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BackgroundTransoral thyroid surgery is an ideal method for minimally invasive thyroidectomy, as there is less flap dissection during the procedure and no postoperative scars. Nonetheless, technical obstacles have precluded the wide dissemination of this procedure. We present the surgical procedures and outcomes of transoral robotic thyroidectomy (TORT).MethodsFrom September 2012 to June 2016, we performed TORT at Korea University Hospital. We used three intraoral ports and a single axillary port for the system’s four robotic arms. The surgical outcomes were retrospectively reviewed.ResultsTwenty-four female patients (mean age 39.6 ± 11.6 years; mean tumor size 1.0 ± 1.3 cm) underwent unilateral thyroid lobectomies with or without ipsilateral central neck dissection. Twenty patients had papillary thyroid carcinomas (PTC), three had benign nodules, and one had a follicular thyroid carcinoma. The mean surgical time was 232 ± 41 min; the mean hospital stay was 3.3 ± 0.8 days. The number of retrieved central lymph nodes in the PTC patients was 4.7 ± 3.2. There were no reports of transient or permanent vocal cord palsy, recurrence, or mortality during the median follow-up period of 16.8 months. Paresthesia of the lower lip and the chin due to mental nerve injury was observed in nine of the first 12 patients (six transient, three permanent), but no further reports of paresthesia were recorded after patient 12, when the locations of the intraoral incisions were modified.ConclusionsTORT is feasible and safe for selected patients after technical refinements, and can be a potential alternative approach for scarless thyroid surgery.

Iatrogenic nerve injury is a surgical complication with significant morbidity. This clinical trial, now complete, investigates the systemic administration of bevonescein, which selectively binds to nerves, in a single-arm, prospective multi-center, dose-escalation Phase 1 trial in adult patients with head and neck neoplasms undergoing parotidectomy or thyroidectomy in the United States. Twenty-seven participants are enrolled in the trial and receive the systemic agent. The primary outcome is safety with no dose-limiting toxicity among the 27 patients, but a single adverse event was identified that was possibly related to the study drug (vomiting). Secondary outcomes include the pharmacokinetics, optimal dose, and timing of bevonescein. The half-life of bevonescein is 29–72 min, and the optimal dose is 500 mg by objective measures, with the fluorescence signal-to-background ratio (SBR; 2.1 ± 0.8) significantly higher compared to white light (1.3 ± 0.2; p  = 0.003). The fluorescent SBR of nerves between the early (1–3 h) versus late (3–5 h) timing cohorts is not statistically different. Here, we present data of a nerve imaging agent showing that preoperative intravenous infusion of bevonescein is well tolerated. This trial is registered at ClinicalTrials.gov (NCT04420689) and is sponsored by Alume Biosciences (San Diego, CA). Surgical nerve injuries can cause significant morbidity, yet no approved fluorescent agents exist for visualization. Here, the authors show in a Phase I multi-site trial that bevonescein was safe, established optimal dosing and timing, and provided a fluorescence signal for intraoperative nerve identification.

Objectives The robotic retroauricular approach and transoral endoscopic thyroidectomy vestibular approach (TOETVA) have been employed to avoid anterior neck scarring in thyroidectomy with good success. However, outcomes have yet to be compared between techniques. We compare our initial clinical experience with these approaches for thyroid lobectomy at our institution. Methods A review of initial consecutive patients who underwent robotic facelift thyroidectomy (RFT) (August 2011–August 2016) at our institution was conducted. This was compared with the same number of initial consecutive patients who underwent TOETVA (September 2016–September 2017) at our institution. Demographics, operative time, pathology, complications, and learning curve were compared between cohorts. Learning curve was defined based on the slope of linear regression models of operative time versus case number. Results There were 20 patients in each cohort. There was no statistically significant difference in demographic data between cohorts. One hundred percent of RFT cases versus 95% TOETVA cases (P = .999) were completed without conversion to standard open technique with median operative times of 201 (124–293) minutes versus 188 (89–343) minutes with RFT and TOETVA, respectively (P = .36). There was no incidence of permanent recurrent laryngeal nerve injury in either cohort. The slopes of the regression models were 0.29 versus −8.32 (P = .005) for RFT and TOETVA, respectively. Conclusion RFT and TOETVA are safe and feasible options for patients motivated to avoid an anterior neck scar. However, the quicker learning curve without the need for a costly robotic system may make TOETVA the preferred technique for institutions wishing to perform anterior cervical incision‐sparing thyroidectomy. Level of Evidence 4

IntroductionThe Transoral Neck Surgery (TONS) Study Group was established at the 1st International Thyroid NOTES Conference in February 2016 with the intention of standardizing and refining thyroid NOTES techniques, including both transoral endoscopic and robotic thyroidectomy approaches. Herein, the authors report the modification of indications, preparation, and step-by-step explanations for operative techniques, as well as results and postoperative care for transoral endoscopic thyroidectomy vestibular approach (TOETVA).MethodsBetween February 2015 and December 2015, a total of 200 patients comprising 8 males (4%) and 192 females (96%) underwent TOETVA using 3 laparoscopic ports inserted at the oral vestibule. Of these patients, 111 presented with single thyroid nodules (55.5%), while 66 patients had multinodular goiters (33%), 12 had Graves’ disease (6%) and 11 had papillary microcarcinoma (5.5%). The CO2 insufflation pressure was maintained at 6 mmHg. Each surgery was performed using laparoscopic instruments and ultrasonic devices.ResultsTOETVA was performed on 200 consecutive patients. No conversion to conventional open surgery was necessary. Average tumor size was 4.1 ± 1.78 cm (1–10 cm). Median operative time was 97 ± 40.5 min (45–300 min). Median blood loss was 30 ± 46.25 mL (6–300 mL). Mean visual analog scale measurements were 2.41 ± 2.04 (2–7), 1.17 ± 1.4 (0–5), and 0.47 ± 0.83 (0–3) on the first, second, and third days, respectively. Temporary hoarseness and hypoparathyroidism occurred in 8 patients (4%) and 35 patients (17.5%), respectively. No permanent hoarseness or hypoparathyroidism occurred. Mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma that required open surgery. No infection was identified.ConclusionTOETVA was shown to be safe and feasible with a reasonable surgical duration and minimal pain scores. This approach shows promise for those patients who are motivated to avoid a neck scar.

