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Rubin SJ, Wang JJ, Nodoushani AY, Yarlagadda BB, Wulu JA, Edwards HA. The effect of a statewide prescription drug monitoring program on opioid prescribing patterns. Am J Otolaryngol 2022; 43:103262. [PMID: 34626913 DOI: 10.1016/j.amjoto.2021.103262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Determine whether opioid prescribing patterns have changed as a result of implementation of a prescription drug monitoring program (PDMP) in the state of Massachusetts. MATERIALS AND METHODS A multicentered retrospective study was performed including patients who received tonsillectomy, parotidectomy, thyroidectomy or direct laryngoscopy and biopsy with or without rigid esophagoscopy and/or rigid bronchoscopy at Lahey Hospital and Medical Center (Burlington, MA) or Boston Medical Center (Boston, MA). Opioid prescribing patterns were compared for the 12 months prior to implementation of the Massachusetts Prescription Awareness Tool (MassPAT) to 36 months of prescribing patterns post implementation. Quantity of opioids prescribed was based on morphine milligram equivalents (MME). Continuous variables were compared using analysis of variance (ANOVA) while categorical variables were compared using chi-squared test or Fisher's exact test. Multivariate analysis was performed using linear regression. RESULTS A total of 2281 patients were included in the study. There was a significant association in mean overall MME prescribed comparing pre-MassPAT and post-MassPAT data [tonsillectomy: 635.9 ± 175.6 vs 463.3 ± 177.7 (p < 0.0001), parotidectomy: 250.4 ± 71.33 vs 169.8 ± 79.26 (p < 0.0001), thyroidectomy: 186.2 ± 81.14 vs 118.3 ± 88.79 (p < 0.0001), direct laryngoscopy with biopsy: 308.3 ± 246.9 vs 308.3 ± 246.9 (p = 0.0201)]. There was also a significant association between length of opioid prescription (days) and implementation of MassPAT, but there was no significant difference in the percent of patients requiring refills pre- MassPAT and post-MassPAT. CONCLUSION This study demonstrates that prescribers have been able to significantly decrease the amount of opioids prescribed for tonsillectomy, parotidectomy, thyroidectomy, and direct laryngoscopy and biopsy and patients have not required additional opioid refills.
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Affiliation(s)
- Samuel J Rubin
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, 800 Harrison Ave BCD 5th floor, Boston, MA 02118, United States of America; Boston University School of Medicine, 72 East Concord St, Boston, MA 02118, United States of America.
| | - Judy J Wang
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, 800 Harrison Ave BCD 5th floor, Boston, MA 02118, United States of America; Boston University School of Medicine, 72 East Concord St, Boston, MA 02118, United States of America
| | - Ariana Y Nodoushani
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, 800 Harrison Ave BCD 5th floor, Boston, MA 02118, United States of America; Boston University School of Medicine, 72 East Concord St, Boston, MA 02118, United States of America
| | - Bharat B Yarlagadda
- Boston University School of Medicine, 72 East Concord St, Boston, MA 02118, United States of America; Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA 01850, United States of America
| | - Jacqueline A Wulu
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, 800 Harrison Ave BCD 5th floor, Boston, MA 02118, United States of America; Boston University School of Medicine, 72 East Concord St, Boston, MA 02118, United States of America
| | - Heather A Edwards
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, 800 Harrison Ave BCD 5th floor, Boston, MA 02118, United States of America; Boston University School of Medicine, 72 East Concord St, Boston, MA 02118, United States of America
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2
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Tjoa T, Rathi VK, Goyal N, Yarlagadda BB, Barshak MB, Rich DL, Emerick KS, Lin DT, Deschler DG, Durand ML. Pneumonia, urinary tract infection, bacteremia, and Clostridioides difficile infection following major head and neck free and pedicled flap surgeries. Oral Oncol 2021; 122:105541. [PMID: 34564017 DOI: 10.1016/j.oraloncology.2021.105541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/21/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Medical postoperative infections (MPIs) are important causes of morbidity following major head and neck free and pedicled flap reconstruction, but the incidence, time of onset, and microbiology are not well characterized. MATERIALS AND METHODS Medical records were reviewed of