From its application to head and neck surgery in 2017, ERAS protocols have developed significantly by incorporating novel evidence and creating guidelines substantiated from studies examining head and neck surgical reconstructive patients. The major benefits of ERAS include reduced duration of hospitalization and improved patient outcomes. Changes in surgical technology and novel evidence from head and neck free flap studies will guide future guidelines and recommendations. The key points have been summarized in Fig. 5 below.

OBJECTIVE:We hypothesized that a method to segment human airways from clinical cases and import them into a case presentation environment in Virtual Reality (VR) could be developed to model and visualize complex airway stenosis for efficient surgical planning. METHODS:One normal and two pathological airways modeled from CT scans at a slice thickness of 0.625 mm were processed. A multidisciplinary team composed of airway surgeons, VR engineers, educators, and radiologists collaborated to create a clinically relevant VR rendering and explanatory Narrations of the three clinical cases. Segmentation and postprocessing were completed in the Mimics Innovation Suite v24 from Materialize. Structures were segmented from the level of bifurcation of common carotid arteries to the level of bifurcation of the main bronchi, including cartilaginous and bony airway structures, vessels, and soft tissues. They were then postprocessed into 3D image volumes and imported into syGlass (IstoVisio Inc.), a VR software. RESULTS:Direct visualization and free manipulation of these 3D airway models within the VR environment provided improved geometrical and anatomical details compared to traditional two-dimensional (2D) CT. Then, specialized presentation and active learning tools developed for scientific communication using the VR environment permitted the creation of VR Narrations to explain pathological cases. CONCLUSION:The method to segment human airways from clinical cases used in this paper, combined with intuitive VR tools to overlay segmentation and image data in an active learning environment, shows potential in the use of 3D airway modeling and VR in clinical practice for the description and surgical planning of complex airways. Further work is needed to validate the use of these models in clinical practice and patient education. LEVEL OF EVIDENCE:Level 4.

Our review aims to clarify the incidence of carotid artery stenosis, risks of development, screening, management, and primary prevention strategies documented in the literature after radiation therapy for head and neck cancers. The high prevalence of carotid stenosis after radiation therapy for head and neck cancers has made surveillance and risk stratification critical. In addition to general cardiovascular risk factors such as smoking, diabetes, and dyslipidemia, risk factors for carotid artery stenosis after head and neck radiation included total plaque score, radiotherapy use and dosage, length of time after radiotherapy, and age greater than 50. Cancer subtype, namely nasopharyngeal cancer, may be correlated with increased risk as well, though contrasting results have been found. Interestingly, however, no significant relationship has been found between radiotherapy dose and stroke risk. Surgical management of post-radiation carotid stenosis is similar to that of stenosis unrelated to radiation, with carotid endarterectomy considered to be the gold standard treatment and carotid artery stenting being an acceptable, less-invasive alternative. Medical management of these patients has not been well-studied, but antiplatelet therapy, statins, and blood pressure control may be beneficial. The mainstay of screening for radiation-induced stenosis has been Doppler ultrasound, with measurement of changes in the intima-media thickness being a primary marker of disease development. A literature review was carried out using the MeSH terms "Carotid Artery Stenosis," "Head and Neck Neoplasms," and "Radiotherapy."

There are well documented challenges related to dental care in the head and neck cancer population. Perioperative management of dental disease is critical, especially for patients requiring adjuvant radiation therapy. Head and neck cancer patients in the United States often have limited or no access to dental care. As a result, head and neck surgeons may be the sole practitioners able to deliver dental care. This paper summarizes the existing literature on dental care for head and neck cancer patients and outlines a streamlined approach to the perioperative management of dental disease.

