Microvascular flap reconstruction by otolaryngologists: prevalence, postoperative care, and monitoring techniques

BACKGROUND/OBJECTIVES: Microvascular "free flap" transplants have become the preferred method of reconstruction for a great variety of complicated head and neck defects. As recently as 10 years ago, having a microvascular surgeon within a department of otolaryngology was the exception rather than the rule, whereas it is our impression that today most academic programs have one or more microvascularly trained head and neck surgeons. Among microvascular surgeons, postoperative care and management regimens vary greatly. Through informal conversations, we discerned that some surgeons take a very aggressive approach to monitoring, perhaps including prolonged stays in an intensive care setting with implanted Doppler devices to monitor flap blood flow and intravenous administration of dextran or other pharmaceutical projects. Others report that patients are quickly discharged from the hospital after just aspirin and subcutaneous heparin for a few days. Some physicians perform "flap checks" hourly, whereas others have residents check only once daily. DESIGN/METHODS: We surveyed academic otolaryngology-head and neck surgery departments that sponsor residency programs in the United States to 1) determine the prevalence of microvascular trained otolaryngologists within training programs and 2) assess variations in postoperative and monitoring regimens. RESULTS: We found that on average, 12.2% of otolaryngologists per department perform free flap transplants, and 71.6% of microvascular trained surgeons continue to do free flaps. The surgeons self reported a 96.4% average success rate and a 6.88% return rate to the operating room for complications. Monitoring methods used included flap color (used by 79.4% of surgeons), Doppler signal (79.4%), pin prick and bleeding rate (67.6%), capillary refill (61.8%), skin surface temperature (11.8%), and implanted Doppler (8.8%). Anticoagulants used included aspirin (used by 76.5% of microvascular surgeons), low-molecular-weight dextran (35.3%), and subcutaneous heparin (26.5%). CONCLUSIONS: Microvascular training has become commonplace in otolaryngology-head and neck surgery training programs, with more than one in eight of these academic physicians reporting microvascular training. There was no self-reported difference in flap failure rates on the basis of postoperative care and monitoring regimen. The results of this survey suggest that a simplified consensus postoperative regimen can be recommended.     

Nd:YAG contact laser surgery. The scalpel of the future?

Lasers have been used in otolaryngology-head and neck surgery since the early 1970s, mainly for endoscopic applications. In particular, the author discusses the use of the Nd:YAG contact laser surgery. The techniques and training required in the use of these newer laser applications, including the flexible fiber system for use in the tracheobronchial tree, are reviewed.     

Robotic surgery in ear nose and throat

The arrival of a commercial surgical robotic platform at our institution has raised the question of its application and usefulness within the department of otolaryngology head and neck surgery. In order to answer this question, we sought to perform a qualitative review to examine the evolution of commercial surgical robotics and examine present and future applications of this emerging technology within our specialty. The main objective of this study is to examine the development and application of robotic surgery in otolaryngology, head and neck surgery. The study includes a qualitative systematic review. We have reviewed research papers and studies that specifically relate to the use of robots in otorhinolaryngology. More specifically, we have attempted to review those studies that have significantly added to the development of this field. In summary, we have examined eight animal studies, six cadaveric studies, nine human trials. Robotic surgery in ENT is a safe and feasible option. In certain procedures, it offers significant benefits over conventional surgery. Instrument and robotic arm size, and costs are limiting factors that prevent the use of robots being applied to many additional ENT procedures. We feel the development of new speciality-specific robots will yield a new era in the common use of robotics in ENT.     

The otolaryngology research paradox

OBJECTIVE: To determine the attitude toward and the state of research within the field of otolaryngology-head and neck surgery. DESIGN: A questionnaire was sent to the chairpersons of departments of otolaryngology where residency training is provided. PARTICIPANTS AND SETTING: Program directors of academic otolaryngology training programs. MAIN OUTCOME MEASURE: Responses to questionnaire. RESULTS: Questionnaires were sent to 95 programs from which 86 responses were received. Respondents believed strongly that research was important to the specialty. Only two thirds of the full-time clinical faculty, however, do research, and on average they devote only 17% of their time to this activity. About a third of those doing research have funding, and the National Institutes of Health support only 12% of clinician-investigators. Although program directors believe that clinicians should do research, three fourths stated that clinicians were too busy to accomplish this goal. Surprisingly, half of the respondents were unaware of residency programs that offered 2 years of research training, aimed to develop clinician-investigators, who can become competitive for attainment of research funding. CONCLUSIONS: Although leaders within our specialty believe that research is important, clinicians are not provided with enough time to conduct research. Furthermore, pathways that would enhance their competitiveness to obtain research funding are not recommended to our future clinicians.     

