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This case report describes a patient with intellectual disability who presented with a neglected midline nasal mass eroding the anterior skull base, which was found to be a Grade II meningioma likely of the olfactory bulb. Points of interest include differential diagnosis of this atypical mass of the sinonasal tract, as well as decision-making in balancing appropriate management and quality of life in a patient with developmental delay who could not make decisions for herself. Literature review regarding the role of adjuvant radiation based on final diagnosis and extent of disease suggests that radiation can improve locoregional control and overall survival with atypical meningioma. Lack of clear information in the literature on these rare conditions can lead to poor understanding on the part of the treatment team and the healthcare proxies who are making decisions, making goals of care discussions and medical decision-making challenging. This case report seeks to add to the available data on management of atypical meningiomas of the sinonasal tract and olfactory bulb.

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Carcinoma ex pleomorphic adenoma (CXPA) is an epithelial malignancy that transforms from benign pleomorphic adenomas (PA) at a rate of 1.5% after 5 years and 10% after 15 years. The average age of reported nasopharyngeal CXPA is 56.7 years. However, the present case describes a 19-year-old making this case exceptionally rare. Standard treatment is wide local excision with adjuvant treatment. We report the demographics, presentation, treatment, and outcomes of 8 cases of nasopharyngeal CXPA. While surgical excision is the mainstay of treatment, negative margins can be difficult to obtain at the skull base, and we report a recurrence rate of 50% in nasopharyngeal primaries. Due to the aggressive nature of the disease and high rate of recurrence, the majority of patients in our review received adjuvant radiation with some receiving adjuvant chemotherapy in addition.

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This study sought to improve nursing staff understanding regarding the differences in postoperative management between patients who have undergone tracheostomy and laryngectomy. The intervention involved a brief didactic session followed by the placement of an informative poster and anatomic diagram above the bed of tracheostomy and laryngectomy patients over a 6-month period. Data were collected before and after the didactic session and poster implementation. Of the 50 nurses surveyed, 32% believed oral ventilation is appropriate for laryngectomy patients compared to 0% of nurses after the intervention. The percentage of nursing staff reporting self-assessed clear understanding of the patient care differences between laryngectomy and tracheostomy improved after the intervention. The use of informational posters and didactic sessions significantly improves nursing staff understanding of the differences between tracheostomy and laryngectomy patients. Level of Evidence: IV.

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To detail the early experience with and results of a transfeminine (TF) genital reconstruction at an established plastic surgery practice in Western New York. METHODS: Between June 2016 and June 2019, 30 patients underwent penile inversion vaginoplasty for TF gender reassignment. All patients fulfilled World Professional Association for Transgender Health and NY State criteria for reassignment surgery. All surgeries were carried out at a large, government-owned tertiary care center. RESULTS: There were 30 patients in this retrospective study, with a mean age of 37 years (SD 5.4) and a mean body mass index of 27.3 kg/m2 (SD 3.2 kg/m2). Nineteen patients never smoked, 4 were former smokers, and 7 were current smokers. Primary surgery was an orchiectomy and modified single-stage penile inversion vaginoplasty. Mean operative time was 6.0 hours. Mean initial hospital stay was 8.2 days. Three of the 30 (10%) patients required transfusion. There were 6 (20%) complications. Three complications (10%) required reoperation: 1 patient for wound dehiscence on postoperative day 7, 1 for rectal perforation identified on postoperative day 10, and 1 for urethrovaginal fistula. All complications were addressed without sequalae. Twenty of the 30 (66%) patients have undergone revision surgery. Indications for revision were prolapse correction/deepening, labiaplasty, clitoral hood construction/revision, meatal asymmetry, urinary fistula repair, and posterior vaginal flap revision. Twenty-one of 28 (75%) revisions were outpatient surgeries. There were no complications from these procedures. Overall satisfaction via survey was 92% (24 respondents). CONCLUSIONS: TF gender reassignment is a novel, challenging set of procedures for the specialty of plastic surgery. With appropriate consideration and technique, penile inversion vaginoplasty is a safe, effective means of achieving this goal.

