The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate ...reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity.
To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review.
A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded.
The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases.
Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.
Reconstruction of the lateral mandibular defect presents a complex challenge to the reconstructive surgeon, often involving interconnected soft-tissue and bone requirements. This review examines the ...current literature on functional outcomes of lateral mandibular reconstruction and presents an algorithm on selecting an optimal reconstructive choice for patients with lateral mandibular defects resulting from oncologic ablative surgery or trauma. PubMed and Medline searches on reconstructing lateral mandibular defect were performed of the English literature. Search terms included lateral mandibular defect, outcomes of mandibular reconstruction, and free flap reconstruction of mandible. Although most of the articles presented are retrospective reviews, priority was given to the articles with high-quality level of evidence. Restoration of function, including speech and swallow, and acceptable cosmetic result are the primary objectives of lateral mandibular reconstruction. When reconstructing the mandible in a patient following tumor extirpation, the patient's overall prognosis, medical comorbidities, and need for adjuvant therapy should be considered. In the patient with aggressive malignant disease and a poor prognosis, a less complex reconstruction, such as soft-tissue flap with or without a reconstruction plate, may be adequate. In a dentate patient with favorable prognosis, a durable reconstruction, such as osseocutaneous microvascular free flap, is often preferred. Various reconstructive options are available for patients with lateral mandibular defects. Depending on the predominance of the soft-tissue or bony components of the defect, with consideration of the patient's characteristics and functional and aesthetic goals, the surgeon can wisely select from these reconstructive possibilities.
Microvascular osseous free tissue transfer is the standard of care for reconstructing significant mandibulectomy defects; however, this procedure can carry a significant rate of morbidity.
To ...describe the use of recombinant human bone morphogenetic protein 2 (rhBMP-2) as an option for segmental or near-complete rim mandibulectomy defects in a select group of patients, precluding the need for free tissue transfer.
A retrospective review was performed of 6 patients who had undergone repair of a mandible defect using rhBMP-2 with beta-tricalcium phosphate matrix or a cadaveric bone graft at a single tertiary care institution. The defects resulted from resection of benign neoplasms or from previous trauma. Reconstruction success was defined as no hardware problems, healing without infection, no need for further surgical procedures, and imaging evidence of healing and union without resorption. The median follow-up period was 37.5 months (range, 12-51 months).
Five of 6 patients underwent successful restoration of the mandibulectomy defect. One patient with a compromised immune system developed a significant postoperative wound infection requiring further reconstructive surgery.
The use of an rhBMP-2-based reconstructive approach is a feasible option for segmental or near-complete rim mandibulectomy defects in a select group of patients.
4.
Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Surgical 30-day readmission rates are ...important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties from third-party payers and government agencies.
To determine the rate of 30-day hospital revisits following septorhinoplasty and the risk factors associated with revisits.
A retrospective cohort analysis was conducted of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, using data from the Healthcare Cost and Utilization Project state inpatient database, state ambulatory surgery database, and state emergency department database from California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. Data analysis was conducted from September 1, 2014, to May 1, 2015.
Hospital revisits within 30 days after an index septorhinoplasty and the primary diagnosis at the time of the revisit were the main outcome measures. The revisit rate was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the occurrence of a hospital revisit within 30 days of the septorhinoplasty procedure.
In total, 11 456 of 175 842 patients (6.5%) who underwent septorhinoplasty procedures revisited the hospital within 30 days of the procedure. Most of these revisits (6353 55.5%) were to the emergency department. The most common primary diagnosis was bleeding or epistaxis, occurring in 2150 patients (1.2%). Multivariable logistic regression showed that patients aged 41 to 65 years (adjusted odds ratio aOR, 1.09; 99% CI, 1.02-1.16) or older than 65 years (aOR, 1.23; 99% CI, 1.06-1.43) had an increased revisit rate, as did black patients (aOR, 1.39; 99% CI, 1.16-1.66); those with Medicare (aOR, 1.55; 99% CI, 1.32-1.81) and Medicaid (aOR, 1.63; 99% CI, 1.33-2.01); those with diagnoses of autoimmune disorders or immunodeficiency (aOR, 2.69; 99% CI, 1.20-6.03), coagulopathy (aOR, 2.06; 99% CI, 1.33-3.20), anxiety (aOR, 1.79; 99% CI, 1.55-2.07), and alcohol use (aOR, 1.70; 99% CI, 1.35-2.14); and those who had a conchal cartilage graft (aOR, 2.01; 99% CI, 1.29-3.14).