Fellowship training in otolaryngology-head and neck surgery

Fellowship training in otolaryngology-head and neck surgery is a relatively new phenomenon that reflects the increasing complexity of clinical medicine. Despite an expansion of fellowship opportunities over the last three decades, there is still incomplete regulation and standardization of fellowship training. Approximately one third of residency graduates obtain some form of fellowship training. This article describes the fellowship opportunities that are currently available within the field of otolaryngology. Fellowship training serves as an avenue to gain further credentials and certification, although only the fields of neurotology, pediatric otolaryngology, and sleep medicine are accredited by the ACGME.     

Evaluation of head and neck cancer patients. A national survey

A review of the recent literature of otolaryngology-head and neck surgery reveals minimal guidance as to the use of laboratory and radiographic studies in the initial evaluation and subsequent follow-up of patients with head and neck cancer. A national survey was prepared and was sent to 105 otolaryngology-head and neck surgery teaching departments with 53 institutions responding. This survey shows that a baseline of laboratory and radiographic studies are routinely ordered. Follow-up is monthly the first year and every other month the second year. Specialized laboratory tests and radiographic studies are ordered on a case-by-case basis and based on cost effectiveness, research orientation, available resources, and, most importantly, the patient's needs.     

A contemporary review of machine learning in otolaryngology–head and neck surgery

One of the key challenges with big data is leveraging the complex network of information to yield useful clinical insights. The confluence of massive amounts of health data and a desire to make inferences and insights on these data has produced a substantial amount of interest in machine-learning analytic methods. There has been a drastic increase in the otolaryngology literature volume describing novel applications of machine learning within the past 5 years. In this timely contemporary review, we provide an overview of popular machine-learning techniques, and review recent machine-learning applications in otolaryngology–head and neck surgery including neurotology, head and neck oncology, laryngology, and rhinology. Investigators have realized significant success in validated models with model sensitivities and specificities approaching 100%. Challenges remain in the implementation of machine-learning algorithms. This may be in part the unfamiliarity of these techniques to clinician leaders on the front lines of patient care. Spreading awareness and confidence in machine learning will follow with further validation and proof-of-value analyses that demonstrate model performance superiority over established methods. We are poised to see a greater influx of machine-learning applications to clinical problems in otolaryngology–head and neck surgery, and it is prudent for providers to understand the potential benefits and limitations of these technologies. Laryngoscope, 130:45–51, 2020     

Potential applications of the da Vinci minimally invasive surgical robotic system in otolaryngology

Anatomic constraints and instrumentation design characteristics have limited the exploitation of endoscopic surgery in otolaryngology. The move toward less invasive and less morbid procedures has paved the way for the development and application of robotic and computer-assisted systems in surgery. Surgical robotics allows for the use of new instrumentation in our field. We review the operative advantages, limitations, and possible surgical applications of the da Vinci Surgical System in otolaryngology. In the laboratory setting, we explored the setup and use of the da Vinci system in porcine and cadaveric head and neck airway models; the setup was configuredfor optimal airway surgery. Endoscopic cautery, manipulation, and suturing of supraglottic tissues were performed in both the porcine and cadaveric models. We found that the da Vinci system provided the advantages of the lower morbidity associated with endoscopic surgery, more freedom of movement, and three-dimensional open surgical viewing. We also observed that the system has several limitations to use in otolaryngology.     

Matching graduate education with societal need

OBJECTIVES/HYPOTHESIS: A number of prior Ogura lecturers have focused on the need to change residency education in otolaryngology-head and neck surgery; nothing has changed. The present discussion is based on the notion that graduate medical education should reflect societal need. STUDY DESIGN: Lecture. METHODS: Information on graduate medical education is presented. RESULTS: The information presented substantiates the maldistribution of otolaryngologists and the mismatch of the design and output of our programs from the perspective of public need. CONCLUSION: It is proposed that the American Board of Otolaryngology should take the lead in substantive change with the targets being 1) providing flexibility in program design, 2) a 1-year reduction in core training in otolaryngology, and 3) expanded interaction with family medicine.     

