Predicting length of stay in head and neck patients who undergo free flap reconstruction

ObjectiveUnderstanding factors that affect postoperative length of stay (LOS) may improve patient recovery, hasten postoperative discharge, and minimize institutional costs. This study sought to (a) describe LOS among head and neck patients undergoing free flap reconstruction and (b) identify factors that predict increased LOS.MethodsA retrospective cohort was performed of 282 head and neck patients with free flap reconstruction for oncologic resection between 2011 and 2013 at a tertiary academic medical center. Patient demographics, tumor characteristics, and surgical and infectious complications were characterized. Multivariable regression identified predictors of increased LOS.ResultsA total of 282 patients were included. Mean age was 64.7 years (SD = 12.2) and 40% were female. Most tumors were located in the oral cavity (53.9% of patients), and most patients underwent radial forearm free flap (RFFF) reconstruction (RFFF—73.8%, anterolateral thigh flap—11.3%, and fibula free flap—14.9%). Intraoperative complications were rare. The most common postoperative complications included nonwound infection (pneumonia [PNA] or urinary tract infection [UTI]) (15.6%) and wound breakdown/fistula (15.2%). Mean and median LOS were 13 days (SD = 7.7) and 10 days (interquartile range = 7), respectively. Statistically significant predictors of increased LOS included flap take back (Beta coefficient [C] = +4.26, P < .0001), in‐hospital PNA or UTI (C = +2.52, P = .037), wound breakdown or fistula (C = +5.0, P < .0001), surgical site infection (C = +3.54, P = .017), and prior radiation therapy (C = +2.59, P = .004).ConclusionSeveral perioperative factors are associated with increased LOS. These findings may help with perioperative planning, including the need for vigilant wound care, optimization of antibiotics prophylaxis, and institution‐level protocols for postoperative care and disposition of free flap patients.Level of Evidence2b; retrospective cohort.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/155916/1/lio2410.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/155916/2/lio2410_am.pd

Management of a Long-Standing Organic Intracranial Foreign Body

Organic foreign bodies of the skull base are an uncommon problem with the potential for serious morbidity that present complicated treatment dilemmas best managed by a multidisciplinary approach. A 58-year-old male presented to the emergency department with fevers and mental status changes and was found to have bacterial meningitis. Computed tomography of the sinuses revealed two adjacent defects of the ethmoid roof with associated soft tissue density concerning for an encephalocele. He had a remote history of a penetrating left maxilla injury with a stick 13 years earlier. An attempted endoscopic repair of the defects revealed a pulsating splinter of wood emanating from the ethmoid roof defect. Neurosurgery and infectious disease were consulted and several wood fragments were removed endoscopically from the intracranial space. The skull base defects were closed using a septal cartilage underlay and free mucosal overlay graft. The patient has done well in follow-up with no evidence of cerebrospinal fluid leak. Organic foreign bodies from skull base trauma can have a delayed presentation and require a multidisciplinary team approach. In the appropriate setting endoscopic removal is a minimally morbid option

Endophthalmitis

Endophthalmitis is a serious eye infection that can cause blindness if not promptly diagnosed and appropriately treated. The goals of this book are to provide the latest information about endophthalmitis and offer recommendations for diagnosis and treatment. Each chapter is written by experts in the field with the practicing clinician in mind. Several chapters focus on the major types of endophthalmitis such as postoperative, post-intravitreal injection, bleb-related, exogenous fungal, chronic, and endogenous endophthalmitis. Other chapters describe endophthalmitis in special populations such as diabetic or immunocompromised hosts or those with a glaucoma drainage device, keratoprosthesis, or other artificial implant. Also included are chapters that provide an overview of endophthalmitis as seen around the world, summarize current understanding of endophthalmitis pathogenesis, describe the latest microbiologic and molecular diagnostic techniques, and discuss emerging problems such as multidrug-resistant pathogens. A final chapter offers recommendations for ways to prevent this devastating eye infection

Treatment of Refractory Acute Retinal Necrosis with Intravenous Foscarnet or Cidofovir

Purpose: To report use of intravenous foscarnet or cidofovir for the treatment of refractory acute retinal necrosis (ARN). Methods: Retrospective chart review. Results: Four immunocompetent men aged 45-90 years presented with ARN from 2008-2014. One patient with two prior episodes of herpes simplex virus (HSV) ARN developed ARN after 6 years of antiviral prophylaxis. His condition worsened on acyclovir followed by intravenous foscarnet but responded to intravenous cidofovir (final VA in involved eye 20/20). Another patient with HSV ARN had received prolonged acyclovir prophylaxis for HSV keratitis; ARN improved after switching from acyclovir to intravenous foscarnet (final VA 20/125). Two patients with varicella zoster virus (VZV) ARN initially responded to acyclovir but developed fellow eye involvement 2-8 weeks later that worsened on acyclovir but responded to intravenous foscarnet (fellow eye final VA 20/20, 20/40). Conclusions: Cases of HSV or VZV ARN that worsen despite intravenous acyclovir treatment may respond to intravenous foscarnet or cidofovir