How Do I Salvage That Flap?; An Evidence-Based Primer on Salvage Techniques for Head & Neck Microvascular Free Flaps

How Do I Salvage That Flap?; An Evidence-Based Primer on Salvage Techniques for Head & Neck Microvascular Free Flaps

Background: Interventional strategies for dealing with microvascular free flap failure are varied among institutions and even individual surgeons. This systematic review aims to identify the published methods for salvaging a failing free flap and provide surgeons with a comprehensive toolset for successful intervention.
Methods: A title and abstract search of the PubMed, Embase, and Web of Science databases was performed. 1,694 abstracts were screened by three reviewers according to Prisma guidelines.
Results: 62 full text articles meeting inclusion criteria detailed techniques which were separated into the categories of thrombectomy, thrombolysis, leech therapy, vascular fistula, and an “other” category outlining techniques which did not fit into the prior framework.
Conclusions: Assessment of the efficacy of individual salvage techniques is limited due to limited empirical data. Approach to successful salvage should be based on timely identification of flap compromise, followed by the implementation of one or several of the aforementioned techniques.

Use of 3-Dimensional (3D) Airway Modeling and Virtual Reality (VR) for Diagnosis, Communication, and Surgical Planning of Complex Airway Stenosis

Use of 3-Dimensional (3D) Airway Modeling and Virtual Reality (VR) for Diagnosis, Communication, and Surgical Planning of Complex Airway Stenosis

Background: In recent years, technology has drastically advanced to accurately and efficiently visualize pathologies in human anatomical structures. Computed tomography (CT) segmentation is a method of generating 3-dimensional (3D) models of anatomical structures of interest. Virtual reality (VR) establishes an excellent environment for clinicians to visualize and directly interact with 3D CT image volumes and segmented anatomical models. Surgical planning for complex airway stenosis poses important challenges for airway surgeons. While soft tissue stenosis can often be managed endoscopically, framework deformities might need open surgical intervention for laryngotracheal reconstruction.

Objective: We hypothesized that a method to segment human airways from clinical cases and import them into a case presentation environment in VR could be developed and used to modelize and visualize complex airway stenosis for efficient surgical planning.

Methods: One normal and two pathological airways modeled from head, neck, and chest CT scans at a slice thickness of 0.625 mm were processed. A multidisciplinary team composed of airway surgeons, VR engineers, and radiologists collaborated to create a clinically relevant, anatomically accurate VR rendering and explanatory Narrations of the 3 clinical cases.

Results: Segmentation and post-processing was completed in the Mimics Innovation Suite v24 from Materialise. Structures were segmented from the level of bifurcation of common carotid arteries to the level of bifurcation of the main bronchi, including cartilaginous and bony airway structures, vessels, and soft tissues. The segmented laryngeal framework and surrounding anatomical structures were then post-processed into 3D image volumes and imported into syGlass, a VR software. Direct visualization and free manipulation of these 3D airway models within the VR environment provided improved geometrical and anatomical details compared to traditional 2-dimensional (2D) CT. This allowed medical image data to be more readily understandable to non-radiologists and surgeons alike, as only using 2D data limits the details that can be gleaned from the dataset. Then, specialized presentation and active learning tools developed for scientific communication using the VR environment permitted creation of Narrations to explain pathological cases. Users could visualize superimposed segmented models and VR scans, and explore either or both by altering opacity settings and using a variety of tools including measuring, sectioning, and resectioning.

Conclusion: The method to segment human airways from clinical cases used in this paper shows a potential in the use of 3D airway modeling and VR in clinical practice for description and surgical planning of complex airways. Intricate collaboration between VR engineers, radiologists, 3D modeling experts and airway surgeons was key to create a clinically relevant and radiologically accurate model. Further work is needed to validate use of these models in clinical practice and patient education.

Subscapular System Free Flap Using Trimano Fortis Support Arm

Subscapular System Free Flap Using Trimano Fortis Support Arm

Introduction
The subscapular system is a highly versatile donor site to obtain free tissue for both bony and soft tissue head & neck reconstruction. Traditional methods of harvesting subscapular flaps required intraoperative repositioning of the patient to a lateral decubitus position, which significantly increased the operative time and prevented simultaneous harvesting of the flap. Various surgical teams have described advances on this technique, but these methods are dependent on either added assistants, a secondary sterile Mayo stand, or a somewhat bulky Spider Limb Positioner® placed on the contralateral side of the table from the harvest site. To overcome these limitations, we have introduced the Trimano Fortis limb positioning system in our practice.