The study results suggest that patients with more medical comorbidities and lower socioeconomic status most commonly returned to the emergency department for surgical complications, such as bleeding or epistaxis, in the 30-day period after the procedure. These data provide valuable preoperative counseling information for patients and physicians. In addition, this study provides data to third-party payers or government agencies in which postprocedure readmissions in the 30-day period are used as a quality care metric affecting reimbursements and financial penalties.
3.
Head and neck melanoma is one of the leading causes of death in the United States and is currently increasing in prevalence. While there is a tremendous amount of research published on melanoma, the ...actual evidence for complex clinical decision-making can be difficult to interpret and to stay up-to-date on current clinical standards.
To address, in a systematic and evidence-based approach, the most common clinical controversies with regard to the workup and management of head and neck melanoma.
A PubMed and Medline search was performed of the entire English literature with respect to head and neck melanoma. Priority of review was given to those studies with higher-quality levels of evidence.
Main topics reviewed in this article include workup for new melanoma, surgical treatment of the primary site, surgical treatment of the neck, adjuvant radiation therapy, and systemic therapy. Levels of evidence are used for each controversial clinical question to help the clinician understand the reliability of the current evidence when making complex clinical decisions for melanoma management of the head and neck. However, much of the work done in melanoma, particularly large randomized clinical trials, includes many other regions of the body. Therefore, these data must be interpreted in light of the potential differences in clinical behavior and draining lymphatics between trunk, limbs, and head and neck subsites.
The management of head and neck melanoma requires a multidisciplinary approach, particularly for advanced-stage disease. An in-depth knowledge of the current evidence available will help guide the surgeon in the management of this difficult disease.
Objective:
The aim of this study was to evaluate the impact of either left atrial or aortic spontaneous echocardiographic contrast (SEC), as identified on intraoperative transesophageal ...echocardiography, on short-term morbidity and mortality in patients with left atrial enlargement undergoing cardiac valvular surgery.
Design:
Retrospective and observational.
Setting:
Single-center, university teaching hospital.
Participants:
The authors identified 197 patients (105 males and 92 females; mean age, 68 ± 14 years) with left atrial enlargement who underwent surgical intervention for valvular heart disease from January 1, 2004 to January 1, 2005.
Main Results:
Of the total population, 40 patients (20.3%) showed left atrial SEC, and 10 patients (5.1%) showed aortic SEC. On multivariate analysis, increasing left atrial size and the absence of mitral regurgitation were independent predictors for the presence of left atrial SEC. On multivariate analysis, the presence of atrial fibrillation and a dilated descending aorta were predictive of aortic SEC. Although the identification of left atrial SEC was an echocardiographic marker of an increased risk for thromboembolic events postoperatively, this finding did not hold true for the presence of aortic SEC.
Conclusions:
Intraoperative identification of left atrial dilatation or aortic dilatation is predictive of SEC in the left atrium or descending aorta, respectively. The identification of left atrial SEC is an echocardiographic marker of an increased risk for thromboembolic events in this high-risk population.
