10:40 AM

11:40 AM Additional Palatal Implants for Refractory Snoring Peter J Catalano, MD (presenter); John H Romanow, MD Burlington MA OBJECTIVE: Palatal implants for the treatment of snoring have been shown to be effective based upon bed-partner satisfaction. Despite this success, some bed-partners are not satisfied with the patients’ reduction in snoring intensity after implantation. This prospective multi-center study evaluates the safety and efficacy of additional palatal implants in snorers who did not respond to the initial procedure. METHODS: Fifty patients treated with three palatal implants and who continue to snore were included. All procedures were performed in an office setting using local anesthesia. Snoring was evaluated by the bed-partner using a 10 centimeter visualanalog scale. These questionnaires were obtained at baseline

SCIENTIFIC SESSION ORALS: HEAD AND NECK SURGERY 10:30 AM to 12:00 PM MTCC Room 715AB 䡲 Moderators: Amelia F Drake, MD; David J Terris, MD 10:32 AM Vascular Anatomy Analysis of Anterolateral Thigh Free Flaps Kavita Malhotra, MD (presenter); Vinaya Kedar Chakradeo, MBBS MD; Timothy S Lian, MD Shreveport LA OBJECTIVE: 1. Understand the vascular anatomy of the anterolateral thigh free flap. 2. To anatomically determine if including a 2 cm cuff of vastus lateralis muscle (VLM) incorporates musculocutaneous perforators in the harvest of the anterolateral thigh free flap (ALT). METHODS: Twenty-seven cadaver thighs were dissected. Musculocutaneous perforators from the vascular pedicle of the ALT free flap were identified. The distance from the anterior border of the VLM to the point where perforators entered the muscle was measured. RESULTS: An average of four musculocutaneous perforators to the ALT free flap were identified per thigh. The distance from the anterior border of the VLM to the point where perforators entered the muscle ranged from 0.1 cm to 7 cm with the mean distance being 1.72 cm; 64.86 percent of perforators entered the VLM within 2 cm of the muscle’s anterior border. At least one perforator entered the VLM within 2 cm of the muscle’s anterior border per thigh.

P65 and 90 days after the three initial implants. Snorers were treated with a fourth implant and evaluated via bed-partner questionnaire after 90 days; persistent snorers received a fifth implant and a final questionnaire after another 90 days. RESULTS: Patient age ranged from 24-67 years; BMI ranged from 23-32. Two complications were observed postprocedure (partial extrusion of a 4th implant), which were easily resolved. Lateral positioning of the additional implants (right or left of the initial implants) did not adversely effect outcomes. Bedpartner responses demonstrate a reduction in snoring intensity with additional implants. CONCLUSIONS: Palatal implants for the treatment of socially unacceptable snoring have been shown to be safe and effective. This study demonstrates that one or two additional implants may offer relief for those snorers who do not have acceptable reduction in snoring intensity according to their bed-partner without increased risk of adverse events.

CONCLUSIONS: Most musculocutaneous perforators to the ALT free flap enter the VLM within 2 cm of the muscle’s anterior border, thus providing for an anatomical basis for including a 2 cm cuff of VLM when harvesting the ALT free flap. By including a 2 cm cuff of VLM, the tedious dissection of individual musculocutaneous perforators is unnecessary, thereby increasing the ease of dissection and expediting the harvest of the ALT free flap.

10:40 AM Descending Necrotizing Mediastinitis: Treatment and Outcome Gerd Jurgen Ridder, MD (presenter); Susanne Kinzer, MD; Wolfgang Maier, MD; Carsten Christof Boedeker, MD Freiburg Germany; March-Holzhausen Germany OBJECTIVE: Descending necrotizing mediastinitis (DNM) results from oropharyngeal, odontogenic, and deep neck space infection spreading along the fascial planes into the mediastinum. The different surgical approaches are still controversial. The aim of this study is to evaluate the results of DNM treated primarily by cervicotomy. METHODS: Retrospective single-center study of 27 patients with DNM treated between 1997 and 2005. There were 19 male and 8 female patients. The mean age was 49.9 years (26 – 81 years). RESULTS: In 14 cases, the DNM was caused by a parapharyngeal abscess. Other causes included iatrogenic perforation of the hypopharynx or esophagus, hypopharyngeal foreign bodies (n⫽4 each), as well as odontogenic and peritonsillar abscesses (n⫽2 each). Twelve patients had underlying diseases such as diabetes mellitus, malignant tumors, or substance abuse. The mean duration of hospitalization was 27 days. In addition to a cervical mediastinotomy, all abscesses were drained by either a transcervical or intraoral approach. A cer-