Methods
Single institution retrospective chart review and analysis of patients between 2020 and 2022 that underwent a subscapular system free flap with use of the Trimano Fortis limb positioning system. Forty-one patients in total were reviewed. Variables regarding age, procedure indications, cancer staging, bony defects, anesthesia time, hospital length of stay, and postoperative complications were recorded.

Results
68% of patients were managed for an active cancer (46% oral cavity primary) with all these staged as with T4a or T4b utilizing the AJCC 8th edition system. Median total anesthesia time was 567 minutes ranging from 456 – 753 minutes depending on the extent of resection and complexity of the surgical defect. Median hospital of stay was seven days. Five patients developed a major surgical site complications including 4 with pharyngocutaneous fistula formation and 1 with culture confirmed wound infection. There was one case of partial free flap failure and no cases of total free flap failure in this series.

Discussion
At our institution, application of this positioning system is in part responsible for making the subscapular system the preferred reconstruction for mandibulectomy/maxillectomy defects unless a large volume (>10cm) of bone or dental implantation is expected. It has thus allowed us to fully take advantage of the subscapular system, facilitating a two-team approach, decreasing operative times to match that of other bony free flaps, limits the number of required intraoperative assistants, and simplifies flap harvest to ensure consistent perioperative results.

Intratympanic Autologous Blood Patches: A Conservative Therapy for Traumatic Perilymphatic Fistulas

Intratympanic Autologous Blood Patches: A Conservative Therapy for Traumatic Perilymphatic Fistulas

A perilymphatic fistula is an abnormal communication between the middle ear or mastoid and the inner ear. Trauma is a well-documented etiology of this pathology. We discuss a 10 yr old male who presented with unilateral hearing loss, vertigo and tinnitus after getting hit with a baseball to his left ear. The patient underwent an intratympanic autologous blood patch with complete resolution of his complaints. Although, intratympanic autologous blood patches have limited data, the procedure appears to be a cost-effective option to pursue before surgical intervention.

What is the best intervention for management of pediatric sialorrhea?

What is the best intervention for management of pediatric sialorrhea?

Background. Sialorrhea, also known as excessive salivation, is considered abnormal beyond four years of age. Sialorrhea severity is best measured using a combination of quantitative and qualitative metrics to guide clinical decision making. Severe cases warrant intervention to improve patient quality of life and reduce caretaker burden.

Objective. The primary aim of this study is to review the five major forms of sialorrhea management ranging from least-to-most invasive: oral-motor therapy, anticholinergic medications, botulinum neurotoxin, sialendoscopy sclerotherapy, and surgical intervention.

Data Sources and Review Methods. An electronic literature review identified articles through a comprehensive search of sialorrhea management in pediatric patients in Cambridge Scientific Abstracts, EMBASE, PubMed, and Web of Science.

Conclusions and Implications for Practice. Sialorrhea management starts with more conservative approaches. Viable candidates begin with oral-motor therapy. Anticholinergic medications can decrease saliva production, but adverse side effects may outweigh benefits. Botulinum neurotoxin injection of the salivary glands decreases salivary flow rate; however, relief is transient and thus requires multiple treatments. Sialendoscopy sclerotherapy is the latest treatment option that shows promising results. Surgical intervention is reserved as a treatment option of last resort for patients who suffer from severe sialorrhea due to potential adverse consequences, which include airway swelling/obstruction, facial nerve paralysis, postoperative hemorrhage, and xerostomia with its downstream effects. In conclusion, this review found that the underlying cause and severity of sialorrhea dictate the approach to management.

Do Some Florida Counties Have Improper Access to Audiology Services?

Do Some Florida Counties Have Improper Access to Audiology Services?

Introduction

It is estimated that 15% of American adults aged 18 and over report some trouble hearing.1 Hearing loss in the US is increasing as the population grows older and youth hearing loss increases- with the most recent data suggesting a 4.6% increase from 1988-2006.1 Age is the strongest predictor of hearing loss, but gender and ethnicity also seem to play a role with non-white Hispanics having higher reports of hearing loss.1 Access to proper hearing healthcare is vital to prevent complications such as cognitive decline, dementia, social isolation, increased rates of hospitalization and increased healthcare costs.2 To our knowledge, there is limited data on access to proper hearing healthcare in the US and practically none in the state of Florida.