The resident selection process in otolaryngology-head and neck surgery

This study was undertaken to characterize the objective information available about applicants to otolaryngology-head and neck surgery residency positions, and to determine the influence of these factors on obtaining a residency position. Applicants to the otolaryngology-head and neck surgery programs at University of Utah, Salt Lake City, University of Texas Medical Branch, Galveston, and University of Louisville (Ky) were studied. Thirty-one variables were examined, representing demographic and academic factors. Excellent academic performance in medical school (as represented by medical school grade-point average greater than 3.4, National Board part I score greater than 650, class percentile rank greater than 85th percentile, honors grades in both junior medicine and surgery clinical clerkships, or [5] election to Alpha Omega Alpha) was significantly correlated with success in obtaining an otolaryngology-head and neck surgery residency position.     

Otolaryngology-head and neck surgery in the Canadian military: practice trends

The practice of medicine in the Canadian military is poorly publicized except in times of war. The specialty of otolaryngology-head and neck surgery is not well known, even in medical circles. To correct this deplorable ignorance, a review was conducted on the otolaryngologic activities within the Canadian Forces. This revealed a dynamic specialty whose many contributions warrant acknowledgment. Starting with Major-General M.J.C.E. Fiset, who was the first such specialist in Canada, military otolaryngologists have maintained excellent standards of medical practice for the benefit of the Canadian soldier. This paper traces the development of military otolaryngology in Canada. Trends in the practice of this versatile specialty are presented.     

Surgical aptitude test for otolaryngology-head and neck surgery resident applicants

The search for a convenient, rapid manual dexterity examination, which could be used at the time of the otolaryngology resident applicant's interview, led us to assess the following areas: purposeful hand direction, depth perception, tactile discrimination, finger pressure coordination, finger visual tracking of moving objects, spatial visualization, finger strength, speed of movements, fine control precision, finger dexterity, steadiness during movement, steadiness without movement, and neatness. With the astronomical increase in applicants to a limited number of positions in the field of otolaryngology-head and neck surgery, the application of an accurate, efficient manual dexterity assessment at the time of applicant interview is desirable. Presently, dental school applicants are screened by a series of manual dexterity tests. To develop our screening test, we integrated manual performance tests currently in use by private industry, occupational therapists, and dental school admission committees. Thus, applicants who are able to master fine microsurgical and macrosurgical techniques common in our specialty will be preferentially selected.     

Intraoperative neurophysiologic monitoring: indications and techniques for common procedures in otolaryngology-head and neck surgery

Intraoperative cranial nerve monitoring can be an effective adjunct in otolaryngology-head and neck surgery. Monitoring is not considered standard of care, despite indications of cost effectiveness and improved functional outcomes. Lessons learned performing facial nerve monitoring are applicable to upper and lower cranial motor nerves. Auditory nerve monitoring can be modified accord-ing to need for selected otologic and neurotologic surgery. Process standardization and effective communication can lead to improved patient outcomes.     

前臂皮瓣Ⅰ期修复面及咽部肿瘤术后软组织缺损

目的 :探讨前臂皮瓣在耳鼻咽喉 头颈外科头颈部恶性肿瘤手术中的应用。方法 :对 6例咽喉部肿瘤切除后软组织缺损的病例 ,通常采用前臂皮瓣修复 ,即将皮瓣的桡动脉、头静脉与甲状腺上动脉和面静脉分别端端显微吻合 ,Ⅰ期修复组织缺损。结果 :修复成功 4例 ,失败 2例。结论 :前臂皮瓣具有血管表浅 ,行程稳定 ,口径粗 ,血管长 ,前臂皮肤薄、软、皮下脂肪少 ,具可塑性 ,可折叠等优点。经临床应用证实 ,前臂皮瓣修复是一种灵活多用 ,技术完善的头面、咽部及口底缺损修复的手段     

Searching the literature using medical subject headings versus text word with PubMed

OBJECTIVE/HYPOTHESIS: This study was conducted to investigate the performance of two search strategies in the retrieval of information from the National Library of Medicine (NLM) on otolaryngology-head and neck surgery related conditions and diagnoses using PubMed. METHODS: Two search strategies-one based on the use of Medical Subject Headings (MeSH) and the second based on text word searching-were compared. RESULTS: The MeSH search provided a more efficient search than the text word search. CONCLUSIONS: Head and neck surgeons can most efficiently search the NLM using PubMed as a search engine by initiating the search with MeSH terms. Once a key article is identified, the searcher should use the "Related Articles" feature.     