all head and neck flap surgeries performed 2009-2014 at an academic medical center. Postoperative pneumonia, urinary tract infection (UTI), bloodstream infection (BSI), Clostridioides difficile (CDI), and surgical site infections (SSI) were noted. Catheter-associated UTI (CAUTI), central line-associated BSI (CLABSI), and methicillin-resistant Staphylococcus aureus (MRSA) BSI were also evaluated. RESULTS Following 715 free (540) or pedicled (175) flap surgeries, 14.1% of patients developed ≥one MPI including pneumonia (10.6%), UTI (2.1%), BSI (0.7%), and CDI (2.4%). Onset was ≤7 days in 77%. The MPI incidence in free vs pedicled flaps was similar. By multivariate analysis, age ≥65 and clindamycin perioperative prophylaxis were associated with increased MPI risk, clean class surgery with decreased risk. The incidence of CAUTI (<1.0%), CLABSI (0.1%), and hospital-onset MRSA BSI (0.1%) was low. SSI rate (7.8% overall) was higher in patients who developed pneumonia (18.4 vs 6.6, p = 0.004). MPI cultures grew gram-negative bacilli or S. aureus in 75%. The length of stay was longer in patients who developed a MPI than those who did not (17.4 vs 10.4 days, p < 0.0001). CONCLUSIONS One-seventh of major head and neck flap surgeries were complicated by MPIs, three-quarters of infections developed within 1 week postoperatively. Gram-negative bacilli and S. aureus were the predominant pathogens.
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Affiliation(s)
- Tjoson Tjoa
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Vinay K Rathi
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Neerav Goyal
- Department of Otolaryngology, Penn State Milton S. Hershey Medical Center, 200 Campus Drive, Hershey, PA 17033, United States.
| | - Bharat B Yarlagadda
- Department of Otolaryngology, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805, United States.
| | - Miriam B Barshak
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States.
| | - Debbie L Rich
- Department of Nursing, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States
| | - Kevin S Emerick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Derrick T Lin
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Daniel G Deschler
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Marlene L Durand
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States.
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Donahue C, Pantel HJ, Yarlagadda BB, Brams D. Does Preoperative Calcium and Calcitriol Decrease Rates of Post-Thyroidectomy Hypocalcemia? A Randomized Clinical Trial. J Am Coll Surg 2021; 232:848-854. [PMID: 33631337 DOI: 10.1016/j.jamcollsurg.2021.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Postoperative hypocalcemia is the most common complication after thyroidectomy. Postoperative supplementation with calcium and calcitriol reduces its occurrence; however, prophylactic preoperative supplementation has not been studied systematically. The primary objective of this study was to determine whether pre- and postoperative calcium and calcitriol supplementation reduces postoperative hypocalcemia after total thyroidectomy compared with postoperative supplementation alone. STUDY DESIGN We conducted a single-institution prospective randomized trial enrolling 82 patients undergoing total thyroidectomy from July 2017 through May 2019. Those undergoing partial thyroidectomy or concurrent planned parathyroidectomy were excluded. The intervention group started calcitriol 0.25 μg po bid and calcium carbonate 1,500 mg po tid 5 days preoperatively and continued postoperatively. The control group started these medications postoperatively. The primary end point was clinical or biochemical hypocalcemia. Secondary outcomes were postoperative calcium levels, need for intervention, length of stay, and readmission. RESULTS Thirty-eight patients were randomized to the intervention group and 44 to the control group. There were 12 episodes of hypocalcemia; 5 (13.2%) in the intervention and 7 (15.9%) in the control group (p = 0.76). No differences were found in secondary outcomes; including postoperative calcium levels at each measured time point, need for intervention (n = 10 [26.3%], n = 15 [34.1%]; p = 0.48), length of stay (mean [SD] 32.3 [15.6] hours, 30.7 [10.5] hours; p = 0.6), or readmissions (n = 0 [0.0%], n = 3 [6.8%]; p = 0.24). CONCLUSIONS Starting supplementation with calcium and calcitriol preoperatively does not reduce postoperative hypocalcemia compared with postoperative supplementation alone after total thyroidectomy. These findings do not support the practice of routine calcium and calcitriol supplementation before total thyroidectomy.