Objectives

The objective of this study is to determine the distribution of hearing loss across all 67 Florida counties as well as access to hearing healthcare.

Methods

Hearing health data was collected for adults over the age of 18 from Florida Health Charts in 2020. Social and demographic data was collected using County Health Rankings and Roadmaps for each Florida county from 2018-2021, depending on the variable. Data analysis was performed using JMP 16.2.0.

Results

The mean hearing loss for adults 18 and older for the 67 Florida counties is 17.5% (95% CI 16.5, 18.6). We further divided hearing loss for adults 18-64, with a mean of 2.4 (95% CI 2.2,2.6), and adults 65 and older, with a mean of 15.2 (95% CI 14.2,16.1). The mean active audiology license for each county is 21.5 (95% CI 12.9, 30.1). Florida Health Charts does not provide ethnicity data counts for adults with hearing loss, however, there was no significant difference in rates of hearing loss in all counties with varying ethnicity rates. Moreover, there is a significant difference in active audiology license in counties with higher rates of Asians (p-value 0.015). There is also a significant decrease in the amount of active audiologist license in counties with higher percentage of rural population (p-value

Hearing Loss and Socioeconomic Status: A Statistical Review of All 67 Florida Counties

Hearing Loss and Socioeconomic Status: A Statistical Review of All 67 Florida Counties

Introduction
Approximately 13% of adults 18 and older had some difficulty hearing even when using a hearing aid in the United States.1 Hearing difficulties increase with age and up to 26.8% of adults 65 and older have some difficulty hearing.1 Hearing loss is associated with a variety of poor health outcomes such as dementia, depression, increased risk of falls, poor physical health, cognitive decline, and increased healthcare costs.2 Because of the large portion of aging adults that are effected by hearing loss, it is a major public health and social concern. To our knowledge, there is limited data that explores the demographic and socioeconomic status of counties that may be disproportionately affected with hearing loss.

Objectives
To compare hearing loss rates in adults in the 67 Florida counties and socioeconomic status of each county.

Methods
Hearing loss rates were collected using Florida Health Charts from 2020. Demographic and socioeconomic data was collected using County Health Rankings and Roadmaps for each Florida county from 2018-2021, depending on the variable. Linear regression was used with a p-value of less than 0.05 set as significant.

Results
The mean percentage of hearing loss for each county for individuals aged 18-64 is 2.4% (95% CI 2.2-2.6) and those older than 64 is 15.2 (95% CI 14.2-16.1). Counties with lower rates of Hispanics and Asians had less rates of adult hearing loss while counties with higher rates of non-Hispanic whites had the highest rates of hearing loss (p-value

An Assessment of Three Clinically Available Speech-in-Noise Test with Varying Contextual Cues

An Assessment of Three Clinically Available Speech-in-Noise Test with Varying Contextual Cues

Objectives: Clinically, there is a lack of routine speech-in-noise testing due to a variety of barriers, including clinician perceived time constraints, uncertainty in which test material is most appropriate for a specific patient, and lack of materials which clearly quantify degrees of speech-in-noise impairment. The speech-in-noise tests available at present use a variety of target signals, such as digits, sentences, or monosyllabic words. Linguistic cues of speech, such as semantics, syntactics, word familiarity and word frequency, influence speech-in-noise performance; and, thus, may add to the clinician confusion about performance interpretation. Our study aimed to evaluate the performance between three speech-in-noise tests with varying linguistic cues currently available for clinical implementation: the Digits in Noise test (DIN), the Words in Noise test (WIN), and the American English Matrix Test (AEMT). To our knowledge, the AEMT, that is available in 15 languages, has yet to be compared to other clinically available speech-in-noise tests. We hypothesized that performance across tests would be correlated for both listeners with normal hearing and listeners with hearing loss. Understanding correlational relationships on these tests will both allow for standardization of degrees of speech-in-noise hearing loss and determine if these tests can be used interchangeably in clinic.

Design: Participants were 27 listeners with normal hearing and 32 listeners with sensorineural hearing loss. All participants were native English speakers. The outcome of interest was performance on the DIN (most linguistic cues), the AEMT (some linguistic cues), and the WIN (least amount of linguistic cues). The DIN and the WIN were presented in the presence of multi-talker babble and used a descending paradigm to derive the 50% correct recognition point using the Spearman-Karber Equation. The AEMT was presented in an open set in the presence of steady-state speech-spectrum noise and used an automated adaptive procedure to converge to the 50% correct recognition point.

