a review of our series of pediatric patients with unilateral sensorineural hearing loss (USNHL) to report abnormalities on imaging studies, review genetic and ophthalmologic results, and survey audiometric findings. Methods This study is a retrospective chart review of all pediatric patients with USNHL seen between 1/1/03 and 12/31/08 at our institution. The study was approved by the institutional review board. Results Eighty-nine cases were identified with audiometric findings confirming unilateral hearing thresholds greater than 20 dBHL with no conductive component. There were 48 males and 41 females. Average age of diagnosis was 7 years. One audiogram showed low-frequency loss, 17 mid-frequency, 29 high-frequency, and 32 flat. Ten patients were diagnosed by auditory brainstem response testing at another institution, with thresholds not available for review. Eleven percent of patients progressed to bilateral loss. Sixty-one patients underwent computed tomography of temporal bones (CTTB). Twenty of 61 scans identified 34 anomalies including 15 enlarged vestibular aqueducts (EVAs), 8 Mondini, and 3 superior semicircular canal dehiscences (SSCDs). Thirty-one of 89 patients underwent magnetic resonance imaging (MRI). Three of these 31 patients had positive findings including 1 EVA, 1 Mondini, and 1 asymmetric internal auditory canal. When CTTB was positive, no additional lesions were detected on MRI. When CTTB was negative and MRI was done in 20 patients, 2 additional lesions were detected by MRI. Fourteen patients had genetics evaluation of which 6 had positive findings, including CHARGE, VACTERL, Goldenhar, and 3 were heterozygous for a Connexin mutation. Conclusions CTTB is an effective diagnostic tool for USNHL. MRI should be considered in patients with negative CTTB. Genetics and ophthalmologic evaluations are recommended for patients with risk factors or an abnormal clinical examination. Close follow-up is essential due to high rate of hearing loss progression.

Objective: 1) Present an abnormal case presentation of an already rare and deadly disease process. 2) Critically review/summarize the literature as it pertained to this case. 3) Increase awareness of a diagnostically challenging reversible deadly disease process. 4) Review current treatment options/recommendations for atypical SBO.Method: This is an unusual case of atypical skull base osteomyelitis in an immunocompetent patient diagnosed in 2010 at the Cleveland Clinic Foundation (CCF). A literature review for “atypical” and “central skull base osteomyelitis” was performed using PubMed.Results: As with other published cases of atypical skull base osteomyelitis, this patient was an elderly male, had no preceding infective source, and presented initially with headache that progressed to multiple lower cranial neuropathies (CN 8, 9, 10, 12). However, our patient is unique because he was not diabetic and had no immunodeficiencies. His work-up initially centered on ruling out a primary headache disorder, tempo...