Diaz, Mayte DNP, APRN, CRNA; Duclos, April MS, APRN, CRNA; Mifsud, Matthew MD, FACS; Wofford, Kenneth A. PhD, APRN, CRNA, CHSE, DiMM, FAWM Author Information

Objectives: Syphilis is a resurging disease which can present itself in many ways, including lesions within the head and neck mucosa. Some of these lesions may clinically mimic oral malignancies. This literature review aims to better characterize the mucosal presentations of syphilis. Methods: PubMed, EMBASE, and clinicaltrials.gov were searched for full-text, English articles published from 1950 to 2022 that reported patients with head and neck mucosal manifestations of syphilis. Articles were screened according to PRISMA guidelines. Results: One hundred forty-three manuscripts documenting 236 individual patients were included in the review. Patients with secondary syphilis accounted for 62% of patients presenting with head and neck mucosal lesions. The most common lesions found in primary and secondary syphilis were ulcerations, primarily found on the tongue, lips, and palate. While serologic studies are the gold standard for diagnosing syphilis, biopsy of these lesions have characteristic syphilitic changes. Conclusions: Syphilis' nickname of "The great imitator" remains to be true, and the head and neck mucosal manifestations of this disease can resemble commonly seen malignancies. Awareness of this disease and its lesions is prudent given the rising incidence of syphilis within the United States.

Study Design Technical Note Objective Pharyngoesophageal injury in the setting of previous anterior cervical discectomy and fusion (ACDF) is a devastating complication with no standard corrective treatment protocol. Reconstruction can thus be a complex endeavour often leading to treatment failure, recurrent pharyngoesophageal fistula and need for multiple surgical procedures. The authors present our novel approach to free tissue reconstruction of these injuries. Methods We utilized a bulk adipofascial flap to completely obliterate the retropharyngeal space and correct the pharyngoesophageal defect. Results An adipofascial flap facilitates complete separation of the injured pharyngeal/oesophageal mucosa form the cervical spine and any retained hardware. Conclusions In our hands, this technique has allowed successful repair of complex pharyngoesophageal injuries after previous ACDF procedures which includes resumption of normal oral intake.

Background Head and neck cancer (HNC) and its treatments often result in adverse effects that impair a patient’s quality of life. Although intensive rehabilitative strategies can be used, their applicability can be limited due to patient-specific and socioeconomic barriers. Telehealth interventions represent a possible novel approach to increase access to these services and improve posttreatment quality of life in the HNC population. Objective The objective of this systematic review was to identify studies investigating telemedicine-based interventions for HNC patients to determine whether there is a consensus concerning the cost-effectiveness, clinical utility, and accessibility of this model for rehabilitation. Methods PubMed, EMBASE, Web of Science, and CINAHL were used to identify literature without time limit for publication. A critical appraisal of individual sources was conducted by 2 reviewers. Sixteen studies met inclusion criteria. Results Studies related to telehealth interventions in the HNC population are limited. Salient themes included feasibility of telehealth as an intervention, effects on self-management and knowledge, impact on quality of life, physical and psychiatric symptoms, and cost. Conclusion Although the current literature presents promising data, indicating that telehealth interventions may be both effective and cost-efficient in the management of HNC patients, more research is needed to definitively elucidate their role in management. Implications for Practice Telehealth interventions are valuable for clinicians as an alternative to expand access to care across the cancer continuum, to strengthen patients’ knowledge and consequently their self-management, and to provide continuity of services as well as for remote monitoring of symptoms and response to treatment.

Head and neck cancers (HNC) treatments can lead to significant side effects, mainly shoulder dysfunction, and trismus (spasm of jaw muscles). Currently patient's progress, while undergoing treatment, is limited to evaluation during scheduled appointments. Development of strategies to enhance monitoring during follow-up period is needed for earlier identification of problems such as trismus and shoulder dysfunction. In this interdisciplinary research, for the first time, we propose an IoMT enabling application, namely, Automatic Measurement of Trismus and Shoulder Dysfunction (AMTSD), to remotely monitor the recovery. An HNC patient can use AMTSD as a web application frequently (twice/daily) to virtually measure the mouth extension and shoulder range of motion (ROM). The data collected is stored in a database and can be automatically analyzed to assess the progress. Triggers can be set to alert the healthcare team if the patient's condition is regressing. The virtual range of motion measurements are based on the open-source MediaPipe, a cross-platform library from Google. For five volunteers, AMTSD yielded the average measurement error for mouth extension of 1.77% and shoulder ROM of 2.89%.