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Affiliation(s)
| | | | | | - David Brams
- Lahey Hospital and Medical Center, Burlington, MA
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Rubin S, Wulu JA, Edwards HA, Dolan RW, Brams DM, Yarlagadda BB. The Impact of MassPAT on Opioid Prescribing Patterns for Otolaryngology Surgeries. Otolaryngol Head Neck Surg 2021; 164:781-787. [PMID: 33588624 DOI: 10.1177/0194599820987454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Determine whether opioid prescriber patterns have changed for tonsillectomy, parotidectomy, and thyroidectomy after implementation of the Massachusetts Prescription Awareness Tool (MassPAT). STUDY DESIGN Retrospective cohort study. SETTING Single-center tertiary care hospital. METHODS Patients were included if they received tonsillectomy, parotidectomy, or thyroid surgery at Lahey Hospital and Medical Center (Burlington, Massachusetts) between October 1, 2015, and October 1, 2019. Prescribing patterns were compared prior to implementation of MassPAT, October 1, 2015, to October 14, 2016, to postimplementation of MassPAT, October 15, 2016, to October 1, 2019. Quantity of opioids prescribed was described using total morphine milligram equivalents (MME). Data were analyzed using univariate analysis, multivariate analysis, and trend line using line of best fit. RESULTS A total of 737 subjects were included in the study. There was a downward trend in the quantity of opioids prescribed for all 3 surgeries during the study period. There was a significant difference in the quantity of opioids prescribed pre- and postimplementation of MassPAT for tonsillectomy (647.70 ± 218.50 MME vs 474.60 ± 185.90 MME, P < .001), parotidectomy (241.20 ± 57.66 MME vs 156.70 ± 72.99 MME, P < .001), and thyroidectomy (171.20 ± 93.77 MME vs 108.50 ± 63.84 MME, P < .001). There was also a decrease in the number of patients who did not receive opioids for thyroidectomy pre- and post-MassPAT (7.56% vs 24.14%). CONCLUSION We have demonstrated that there is an association with state drug monitoring programs and decrease in the amount of opioids prescribed for acute postoperative pain control for common otolaryngology surgeries.
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Affiliation(s)
- Samuel Rubin
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Jacqueline A Wulu
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Heather A Edwards
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Robert W Dolan
- Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - David M Brams
- Division of General Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Bharat B Yarlagadda
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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Troiano CA, Yarlagadda BB. Distant metastasis to the external auditory canal. Ear Nose Throat J 2018; 97:E57-E58. [PMID: 29493736 DOI: 10.1177/0145561318097001-215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Chelsea A Troiano
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, MA, USA
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Osborn HA, Rathi VK, Tjoa T, Goyal N, Yarlagadda BB, Rich DL, Emerick KS, Lin DT, Deschler DG, Durand ML. Risk factors for thirty-day readmission following flap reconstruction of oncologic defects of the head and neck. Laryngoscope 2017; 128:343-349. [DOI: 10.1002/lary.26726] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/02/2017] [Accepted: 05/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Heather A. Osborn
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Vinay K. Rathi
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Tjoson Tjoa
- Department of Otolaryngology; University of California; Irvine California
| | - Neerav Goyal
- Penn State Milton S. Hershey Medical Center, Division of Otolaryngology Head and Neck Surgery; Hershey Pennsylvania
| | - Bharat B. Yarlagadda
- Department of Otolaryngology; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Debbie L. Rich
- Department of Nursing; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Kevin S. Emerick
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Derrick T. Lin
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Daniel G. Deschler
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Marlene L. Durand
- Department of Medicine; Infectious Disease Unit, Massachusetts General Hospital and Infectious Disease Service, Massachusetts Eye and Ear Infirmary; Boston Massachusetts
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Yarlagadda BB, Meier JC, Lin DT, Emerick KS, Deschler DG. Locoregional control of tongue base adenoid cystic carcinoma with primary resection and radial forearm free flap reconstruction. Ear Nose Throat J 2017; 96:37-40. [PMID: 28122103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
Adenoid cystic carcinoma of the minor salivary glands can be challenging and marked by high rates of local recurrence despite appropriate surgical resection. Management of this pathology in the base of the tongue is particularly difficult given the poor functional outcomes traditionally associated with an aggressive surgical approach. This article presents a case series of patients who underwent up-front surgical resection followed by free tissue transfer reconstruction. A retrospective analysis was performed of patients with adenoid cystic carcinoma of the base of the tongue who underwent composite resection and reconstruction with a radial forearm free flap. Three patients met inclusion criteria and underwent analysis. All patients achieved locoregional control after at least 4 years of surveillance. In addition, all patients were decannulated and were swallowing without the need for gastrostomy tube feeding. This series demonstrates that for select patients with adenoid cystic carcinoma of the base of the tongue, excellent locoregional control can be achieved with acceptable functional outcomes and prolonged survival when appropriate reconstructive measures are employed.