COVID-19防控期间疫情非高发地区综合医院耳鼻咽喉头颈外科病房诊疗实践

新型冠状病毒病(COVID-19)疫情防控形势持续严峻,耳鼻咽喉头颈外科同道既要防控疫情同时还要更好开展必要的病房日常诊疗工作,杜绝医护人员感染。绵阳地区的COVID-19疫情有其自身特点,结合科室在这方面的经验举措,分享"疫情防控+诊疗工作"的病房诊疗实践经验,期望对湖北以外疫情非高发地区的耳鼻咽喉头颈外科同道有所帮助。     

浅谈数字化病区在耳鼻咽喉头颈外科的应用

目的：结合耳鼻咽喉头颈外科疾病应急性、风险性的特点，浅谈数字化病区在耳鼻咽喉头颈外科的应用。方法：采用现代信息集成技术、计算机软件技术及卫生信息学等理论和方法，以医院信息管理系统为平台，以网络信息技术为手段，构建耳鼻咽喉头颈外科数字化病区。结果：创建高效、合理的耳鼻咽喉头颈外科数字化病区可优化工作流程，提高工作效率、消除手工操作，使患者得到及时的救治，为挽救危急重患者的生命赢取宝贵的时间。结论：数字化病区的成功建立为提升医护人员的工作质量与水平，推进医院信息化进程起着重要的作用。不仅体现了现代医学带给医疗卫生行业的新观念，而且还带来了广泛的社会与经济效益。     

Occult surgical glove perforations in otolaryngology-head and neck surgery

With the advent of the acquired immunodeficiency syndrome crisis, it has become imperative that all surgeons minimize their risk of direct contact with the patient's body fluids. In the course of performing surgery, perforations are frequently created in surgical gloves, which often go unnoticed. This study determined the frequency with which occult glove perforations occurred in 134 consecutive head and neck surgical procedures. One thousand fifty gloves (650 gloves used in surgery, 400 unused control gloves) were analyzed for the presence of perforations large enough to permit the passage of fluid. An unrecognized glove perforation was detected in 25% of surgical cases. The duration of surgery correlated strongly and positively with the incidence of perforation. Perforation rates varied widely for specific types of procedures, and are reported for each of the five subdivisions within otolaryngology-head and neck surgery. The implications of these results are described, and recommendations for the use of protective measures, especially in reference to the use of double-gloving, are made.     

Update on botulinum toxin use in facial plastic and head and neck surgery

PURPOSE OF REVIEW: The purpose of this review is to discuss current trends in the medicinal use of botulinum toxin in head and neck and facial plastic surgery. The basic science of botulinum toxin is presented along with a comparison of the subtypes currently available on the market. Site-specific applications of botulinum toxin in the head and neck region are presented. RECENT FINDINGS: The use of botulinum toxin continues to expand, both in volume and in number of applications. The main application of botulinum toxin in facial plastic surgery is in the effacement of dynamic or hyperkinetic facial lines. The granting of US Food and Drug Administration approval for the use of Botulinum Toxin type A in the treatment of glabella lines marks a major milestone for the more widespread usage of this product in cosmetic settings. Additional cosmetic applications include crow's feet, marionette lines, and platysma banding. Noncosmetic applications in the head and neck include dystonias (including torticollis), facial and generalized muscle spasms, migraine headaches, hyperhidrosis, spasmodic dysphonia, sialorrhea, gustatory sweating, and involuntary movement disorders. SUMMARY: The use of botulinum toxin in the treatment of hyperkinetic conditions and disorders of excessive salivation is well established and enjoys an excellent safety profile. The cosmetic use of botulinum toxin continues to expand. The chronic use of botulinum toxin specifically for cosmetic purposes is worthy of additional study.     

Radionuclide imaging in otolaryngology-head and neck surgery

Radionuclide imaging provides both qualitative and quantitative information that can have dramatic effects on patient management in diseases of the head and neck. The general concepts of nuclear medicine imaging, including radiopharmaceuticals and radiation effects, are discussed. The principles and techniques of thyroid, parathyroid, bone, and salivary radionuclide imaging studies will be reviewed. The intent of this article is to provide a concise and current review of head and neck radionuclide imaging that will be useful in the day-to-day practice of otolaryngology-head and neck surgery.