Interventional strategies for dealing with microvascular free flap failure are varied among institutions and even individual surgeons. This systematic review aims to identify the published methods for salvaging a failing free flap and provide surgeons with a comprehensive toolset for successful intervention. A title and abstract search of the PubMed, Embase, and Web of Science databases was performed. 1694 abstracts were screened by three reviewers according to Prisma guidelines. 62 full text articles meeting inclusion criteria detailed techniques which were separated into the categories of thrombectomy, thrombolysis, leech therapy, vascular fistula, and an "other" category outlining techniques which did not fit into the prior framework. Assessment of the efficacy of individual salvage techniques is limited due to limited empirical data, however, the approach to successful salvage should be based on timely identification of flap compromise, followed by the implementation of one or several of the aforementioned techniques.

BACKGROUND: Anterior cervical disk fusion (ACDF) isa common surgical approach for the treatment of cervicalspine pathology. Esophageal perforations, though uncom-mon, are a devastating complication of this surgery. The objective of this paper is to assess the success of different treatment approaches for the management of esophageal/pharyngeal injury after ACDF. METHODS:Given the absence of prospective trials, thereview includes institutional case reports and case seriesfrom 1985e2020 in the English language literature. Onlycases of esophageal/pharyngeal injury in the setting ofanterior cervical hardware were considered for study in-clusion. For purposes of this study, treatment success isdefined as resumption of oral intake. RESULTS:The database review identified 76 distinctseries that meet criteria for study inclusion, with 173 pa-tients available for analysis. A heterogeneous array oftreatments was used for the management of phar-yngoesophageal injuries after ACDF ranging from obser-vation to complex free tissue reconstruction, with varyingdegrees of treatment success reported. We identified anumber of factors, specifically duration of injury frominitial ACDF procedure, which may impact the complexityof treatment required to maximize likelihood of treatmentsuccess. CONCLUSIONS: Pharyngoesophageal injuries, albeitrare, are a serious and often complex complication afterACDF procedures. We propose a detailed algorithmicapproach to guide decision making if faced with thisclinical challenge. The huge variability in how thesepatients are treated emphasizes the potential utility offuture multiinstitutional studies

Tracheostomies are often utilized in critically ill patients on prolonged mechanical ventilation, to enhance respiratory function and facilitate ventilator weaning. Many coronavirus disease 2019 (COVID-19) patients develop serious respiratory illness requiring ventilator management. In the early phase of this pandemic, the risk of disease spread lead to the development of conservative guidelines which advocated delaying tracheostomy at least two to three weeks from intubation and, preferably, with negative COVID-19 testing. The morbidly obese patient population, however, presents a unique scenario in which early tracheostomy may be beneficial. In this article, we discuss our institution’s current practices along with clinical outcomes with reference to intensive care literature and propose that early tracheotomy in COVID-19 patients should be considered on a case by case basis.

The goal of this systematic review was to define a consensus within the current literature regarding the impact/effect of cannabis or cannabinoids on the treatment of patients with head and neck cancer. We conducted a review of PubMed, Embase, and Web of Science databases, using a comprehensive search strategy, focusing on articles relating to head & neck cancer and cannabis/cannabinoids without a time limit for publication. Two, independent reviewers screened articles based on title/abstract and included the ones selected by both. We then conducted a full-text review and excluded all articles which did not meet inclusion criteria. A single reviewer then assessed studies for methodological quality and extracted relevant data using a premade data collection tool. We identified five studies that met inclusion criteria. Studies were of varying quality and the majority investigated recreational cannabis use with only one study reporting dosing across participants. Lack of standardized cannabis exposure presents a wide array of potential confounding variables across the remaining studies. Meta-analysis was not attempted due to variability in reported outcomes. It is impossible to draw any conclusions regarding the benefit or adverse effects of current medical cannabis products in this patient population. The literature regarding the effect of cannabis/cannabinoids on head & neck cancer patients is limited. However, the current lack of evidence does not definitively disprove the efficacy of cannabis. High-quality studies are necessary for physicians to provide advice to patients who are either using or interested in cannabis as an adjunctive treatment.