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Goyal N, Yarlagadda BB, Deschler DG, Emerick KS, Lin DT, Rich DL, Rocco JW, Durand ML. Surgical Site Infections in Major Head and Neck Surgeries Involving Pedicled Flap Reconstruction. Ann Otol Rhinol Laryngol 2016; 126:20-28. [PMID: 27913719 DOI: 10.1177/0003489416672871] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate surgical site infections (SSI) after pedicled reconstruction in head and neck surgery. METHODS Records of patients with pedicled flap reconstructions between 2009 and 2014 at Massachusetts Eye and Ear were reviewed. Onset of SSI or fistula ≤30 days postoperatively was noted. A free flap cohort was reviewed for comparison. RESULTS Two hundred and eight pedicled reconstructions were performed for cancer (83%), osteoradionecrosis (7%), and other reasons (10%). Most (72%) cases were clean-contaminated and American Society of Anesthesiologists classification 3 or higher (73%); 63% of patients had prior radiation. The SSIs occurred in 9.1% and were associated with a longer length of stay (P = .004) but no particular risk factors. Seventeen patients developed a fistula (11 without SSI). The SSI rates were not significantly different between pedicled and free flaps, but pedicled flap patients were older, more likely to have had prior surgery and/or radiation, and be methicillin-resistant Staphylococcus aureus positive. In the combined population, multivariate analysis demonstrated clean-contaminated wound classification (P = .03), longer operating time (P = .03), and clindamycin prophylaxis (P = .009) as SSI risk factors. CONCLUSIONS The SSI rate following pedicled flap surgeries was low and similar to free flap surgeries despite a significantly different population. No specific risk factors were associated with developing a pedicled flap SSI.
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Affiliation(s)
- Neerav Goyal
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA .,Department of Surgery, Division of Otolaryngology Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Bharat B Yarlagadda
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Lahey Hospital & Medical Center, Department of Otolaryngology, Burlington, Massachusetts, USA
| | - Daniel G Deschler
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Derrick T Lin
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Debbie L Rich
- Department of Nursing, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - James W Rocco
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Marlene L Durand
- Massachusetts General Hospital, Department of Medicine, Infectious Disease Unit, and Massachusetts Eye and Ear, Infectious Disease Service, Boston, Massachusetts, USA
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Goyal N, Emerick KS, Deschler DG, Lin DT, Yarlagadda BB, Rich DL, Durand ML. Risk factors for surgical site infection after supraclavicular flap reconstruction in patients undergoing major head and neck surgery. Head Neck 2016; 38:1615-1620. [PMID: 27098679 DOI: 10.1002/hed.24480] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/03/2016] [Accepted: 03/16/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Surgical site infections can adversely affect flaps in head and neck reconstruction. The purpose of this study was to evaluate the risk factors of surgical site infections in supraclavicular artery island flap reconstructions. METHODS Records of patients undergoing head and neck surgery from 2011 to 2014 with supraclavicular artery island flap reconstruction at a single specialty hospital were reviewed; surgical site infections ≤30 days postoperatively were noted. RESULTS Of 64 patients, 86% underwent resection for malignancy, 55% previously received radiation. Sixty-three percent of surgeries were clean-contaminated. Seven patients (11%) developed recipient site surgical site infections, all in patients who underwent clean-contaminated surgery for malignancy. There was no complete flap loss. No significant differences in demographics or perioperative factors were noted. Oral cavity and laryngeal reconstructions (p = .014) and clean-contaminated surgery (p = .04) were factors associated with increased surgical site infection risk on univariate but not multivariate analysis. Patients with surgical site infections had longer hospitalizations (p = .003). CONCLUSION The supraclavicular artery island flap can be used for head and neck reconstruction with a low rate of surgical site infection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.