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Otolaryngology-Head and Neck Surgery, Vol 135, No 2S, August 2006

vico-mediastinal approach in combination with thoracotomy was performed in only three cases. The mortality rate in our study was 11.1% (n⫽3). CONCLUSIONS: Early diagnosis and aggressive surgical treatment are required to improve the poor prognosis of DNM. The presenters prefer a wide approach consisting of a cervical drainage and mediastinotomy. Postoperative care in an ICU setting is mandatory. Follow-up by CT or MRI as well as revision of the operative procedure are needed in patients that do not improve after initial surgery. In the presenters’ experience, the invasive procedure of thoracotomy makes the prognosis worse in patients in poor general condition. 10:48 AM Utility of Panendoscopy for Unknown Primary and Negative PET Michael Albert Goodier, MPH (presenter); Amol Takalkar, MD; David L Lilien, MD; Timothy S Lian, MD; Todd A Kupferman, MD; Cherie Ann O Nathan, MD Shreveport LA OBJECTIVE: 1. To assess the cost-effectiveness of performing a panendoscopy in HNSCC patients with an unknown primary after a PET or CT/PET failed to reveal the primary. METHODS: Retrospective chart review in 23 patients with cervical nodal metastasis and an unknown primary after physical examination, fiberoptic endoscopy, and CT scan were negative in detecting the primary. All patients underwent PET or PET/CT scan followed by panendoscopy with biopsy. RESULTS: PET revealed the primary in 14 out of 23 (61%) patients confirmed on panendoscopy and biopsy. Panendoscopy with biopsies plus/minus tonsillectomy on the remaining 9 patients revealed the primary in only 1 (11%) patient in the BOT. CONCLUSIONS: PET has a fairly high negative predictive value (89%) and the yield in determining the primary with a panendoscopy plus/minus tonsillectomy in patients with a negative PET is low. In this era of cost-management and advances in imaging it is important to revisit the traditional work-up for an unknown primary with a negative PET. 10:58 AM Prevalence and Patterns of RLN Monitoring in Thyroid Surgery Stefanie K Horne, MD (presenter); Thomas J Gal, Jr, MD MPH; Joseph Brennan, MD Lackland AFB TX; San Antonio TX OBJECTIVE: To estimate the patterns of use of intraoperative recurrent laryngeal nerve (RLN) monitoring devices during thyroid surgery by otolaryngologists in the United States. METHODS: A questionnaire was mailed to 1,685 randomly selected otolaryngologists, representing approximately half of all otolaryngologists currently practicing in the United States. Topics covered include training history and current practice

setting, use and characteristics of use of RLN monitoring during thyroid surgery, as well as history of RLN injury and/or subsequent lawsuits. Chi square test was used to examine associations between monitor usage and dependent variables, and odds ratios calculated by logistic regression were utilized to refine the magnitude of these associations. RESULTS: Some 685 questionnaires were returned (40.7%), and 81% (555) of respondents reported performing thyroidectomy. Of those, only 28.6% (159) reported using intraoperative monitoring for all cases. Respondents were 3.14 times more likely to currently use intraoperative monitoring if they used it during their training. Surgeons currently using intraoperative RLN monitoring during thyroidectomy were 41% less likely to report a history of permanent RLN injury. Further information about surgeon background and rationale for decisions regarding RLN monitor usage are discussed. CONCLUSIONS: While the incidence of RLN injury from thyroidectomy ranges from 0.5% to 5%, no studies to date demonstrate reduced complication rates with the use of intraoperative RLN monitoring. Presently, the majority of otolaryngologists in the United States do not report regular usage of RLN monitoring in their practices. Surgeon background and training, more so than surgical volume, significantly influenced the use of intraoperative RLN monitoring. 11:06 AM Dysphagia in Patients Treated for Oropharyngeal Cancer Stacey Leigh Smith, MD (presenter); Amy Clark Hessel, MD Houston TX OBJECTIVE: The treatment of stage IV oropharyngeal cancer with radiation or chemoradiation is dependent on the need for radio-sensitizers and increased distant metastatic risk. In lowvolume disease patients, it is uncertain whether chemoradiation adds a survival benefit; yet the long-term functional side effects are largely unknown. This study attempts to determine the incidence of dysphasia and differences between treatment modalities. METHODS: This is a retrospective review of T1/T2 oropharyngeal squamous cell carcinoma patients with N2a/N2b lymphadenopathy treated at a tertiary care institution between 2000 and 2004. Medical records were reviewed for treatment information, pre- and post-treatment swallowing, the presence or absence of feeding (PEG) tubes, and diet status. RESULTS: 116 charts were reviewed: 85 received radiation alone (RT) while 31 received combined chemoradiation (CRT). The overall survival rate was 92%. Of the CRT patients, 72% required PEG tube placement during treatment, while only 41% of the RT group required PEG tubes. However, 88% of both groups had the PEG removed and returned to an oral diet. Only 53% received swallowing evaluation. Results revealed pretreatment pain-related difficulties, while, post-treatment, there was moderate pharyngeal dysfunction. Only 17% received MBS that revealed variable degrees of