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OBJECTIVES/HYPOTHESIS: The indications for and efficacy of induction chemotherapy in the management of squamous cell carcinoma of the head and neck is controversial. With the advent of human papillomavirus (HPV)-related cancers, survival has improved significantly. Here we present a group of patients with tonsil cancer treated with induction chemotherapy followed by surgery. STUDY DESIGN: Retrospective cohort study. METHODS: Thirty-eight patients with tonsil cancer were treated with induction chemotherapy, consisting of cisplatin and docetaxel, followed by neck dissection and radical tonsillectomy. Twenty-six patients were HPV+, 28 were nonsmokers or long-term former smokers, and 28 were T1/T2. Fourteen patients required postoperative chemoradiotherapy (CRT). Median follow-up time was 4.1 years. RESULTS: A complete response to induction chemotherapy was achieved in 45% (17) of patients. In total, 76% (29/38) of patients were successfully treated: 53% (20/38) with chemotherapy and surgery alone, and 24% (9/38) required postoperative CRT. Almost 90% (23/26) of HPV+ and half (6/12) of HPV- patients are no evidence of disease (NED). HPV status is a significant prognostic factor (P = .02). Only 38% (5/13) of current smokers were NED compared to 96% (24/25) of nonsmokers (P = .0002). All HPV+ nonsmokers (20/20) were NED at last follow-up. CONCLUSIONS: In this study, the primary driver of prognosis was smoking status. HPV status and T stage were also important. The prognosis for HPV+ nonsmokers is extremely good; most likely regardless of treatment. Treatment failures have a poor chance of salvage, irrespective of treatment type. With the major exception of HPV- smokers, induction chemotherapy followed by surgery with selective CRT is a viable treatment option for tonsil cancer. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1206-1211, 2020.

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BACKGROUND AND OBJECTIVES: The management of the clinically N0 (cN0) neck is controversial for early stage squamous cell carcinoma of the oral cavity (OSCC). This paper represents a single institution series analyzing the efficacy of sentinel lymph node biopsy (SNB) for early stage oral cavity cancers. METHODS: From 2005 to 2017, 108 patients with cN0 OSCC were treated with primary resection and SNB. Patients with positive biopsy results proceeded to neck dissection with or without adjuvant chemoradiotherapy. Mean follow-up for the entire cohort was 50.8 months (range: 8-147 months). Clinically, 56 patients were T1N0, 49 patients were T2N0, and three patients were T3N0 or greater. RESULTS: Disease-specific survival was 93% within the entire cohort. Sentinel lymph nodes were identified in 95.4% of patients. Twenty one patients had a positive biopsy. There were seven false-negative biopsies. The overall rate of nodal disease was 26%. Accuracy of node biopsy was 93%, with sensitivity of 75%, and negative predictive value of 91%. Recurrence rate was 19% (20/108), with an overall survival of 60% in this subgroup. CONCLUSION: SNB is a safe, effective, and well tolerated method for staging cN0 OSCC.

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BACKGROUND: A 270-degree partially tubed pectoralis major myocutaneous flap (PMMF) is an excellent option for total circumferential pharyngoesophageal defects in patients who are not candidates for more complex reconstructions. METHODS: Patients undergoing circumferential pharyngoesophageal reconstruction with partially tubed PMMF were reviewed. End points were stricture, fistula, resumption of oral intake, perioperative death, and recurrence. RESULTS: Eleven patients underwent 270-degree PMMF for reconstruction: 6 (55%) were men and 5 (45%) were women (mean, 62 years; range, 42-78 years). Three patients (27%) developed fistulas and 2 (18%) developed stenosis. Ten patients (91%) were able to resume adequate nutrition via oral intake. There were no perioperative deaths. CONCLUSIONS: Patients with severe comorbidities, metastatic disease, a lack of donor vessels, or a potentially hostile abdomen may not be ideal candidates for free tissue transfer. For these patients, partially tubed PMMF using the prevertebral fascia provides a reliable alternative for reconstruction with excellent functional results.