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Affiliation(s)
- Neerav Goyal
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. .,Penn State Milton S. Hershey Medical Center, Division of Otolaryngology Head and Neck Surgery, Hershey, Pennsylvania.
| | - Kevin S Emerick
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Daniel G Deschler
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Derrick T Lin
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Bharat B Yarlagadda
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Lahey Hospital and Medical Center, Department of Otolaryngology, Burlington, Massachusetts
| | - Debbie L Rich
- Department of Nursing, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Marlene L Durand
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, Massachusetts
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Lin DT, Yarlagadda BB, Sethi RKV, Feng AL, Shnayder Y, Ledgerwood LG, Diaz JA, Sinha P, Hanasono MM, Yu P, Skoracki RJ, Lian TS, Patel UA, Leibowitz J, Purdy N, Starmer H, Richmon JD. Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy. JAMA Otolaryngol Head Neck Surg 2015; 141:797-803. [PMID: 26291031 DOI: 10.1001/jamaoto.2015.1463] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE The optimal reconstruction of total glossectomy defects with or without total laryngectomy is controversial. Various pedicled and free tissue flaps have been advocated, but long-term data on functional outcomes are not available to date. OBJECTIVES To compare various total glossectomy defect reconstructive techniques used by multiple institutions and to identify factors that may lead to improved long-term speech and swallowing function. DESIGN, SETTING, AND PARTICIPANTS A multi-institutional, retrospective review of electronic medical records of patients undergoing total glossectomy at 8 participating institutions between June 1, 2001, and June 30, 2011, who had a minimal survival of 2 years. INTERVENTION Total glossectomy with or without total laryngectomy. MAIN OUTCOMES AND MEASURES Demographic and surgical factors were compiled and correlated with speech and swallowing outcomes. RESULTS At the time of the last follow-up, 45% (25 of 55) of patients did not have a gastrostomy tube, and 76% (42 of 55) retained the ability to verbally communicate. Overall, 75% (41 of 55) of patients were tolerating at least minimal nutritional oral intake. Feeding tube dependence was not associated with laryngeal preservation or the reconstructive techniques used, including flap suspension, flap innervation, or type of flap used. Laryngeal preservation was associated with favorable speech outcomes, such as the retained ability to verbally communicate in 97% of those not undergoing total laryngectomy (35 of 36 patients) vs 44% (7 of 16) in those undergoing total laryngectomy (P < .001), as well as those not undergoing total laryngectomy achieving some or all intelligible speech in 85% (29 of 34 patients) compared with 31% (4 of 13) undergoing total laryngectomy achieving the same intelligibility (P < .001). CONCLUSIONS AND RELEVANCE In patients with total glossectomy, feeding tube dependence was not associated with laryngeal preservation or the reconstructive technique, including flap innervation and type of flap used. Laryngeal preservation was associated with favorable speech outcomes such as the retained ability to verbally communicate and higher levels of speech intelligibility.