Background Risk stratification and appropriate treatment selection are essential for the management of head and neck malignancies, in order to optimize long-term outcomes. Salivary gland carcinomas (SGCs) pose a particular challenge due to their extensive biologic heterogeneity. Primary surgical resection remains the mainstay of treatment; however, outcomes with single modality therapy for 'non-high-risk' lesions are less elucidated in the literature present on the subject. We present our experience with non-high-risk salivary gland malignancies treated by surgery alone. Methods A retrospective analysis of SGCs from 1998-2011 was completed after receiving Institutional Review Board approval. Patient demographic, tumor, treatment, and outcome data were obtained from chart review. The primary outcomes of interest were overall survival (OS) and recurrence-free survival (RFS). Results Of the 62 patients identified, 49 patients underwent resection of the primary tumor alone, while an ipsilateral selective neck dissection was included for 13 patients. The median follow-up was 5.05 years. Of the tumors, 79% were low-intermediate grade, 3% high grade, and 17% poorly classified. The OS and RFS were 91% and 87% at five years and 80% and 79% at 10 years, respectively. The combined failure rate of local, regional, and distance was 13%. Conclusion Surgery alone is an appropriate treatment strategy for patients with non-high-risk salivary gland malignancy, affording a high likelihood of long-term RFS and OS.

Objective Despite increasing recognition of the importance of functional outcomes for patients with head and neck cancer, post‐treatment neck fibrosis remains poorly understood. We sought to develop and validate a patient reported outcome measure for head and neck cancer patients with neck fibrosis. Study Design Prospective multiphase cross‐sectional study. Methods To guide instrument development, we employed the World Health Organization International Classification of Functioning, Disability and Health as our conceptual framework. Items were generated using a composite strategy consisting of patient focus groups, literature review, and expert opinion from a multidisciplinary group. Candidate items were reduced through the item impact method. Preliminary psychometric properties of the finalized instrument were evaluated through measures of internal consistency, test–retest reliability, and construct validity. Results Four in person focus groups were held with 13 head and neck cancer patients. The process of item generation led to 221 relevant citations and 68 unique items. An additional 17 items were identified from review of existing neck disability questionnaires and expert opinion. A draft instrument with 25 candidate items was generated and reduced to its final 15‐item scale using item impact method. Early psychometric testing revealed excellent internal consistency (Cronbach's alpha = 0.95) and test–retest reliability [ICC = 0.95]. Internal consistency at the item level was good (>0.7) for 11/15 individual items. Four separate constructs were evaluated. Three of the four constructs matched our a priori hypotheses. Conclusion The Neck Fibrosis Scale demonstrates preliminary reliability and validity for discriminate use. Further research is needed to confirm dimensionality and assess responsiveness. Level of Evidence NA Laryngoscope , 132:1015–1021, 2022

Testicular choriocarcinoma (CC) is a malignant germ cell tumour which most frequently presents with disseminated metastasis, often involving the lungs, brain and liver. Metastatic are characterised by extensive vascularity, often causing patients to present emergently with potentially life-threatening haemorrhagic complications. We report a patient with disseminated testicular CC, presenting with haemorrhage from a dermal metastatic focus involving the lower lip and mentum, requiring surgical intervention. This unique case illustrates the potential utility of palliative surgery, for the management of symptomatic metastatic disease, such as those caused by testicular CC.

There is a narrow window of opportunity between surgical scheduling and the operative date to optimize patients for an elective surgical procedure. Traditionally, preoperative care has involved extended routine testing batteries with intermittent referrals for medical clearance. These traditions are costly, inefficient, and yield no clear reduction in perioperative morbidity and mortality. Evidence, which has evolved over the past decade, suggests that optimal preoperative care requires a patient‐centric, personalized, and often multidisciplinary approach. We present an up‐to‐date overview of this literature with a focus on the otolaryngologic surgical population. An algorithmic approach to preoperative patient assessment is also proposed in hopes of both optimizing patient outcome and streamlining routine clinical workflow. Laryngoscope , 130:38–44, 2020