Objectives Bilateral vocal fold immobility can occur secondary to bilateral nerve injuries, resulting in paralysis of both vocal folds, known as bilateral vocal fold paralysis (BVFP). BVFP can cause airway obstruction and is associated with significant morbidity. Treatment options include tracheotomy, cordotomy, and arytenoidectomy, which are designed to increase the caliber of the upper airway. In the largest BVFP study to date, we set out to review cases of BVFP to better understand the etiologies of paralysis and subsequent surgical interventions. Methods/Study Design A retrospective review of patients with BVFP over a 17-year period within a single institution was performed. For each patient included in the study, the etiology of paralysis, simultaneous vs sequential onset of paralysis, subsequent surgeries, and spontaneous recovery were reviewed. Logistic regression was performed to determine whether patient factors predicted tracheotomy or recovery of vocal fold motion. Results 86 patients with BVFP followed for greater than 180 days were included in this retrospective cohort study. The majority of patients (84.9%) did not recover any vocal fold motion, while 13 patients (15.1%) recovered motion in at least one vocal fold. Iatrogenic injury was the most common etiology of paralysis. Sixty-seven patients (77.9%) underwent a tracheotomy placement, the most commonly performed procedure. Age, gender, or paralysis progression did not predict whether patients underwent tracheotomy or experienced spontaneous vocal fold motion recovery. Conclusions The most common etiology of BVFP was iatrogenic injury during thyroid surgery. A greater number of patients developed simultaneous paralysis of both vocal folds compared to sequential unilateral paralysis. Tracheotomy was the most commonly performed surgery, and the minority of patients were successfully decannulated. This study helps define the etiologies and treatments of patients with BVFP to better describe the patient-related morbidity associated with this condition.

ObjectiveMandibular reconstruction for segmental defects is a well‐studied topic. However, there are conflicting data on the risks of delayed plate‐related complications. The objective of this systematic review and meta‐analysis was to assess long‐term plate‐related complications following reconstruction of the mandible with soft tissue and a plate as compared with immediate vascularized bony reconstruction.Data SourcesA medical librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946–), Embase (1947–), Scopus (1960–), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov.Review MethodsCandidate articles were independently reviewed by 2 authors. Inclusion/exclusion criteria were uniformly applied. Articles were considered eligible if they included adequate reporting of plate extrusion and/or fracture and had follow‐up ≥12 months.ResultsA total of 2379 patients were included. The risk of plate fracture was low in cases of soft tissue with a plate (5%; 95% CI, 0.03‐0.08) and osseous reconstruction (1%). The risk of extrusion following soft tissue and plate reconstruction was 20% (95% CI, 0.15‐0.27). In the osseous reconstruction group, the risk of extrusion was 10% (95% CI, 0.06‐0.18). Revision surgery was performed twice as often following soft tissue with a plate as compared with vascularized bony reconstruction (32% [95% CI, 0.25‐0.40] vs 14% [95% CI, 0.09‐0.21], respectively).ConclusionDelayed plate‐related complications remain a significant problem following segmental defect reconstruction. Soft tissue and plate reconstruction techniques may increase the risk of plate removal and revision surgery.

OBJECTIVE:To comprehensively examine the prognostic significance of extranodal extension (ENE) in human papillomavirus-positive oropharyngeal squamous cell carcinoma (HPV-positive OPSCC). METHODS:Retrospective cohort of cases diagnosed with HPV-positive OPSCC from 2010 to 2015 in the National Cancer Database. Inclusion of all OPSCC HPV-positive cases with appropriate International Classification of Diseases-0-3 codes that received surgery with a neck dissection. Univariate and multivariable analyses were conducted. Hazard ratios (HR) for the independent effects of ENE and N stage on overall survival were estimated by Cox proportional hazards regression. RESULTS:Cases that were ENE-negative had the highest 5-year survival (92.6%; 95% confidence interval [CI]: 90.5%-94.7%). ENE-positive cases had the lowest 5-year survival (84.0%; 95% CI: 80.7%-87.4%). After adjusting for confounding variables, ENE-positivity was associated with almost twice the hazard of death (HR = 1.90; 95% CI: 1.35-2.67) compared to ENE-negative cases. Nodal (N) category 1, ENE-positive status was associated with an increased risk of death (HR = 1.88; 95% CI: 1.26-2.80) compared with N1, ENE-negative status. Compared to N1/ENE-negative cases, N2/ENE-positive cases had the poorest survival (HR: 2.93; 95% CI: 1.94-4.43). Both microscopic and macroscopic ENE were associated with worse outcomes compared to node-positive/ENE-negative status. CONCLUSION:The implementation of the American Joint Committee on Cancer 8th edition staging system provides a much-improved framework to develop and discuss treatment plans for HPV-positive OPSCC. We feel that careful consideration should be given to the importance of ENE in patients with HPV-positive OPSCC. LEVEL OF EVIDENCE:4 Laryngoscope, 130:939-945, 2020.