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Affiliation(s)
- Derrick T Lin
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
| | | | | | - Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Yelizaveta Shnayder
- Department of Otolaryngology-Head and Neck Surgery, Kansas University Medical Center, Kansas City
| | - Levi G Ledgerwood
- Department of Otolaryngology-Head and Neck Surgery, Kansas University Medical Center, Kansas City
| | - Jason A Diaz
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Parul Sinha
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Roman J Skoracki
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Timothy S Lian
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Urjeet A Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, Illinois
| | - Jason Leibowitz
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Nicholas Purdy
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Heather Starmer
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University, Baltimore, Maryland
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Yarlagadda BB, Deschler DG, Rich DL, Lin DT, Emerick KS, Rocco JW, Durand ML. Head and neck free flap surgical site infections in the era of the Surgical Care Improvement Project. Head Neck 2015; 38 Suppl 1:E392-8. [DOI: 10.1002/hed.24005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 12/09/2014] [Accepted: 01/06/2015] [Indexed: 11/07/2022] Open
Affiliation(s)
- Bharat B. Yarlagadda
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Daniel G. Deschler
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Debbie L. Rich
- Department of Nursing; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Derrick T. Lin
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Kevin S. Emerick
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - James W. Rocco
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Marlene L. Durand
- Infectious Disease Service; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
- Department of Medicine; Massachusetts General Hospital; Boston Massachusetts
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Puram SV, Yarlagadda BB, Sethi R, Muralidhar V, Chambers KJ, Emerick KS, Rocco JW, Lin DT, Deschler DG. Transfusion in head and neck free flap patients: practice patterns and a comparative analysis by flap type. Otolaryngol Head Neck Surg 2015; 152:449-57. [PMID: 25628368 DOI: 10.1177/0194599814567107] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize patterns of utilization and outcomes following transfusion in head and neck patients undergoing free flap reconstruction. STUDY DESIGN Case series with chart review. SETTING Tertiary academic medical center. SUBJECTS AND METHODS Two hundred eighty-two head and neck patients undergoing free flap reconstruction from 2011 to 2013. Outcome parameters included post-transfusion hematocrit increase, length of stay (LOS), flap survival, and perioperative complications. RESULTS Of all head and neck free flap patients, 48.9% received blood transfusions. Average pretransfusion hametocrit (Hct) was 24.7%±0.2% with 2.5±0.1 units of blood transfused. Transfused patients were more likely to have been taken back to the operating room. Rates of transfusion were similar between flap types, although anterolateral thigh (ALT) and fibular free flap (FFF) patients had higher transfusion requirements compared to radial forearm free flap (RFFF) patients. Further, FFF patients trended toward receiving transfusions earlier. Transfusion did not influence flap survival but was associated with wound dehiscence, myocardial infarction, congestive heart failure, respiratory distress, and pneumonia. Subset analyses by flap type revealed that differences were significant among the RFFF and FFF cohorts but not ALT patients. When comparing patients who were transfused for Hct<21 to those transfused for Hct<27, there were no differences in LOS, flap survival, or postsurgical complications. CONCLUSIONS Among the different types of flaps, FFF and ALT are associated with higher transfusion requirements. Transfusion in patients undergoing free flap reconstruction does not significantly affect flap survival but was associated with perioperative complications. Our data support consideration of a restrictive transfusion policy in free flap patients.
