A novel neck brace to characterize neck mobility impairments following neck dissection in head and neck cancer patients

Abstract Objective This article introduces a dynamic neck brace to measure the full range of motion (RoM) of the head–neck. This easy-to-wear brace was used, along with surface electromyography (EMG), to study changes in movement characteristics after neck dissection (ND) in a clinical setting. Methods The brace was inspired by the head–neck anatomy and was designed based on the head–neck movement of 10 healthy individuals. A 6 degrees-of-freedom open-chain structure was adopted to allow full RoM of the head–neck with respect to the shoulders. The physical model was realized by 3D printed materials and inexpensive sensors. Five subjects, who underwent unilateral selective ND, were assessed preoperative and postoperative using this prototype during the head–neck motions. Concurrent EMG measurements of their sternocleidomastoid, splenius capitis, and trapezius muscles were made. Results Reduced RoM during lateral bending on both sides of the neck was observed after surgery, with a mean angle change of 8.03° on the dissected side (95% confidence intervals [CI], 3.11–12.94) and 9.29° on the nondissected side (95% CI, 4.88–13.69), where CI denotes the confidence interval. Axial rotation showed a reduction in the RoM by 5.37° (95% CI, 2.34–8.39) on the nondissection side. Neck extension showed a slight increase in the RoM by 3.15° (95% CI, 0.81–5.49) postoperatively. Conclusions This brace may serve as a simple but useful tool in the clinic to document head–neck RoM changes in patients undergoing ND. Such a characterization may help clinicians evaluate the surgical procedure and guide the recovery of patients

Effect of Overlapping Operations on Outcomes in Microvascular Reconstructions of the Head and Neck

Objective To compare outcomes after microvascular reconstructions of head and neck defects between overlapping and nonoverlapping operations. Study Design Retrospective cohort study. Setting Tertiary care center. Subjects and Methods Patients undergoing microvascular free tissue transfer operations between January 2010 and February 2015 at 2 tertiary care institutions were included (n = 1315). Patients were divided into 2 cohorts by whether the senior authors performed a single or consecutive microvascular reconstruction (nonoverlapping; n = 773, 59%) vs performing overlapping microvascular reconstructions (overlapping; n = 542, 41%). Variables reviewed were as follows: defect location, indication, T classification, surgical details, duration of the operation and hospitalization, and complications (major, minor, medical). Results Microvascular free tissue transfers performed included radial forearm (49%, n = 639), osteocutaneous radial forearm (14%, n = 182), anterior lateral thigh (12%, n = 153), fibula (10%, n = 135), rectus abdominis (7%, n = 92), latissimus dorsi (6%, n = 78), and scapula (<1%, n = 4). The mean duration of the overlapping operations was 21 minutes longer than nonoverlapping operations ( P = .003). Mean duration of hospitalization was similar for nonoverlapping (9.5 days) and overlapping (9.1 days) cohorts ( P = .39). There was no difference in complication rates when stratified by overlapping (45%, n = 241) and nonoverlapping (45%, n = 344) ( P = .99). Subset analysis yielded similar results when minor, major, and medical complications between groups were assessed. The overall survival rate of free tissue transfers was 96%, and this was same for overlapping (96%) and nonoverlapping (96%) operations ( P = .71). Conclusions Patients had similar complication rates and durations of hospitalization for overlapping and nonoverlapping operations

Outcomes and cost implications of microvascular reconstructions of the head and neck

Background Critical review of current head and neck reconstructive practices as related to free flap donor sites and their impact on clinical outcomes and cost. Methods Retrospective multicenter review of free tissue transfer reconstruction of head and neck defects (n = 1315). Variables reviewed: defect, indication, T classification, operative duration, and complications. A convenience sample was selected for analysis of overall (operative and inpatient admission) charges per hospitalization (n = 400). Results Mean charges of hospitalization by donor tissue: radial forearm free flap (RFFF) $127 636 (n = 183), osteocutaneous RFFF (OCRFFF)$125 456 (n = 70), anterior lateral thigh $133 781 (n = 54), fibula$140 747 (n = 42), latissimus $208 890 (n = 24), rectus$169 637 (n = 18), scapula $128 712 (n = 4), and ulna$110 716 (n = 5; P = .16). Mean operative times for malignant lesions stratified by T classification: 6.9 hours (+/- 25 minutes) for T1, 7.0 hours (+/- 16 minutes) for T2, 7.3 hours (+/- 17 minutes) for T3, and 7.8 hours (+/- 11 minutes) for T4 (P < .0001). Complications correlated with differences in mean charges: minor surgical ($123 720), medical ($216 387), and major surgical ($169 821; P < .001). Operations for advanced malignant lesions had higher mean charges: T1 lesions ($106 506) compared to T2/T3 lesions ($133 080; P = .03) and T4 lesions ($142 183; P = .02). On multivariate analysis, the length of stay, operative duration, and type a postoperative complication were factors affecting overall charges for the hospitalization (P < .018). Conclusion Conclusion: The RFFF and OCRFFF had the lowest complication rates, length of hospitalization, duration of operation, and mean charges of hospitalization. Advanced stage malignant disease correlated with increased hospitalization length, operative time, and complication rates resulting in higher hospitalization charges

Tracheostomy Outcomes in Patients With COVID-19 at a New York City Hospital

Objective Tracheostomies have been performed in patients with prolonged intubation due to COVID-19. Understanding outcomes in different populations is crucial to tackle future epidemics. Study Design Prospective cohort study. Setting Tertiary academic medical center in New York City. Methods A prospectively collected database of patients with COVID-19 undergoing open tracheostomy between March 2020 and April 2020 was reviewed. Primary endpoints were weaning from the ventilator and from sedation and time to decannulation. Results Sixty-six patients underwent tracheostomy. There were 42 males (64%) with an average age of 62 years (range, 23-91). Patients were intubated for a median time of 26 days prior to tracheostomy (interquartile range [IQR], 23-30). The median time to weaning from ventilatory support after tracheostomy was 18 days (IQR, 10-29). Of those sedated at the time of tracheostomy, the median time to discontinuation of sedation was 5 days (IQR, 3-9). Of patients who survived, 39 (69%) were decannulated. Of those decannulated before discharge (n = 39), the median time to decannulation was 36 days (IQR, 27-49) following tracheostomy. The median time from ventilator liberation to decannulation was 14 days (IQR, 8-22). Thirteen patients (20.0%) had minor bleeding requiring packing. Two patients (3%) had bleeding requiring neck exploration. The all-cause mortality rate was 10.6%. No patients died of procedural causes, and no surgeons acquired COVID-19. Conclusion Open tracheostomies were successfully and safely performed at our institution in the peak of the COVID-19 pandemic. The majority of patients were successfully weaned from the ventilator and sedation. Approximately 60% of patients were decannulated prior to hospital discharge

Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction

Objective Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction. Study Design Retrospective multi-institutional review of prospectively collected databases at tertiary care centers. Methods Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history. Results Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002). Conclusion This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures. Level of Evidence 4 Laryngoscope, 201