Oral Cancer Carole Fakhry, Karen T. Pitman, Ana P. Kiess
2020
eBook
A state-of-the-art guide on oral cancer management from distinguished experts! Oral Cancer: Evaluation, Therapy, and Rehabilitation edited by prominent Johns Hopkins clinicians and educators Carole ...Fakhry, Karen Pitman, Ana Kiess, and David Eisele provides a comprehensive, state-of-the-art review on the diagnosis and management of oral cancer. This unique resource fills a void in the literature by exploring surgical and reconstructive issues specific to each subsite of the oral cavity. Important pre- and post-treatment evaluations by dental, speech language pathology, and the oncologic care team are reviewed. The comprehensive book is divided into 10 sections, each focused on different facets of the patients' trajectory. The text starts with epidemiology of oral cavity cancer and discussion of patient populations at increased risk of oral cavity cancer. The book details pre-cancers, multidisciplinary diagnostic evaluations, treatment, post-treatment, recurrent and metastatic oral cancer, and palliative care, concluding with future directions such as chemoprevention. A full spectrum of oral neoplasms are covered in depth, including different types of squamous cell cancer, primary malignancies of the mandible, and sublingual and minor salivary gland malignancies. Key Features * All oral cavity subsites are approached from both an ablative and reconstructive standpoint, with dedicated chapters focused on specific oral cancer reconstructive techniques * Discussion of oncologic considerations encompassing radiation and medical oncology including definitive radiation therapy, brachytherapy, adjuvant radiation therapy, and adjuvant chemotherapy/novel therapeutics * Clinical pearls cover complications of both surgery and radiation therapy, as well as psychological and dental implications of therapy * High-quality illustrations, photographs, and videos further elucidate impacted anatomy and techniques Residents and clinicians in otolaryngology-head and neck surgery, oral and maxillofacial surgery, head and neck reconstructive surgery, medical oncology, and radiation oncology will benefit from reading this excellent resource. Dentists who wish to further their knowledge about oral cancers will also find it an invaluable reference.
Influenza is temporally associated with cardiopulmonary morbidity and mortality among those with cardiovascular disease who may mount a less vigorous immune response to vaccination. Higher influenza ...vaccine dose has been associated with reduced risk of influenza illness.
To evaluate whether high-dose trivalent influenza vaccine compared with standard-dose quadrivalent influenza vaccine would reduce all-cause death or cardiopulmonary hospitalization in high-risk patients with cardiovascular disease.
Pragmatic multicenter, double-blind, active comparator randomized clinical trial conducted in 5260 participants vaccinated for up to 3 influenza seasons in 157 sites in the US and Canada between September 21, 2016, and January 31, 2019. Patients with a recent acute myocardial infarction or heart failure hospitalization and at least 1 additional risk factor were eligible.
Participants were randomly assigned to receive high-dose trivalent (n = 2630) or standard-dose quadrivalent (n = 2630) inactivated influenza vaccine and could be revaccinated for up to 3 seasons.
The primary outcome was the time to the composite of all-cause death or cardiopulmonary hospitalization during each enrolling season. The final date of follow-up was July 31, 2019. Vaccine-related adverse events were also assessed.
Among 5260 randomized participants (mean SD age, 65.5 12.6 years; 3787 72% men; 3289 63% with heart failure) over 3 influenza seasons, there were 7154 total vaccinations administered and 5226 (99.4%) participants completed the trial. In the high-dose trivalent vaccine group, there were 975 primary outcome events (883 hospitalizations for cardiovascular or pulmonary causes and 92 deaths from any cause) among 884 participants during 3577 participant-seasons (event rate, 45 per 100 patient-years), whereas in the standard-dose quadrivalent vaccine group, there were 924 primary outcome events (846 hospitalizations for cardiovascular or pulmonary causes and 78 deaths from any cause) among 837 participants during 3577 participant-seasons (event rate, 42 per 100 patient-years) (hazard ratio, 1.06 95% CI, 0.97-1.17; P = .21). In the high-dose vs standard-dose groups, vaccine-related adverse reactions occurred in 1449 (40.5%) vs 1229 (34.4%) participants and severe adverse reactions occurred in 55 (2.1%) vs 44 (1.7%) participants.
In patients with high-risk cardiovascular disease, high-dose trivalent inactivated influenza vaccine, compared with standard-dose quadrivalent inactivated influenza vaccine, did not significantly reduce all-cause mortality or cardiopulmonary hospitalizations. Influenza vaccination remains strongly recommended in this population.
ClinicalTrials.gov Identifier: NCT02787044.
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