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Affiliation(s)
- Sidharth V Puram
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Bharat B Yarlagadda
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Rosh Sethi
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinayak Muralidhar
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kyle J Chambers
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - James W Rocco
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
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Durand ML, Yarlagadda BB, Rich DL, Lin DT, Emerick KS, Rocco JW, Deschler DG. The time course and microbiology of surgical site infections after head and neck free flap surgery. Laryngoscope 2014; 125:1084-9. [PMID: 25425457 DOI: 10.1002/lary.25038] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/02/2014] [Accepted: 10/28/2014] [Indexed: 01/10/2023]
Abstract
OBJECTIVES/HYPOTHESIS Determine the time of onset and microbiology of surgical site infections (SSIs) following head and neck free flap reconstructive surgeries. STUDY DESIGN Retrospective cohort study. METHODS All 504 free flap surgical cases (484 patients) performed April 1, 2009 to September 30, 2013 were reviewed; SSIs occurring ≤30 days postoperatively were evaluated. Admission screening for methicillin-resistant Staphylococcus aureus (MRSA) colonization was performed on all patients. RESULTS Flap-recipient site infections (flap SSIs) occurred in 67 cases (13.3%), one-third week 1 postoperatively, one-third week 2, one-third days 15 to 30; 45% occurred after hospital discharge. Wound cultures were polymicrobial, but 25% grew only normal oral flora, whereas 75% grew pathogens not part of normal oral flora, such as gram-negative bacilli (44% of cases), MRSA (20%), and methicillin-sensitive S aureus (MSSA) (16%). The frequency of these pathogens did not vary significantly by the time of SSI onset. In 67%, cultures included at least one pathogen resistant to the prophylactic antibiotic used. Clindamycin prophylaxis was a significant risk factor for flap SSI and for early partial or complete flap loss from infection. Donor SSIs occurred in 22 cases (4.4%), 95% >1 week postoperatively, and MRSA or MSSA were the primary pathogens in 89%. Of the 25 patients colonized with MRSA on admission, 40% developed a flap or donor SSI, a rate significantly higher than in non-colonized patients. CONCLUSIONS Gram-negative bacilli, MRSA, and MSSA were significant SSI pathogens, and late onset of infection was common. Better screening, decolonization, and prophylaxis may reduce SSI rates. LEVEL OF EVIDENCE 2b
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Affiliation(s)
- Marlene L Durand
- Infectious Disease Service, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
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Richmon JD, Yarlagadda BB, Wax MK, Patel U, Diaz J, Lin DT. Locoregional and free flap reconstruction of the lateral skull base. Head Neck 2014; 37:1387-91. [DOI: 10.1002/hed.23725] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 02/11/2014] [Accepted: 04/28/2014] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jeremy D. Richmon
- Department of Otolaryngology; Johns Hopkins University; Baltimore Maryland
| | - Bharat B. Yarlagadda
- Department of Otology and Laryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Mark K. Wax
- Department of Otolaryngology; Oregon Health and Sciences University; Portland Oregon
| | - Urjeet Patel
- Department of Otolaryngology; Northwestern University; Chicago Illinois
| | - Jason Diaz
- Department of Otolaryngology; Washington University; St. Louis Missouri
| | - Derrick T. Lin
- Department of Otology and Laryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
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Papoian V, Yarlagadda BB, Devaiah AK. Multifocal, recurrent sinonasal leiomyosarcoma: case report and review of literature. Am J Otolaryngol 2014; 35:254-6. [PMID: 24315734 DOI: 10.1016/j.amjoto.2013.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/30/2013] [Indexed: 11/17/2022]
Abstract
Leiomyosarcoma is a rare tumor encountered in the sinus and skull base, and can be difficult to control. We present a case of an 83 year old female with a recurrent sinonasal leiomyosarcoma. The tumor exhibited variable growth rates of recurrences in non-contiguous sites despite having obtained clear surgical margins and use of adjuvant therapy. This case illustrates unusual characteristics of this rare tumor that are important for clinicians to know. Patient demographics, presenting symptoms, risk factors, treatment options, and prognosis are also reviewed.
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Affiliation(s)
- Vardan Papoian
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, MA.
| | - Bharat B Yarlagadda
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, MA.
| | - Anand K Devaiah
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, MA.
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Yarlagadda BB, Brook CD, Stein DJ, Jalisi S. Venous thromboembolism in otolaryngology surgical inpatients receiving chemoprophylaxis. Head Neck 2013; 36:1087-93. [DOI: 10.1002/hed.23411] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 06/06/2013] [Accepted: 06/06/2013] [Indexed: 11/11/2022] Open
Affiliation(s)
- Bharat B. Yarlagadda
- Department of Otolaryngology - Head and Neck Surgery; Boston Medical Center; Boston Massachusetts
| | - Christopher D. Brook
- Department of Otolaryngology - Head and Neck Surgery; Boston Medical Center; Boston Massachusetts
| | | | - Scharukh Jalisi
- Department of Otolaryngology - Head and Neck Surgery; Boston Medical Center; Boston Massachusetts
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