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BACKGROUND: The purpose of this study was to quantify the effect of treatment duration on locoregional progression after definitive concurrent chemoradiation (CCRT) for squamous cell carcinoma of the head and neck (SCCHN). METHODS: We conducted a retrospective chart review of patients treated between 2004 and 2010. After a prior analysis, measures were taken to limit therapy beyond 7 weeks. Comparison of outcomes were made between cohorts 1 (2004-2007, n = 78) and 2 (2007-2010, n = 62). RESULTS: Median therapy duration was statistically significantly different between cohorts as follows: 51 days, cohort 1 and 46 days, cohort 2 (p < .01). Locoregional progression in cohorts 1 and 2 was 19% and 5% (p = .01), respectively. On multivariate analysis, patients with prolonged treatment (≥57 days) had an 8-fold increase in risk of locoregional progression compared to patients who completed on time (p < .01). CONCLUSION: Treatment duration was a significant predictor of locoregional progression in patients with SCCHN who received definitive CCRT.

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Case presentation and literature review for intestinal malrotation presenting in an adult. Although the number of patients with this condition that escape infancy undiagnosed is not clear, it is clear that when the rare patient presents as an adult it can be a perplexing situation for surgeons not familiar with the presenting signs and anatomy. This confusion can lead to diagnostic and intraoperative errors.

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BACKGROUND: Ventilator-associated pneumonia (VAP) is diagnosed in about 30% to 50% of critically ill postsurgical and trauma patients. Early appropriate antibiotic therapy has been associated with improved survival rates. The diagnosis, however, continues to be a challenge. We routinely employ clinical pulmonary infection scores to warrant a bronchoalveolar lavage (BAL) quantitative culture to subsequently diagnose VAP. Presumptive antibiotic therapy for the first 48 to 72 hours is based on the sputum Gram stain, obtained at the time of BAL. This study was conducted to analyze the predictive value of sputum Gram stain for selecting appropriate early antibiotic therapy for VAP as confirmed by a BAL quantitative culture (>10 CFU/mL considered diagnostic). METHODS: The retrospective analysis included 124 consecutive intensive care unit patients with 186 identified episodes of presumed VAP from December 2002 to June 2006. VAP episodes were identified by a clinical pulmonary infection score > or =6, availability of a sputum Gram stain, and a corresponding quantitative culture result from a BAL sample. RESULTS: The overall correlation between Gram stain and subsequent organism identified on the BAL quantitative culture was only fair with a kappa score of 0.314. The best predictive value calculated was for the category of negative Gram stain. However, in 10 of 45 episodes where the sputum Gram stain did not identify a predominant organism, the BAL culture isolated pathogenic strains. Pseudomonas sp. was the most common bacteria isolated from the BAL samples. CONCLUSIONS: Irrespective of sputum Gram stain, presumptive triple antibiotic coverage should be instituted to provide dual antibiotic coverage for gram-negative bacilli, and vancomycin for gram-positive cocci. Additionally, identification of no organisms in the sputum Gram stain should still prompt broad-spectrum antibiotic coverage until the final results of the BAL quantitative culture are available.

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PURPOSE: The aim of this study was to develop new nonoperative strategies for the management of meconium ileus in an attempt to improve on the current unacceptable failure rate. METHODS: Mice were constipated with subcutaneous morphine injection. Each then received an enema solution (perflubron, surfactant, Tween-80, Gastrografin, Golytely, DNase, N-Acetylcysteine, Viokase, or normal saline). After the enema solution was administered, stool output was quantitated. Histologic examination of the intestines was performed on a second group of mice that also received enemas. Finally, viscosity measurements were taken of human meconium at baseline and after variable incubation periods with each test solution. RESULTS: For relieving constipation in vivo, Gastrografin enema was most efficacious. All agents were equally benign to the intestinal mucosa. In vitro, only 4% N-Acetylcysteine and perflubron were less effective at decreasing meconium viscosity than normal saline at T = 0 hours, with N-Acetylcysteine producing greater reduction in viscosity than normal saline at T = 6 hours. CONCLUSIONS: Our results show that surfactant and Gastrografin are the most effective for the in vivo relief of constipation. This is accomplished without mucosal damage. These agents also significantly reduce viscosity in vitro, and we speculate that they may be beneficial in relieving constipation caused by meconium ileus in cystic fibrosis patients.

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