Results: Speech-in-noise performance, reported as the signal to noise ratio (SNR) at which 50% correct word recognition is achieved (SNR-50), for the normal hearing listeners was the following: DIN: -12.6 dB SNR (SD = 1.94), AEMT: -7.8 dB SNR (SD = 4.22), and WIN: 4.8 dB SNR (SD = 1.65). Performance for the listeners with hearing loss was: DIN: -4.9 dB SNR (SD = 2.68), AEMT: -1.5 dB SNR (SD = 4.20), and WIN: 16.6 dB SNR (SD = 5.12). For both groups, performance increased with increasing linguistic cues. Strong positive relationships were found when assessing the materials using a Pearson product moment correlation with r values of: DIN/WIN: r= 0.849*, AEMT/WIN: r= 0.848*, and AEMT/DIN: r= 0.729* (*Indicates a p-value

Cricotracheal Reconstruction with a Pre-laminated Free Flap for Voice Restoration

Cricotracheal Reconstruction with a Pre-laminated Free Flap for Voice Restoration

Background: Reconstruction of large laryngotracheal defects remains a surgical challenge. Rebuilding the airway with rigid, vascularized tissue is optimal to restore function and prevent stenosis. We describe a two-staged reconstruction method for a large laryngotracheal defect using a pre-laminated free flap.

Methods: A 58 year-old male with a history of prolonged intubation and complete tracheal stenosis just below the vocal cords secondary to cricotracheal separation, presented to our clinic with the hope of regaining his natural voice. The first stage of reconstruction consisted of harvesting rib cartilage and implantation of the graft into the right anterolateral thigh. Approximately 2 months later, the patient underwent cricotracheal resection and right sided anterolateral thigh free flap with placement of the pre-laminated rib cartilage into the cricotracheal defect. A t-tube was placed as a stent inferior to the vocal cords to facilitate rigid structure and patency.

Results: Approximately 6 weeks following reconstruction, the t-tube stent was removed, and the patient’s tracheostomy tube was replaced with a t-tube. The patient was immediately able to phonate.

Conclusion: Pre-laminated free flaps using rib cartilage are an effective option for functional restoration of cricotracheal defects. This two-stage approach allows for complex tracheal defects to be replaced with vascular and rigid tissue that withstands airway pressure and prevents recurrent stenosis.

Molecular mechanisms underlying otoprotection by Taurodeoxycholic acid for cochlear implant trauma

Molecular mechanisms underlying otoprotection by Taurodeoxycholic acid for cochlear implant trauma

Background: There is a growing need to develop prophylactic and therapeutic interventions to prevent loss of residual hearing post-cochlear implantation. During cochlear implantation, the initiation of the electrode insertion trauma (EIT) triggers the activation of oxidative stress, apoptosis and inflammatory pathways that can damage sensory cells and consequently lead to the loss of residual hearing. Preserving these sensory cells by blocking the activation of these host pathways can improve hearing preservation and allows implanted individuals to benefit from better hearing outcomes. The aim of this study was to investigate the effect of Taurodeoxycholic acid (TDCA) on the preservation of the residual hearing in a preclinical animal model of cochlear implantation.

Method: Animals were divided into various groups. In first group, animals were implanted unilaterally. In second group, TDCA was applied on the round window membrane before cochlear implantation followed by insertion of the electrode. The animals in third group served as vehicle control whereas naïve animals that were not subjected to treatment with TDCA and cochlear implantation served as the control group. Contralateral ear from each group also served as the control group. Hearing thresholds of animals in each group were determined by auditory brainstem recordings (ABRs). Cochleae harvested from animals in each group was subjected to histopathological examination to determine pathological manifestations. The organ of Corti was dissected and stained with FITC phalloidin to visualize and count the number of hair cells.

Results: Hearing thresholds were significantly lower after TDCA application than in the EIT group. The organ of Corti harvested from cochlea of implanted and TDCA treated animals subject showed a significantly higher number of hair cells after immunostaining compared to implanted animal alone. The molecular mechanisms behind otoprotection involved abrogation of activation of oxidative stress and caspase pathways.

Conclusion: The result of the present study suggests that TDCA provides otoprotection against cochlear implant trauma and can be explored for developing effective interventions. The availability of new interventions to prevent electrode insertion trauma holds great potential to promote hearing preservation and expanding indications of cochlear implantation.