Objectives The submental island flap can be used to reconstruct defects of the oral cavity and oropharynx. The objective of this study is to describe functional outcomes after this reconstruction. Methods Retrospective chart review was performed for 82 patients who underwent submental flap reconstruction of oral cavity cancer defects and 11 with oropharyngeal cancer defects. Primary outcomes were feeding tube use at last follow‐up and time from surgery to first oral intake. The secondary outcome was the need for tracheostomy. Results Feeding tube use at last follow‐up was 9% in the oral cavity group and 36% in the oropharynx group. Median time to oral intake was 7 days in both groups. Tracheostomy was avoided in 87% of oral cavity patients and in 46% of oropharynx patients. In regression analysis of the entire cohort, the outcomes of persistent feeding tube use at last follow‐up and tracheostomy were associated with the following variables: prior irradiation, oropharyngeal primary site, and adjuvant treatment status. Among the oral cavity group, prior irradiation was associated with persistent feeding tube use. Conclusion The submental flap can be used in a wide range of oral cavity and oropharyngeal defects, even in elderly patients. This flap can be performed for oral cancers with avoidance of tracheostomy in most cases and reliable resumption of oral diet. Level of Evidence 4

Objective Describing the use of the submental island flap (SMIF) for reconstruction for maxillectomy defects in elderly patients with regard to surgical and postoperative outcomes. Methods This retrospective single‐center cohort study included patients > 70 years old (n = 8) with oral cavity cancers, treated between July 2017–December 2024. All underwent partial maxillectomy and SMIF reconstruction. Collected data included patient demographics, tumor characteristics, intraoperative details, time to oral diet initiation, and tracheostomy need. Main outcomes were perioperative and functional outcomes including operative time and oral diet initiation. Results Among the eight identified cases: four patients were male and four female, with an average age of 83.0 years (SD 8.6). Primary tumor sites included the retromolar trigone (n = 1), buccal mucosa (n = 3), maxillary alveolus (n = 3), and hard palate (n = 1). Most tumors were stage T3/4 due to bony involvement, with an average size of 3.5 cm in the largest dimension (SD 0.8). Neck dissections were performed in all cases, with one patient having positive lymph nodes. SMIF sizes ranged from 4 × 6 cm to 15 × 8 cm. Average surgical time was 233.5 min (IQR 22.3–244.8) and tracheostomy was not required for any patients. All patients initiated an oral diet postoperatively, with time to oral nutrition ranging from 3 to 7 days (median 6.5 days, IQR 5.3–7). Conclusion The SMIF is a useful alternative for reconstructing maxillectomy defects in elderly patients. This series demonstrates early oral intake, avoidance of tracheostomy, and relatively short operative times, making it a promising option for patients ineligible for more complex reconstructive procedures. Level of Evidence IV

Sinonasal malignancies represent a rare subset of tumors with a wide variety of histopathologic diagnoses and overall poor prognosis. These tumors tend to have an insidious onset with non-specific symptoms which often leads to delayed diagnosis and advanced local disease at presentation. The principal goal of surgery is to obtain a negative margin resection. Open craniofacial techniques are well established in the management of sinonasal malignancies and remain the treatment of choice for many advanced tumors. Over the past couple of decades, there has been tremendous application of endoscopic techniques to skull base pathologies including sinonasal malignancies. For selected cases, endonasal endoscopic techniques can be performed with curative intent and reduced surgical morbidity and mortality. Here we discuss principles of surgical management of sinonasal malignancies, review the techniques of endonasal endoscopic resection of sinonasal malignancies, and highlight the importance of pathology in the multi-disciplinary management of patients with these complex lesions.

The prophylactic placement of a percutaneous endoscopic gastrostomy (PEG) tube in the head and neck cancer (HNC) patient is controversial. We sought to identify factors associated with prophylactic PEG placement and actual PEG use. Since 2010, data regarding PEG placement and use were prospectively recorded in a departmental database from January 2010 to December 2012. HNC patients treated with intensity-modulated radiation therapy (IMRT) were retrospectively evaluated from 2010 to 2012. Variables potentially associated with patient post-radiation dysphagia from previous literature, and our experience was evaluated. We performed multivariate logistic regression on these variables with PEG placement and PEG use, respectively, to compare the difference of association between the two arms. We identified 192 HNC patients treated with IMRT. Prophylactic PEG placement occurred in 121 (63.0 %) patients, with PEG use in 97 (80.2 %) patients. PEG placement was associated with male gender ( p  < .01), N stage ≥ N2 ( p  < .05), pretreatment swallowing difficulties ( p  < .01), concurrent chemotherapy ( p  < .01), pretreatment KPS ≥80 ( p  = .01), and previous surgery ( p  = .02). Concurrent chemotherapy ( p  = .03) was positively associated with the use of PEG feeding by the patient, whereas pretreatment KPS ≥80 ( p  = .03) and prophylactic gabapentin use ( p  < .01) were negatively associated with PEG use. The analysis suggests there were discrepancies between prophylactic PEG tube placement and actual use. Favorable pretreatment KPS, no pretreatment dysphagia, no concurrent chemotherapy, and the use of gabapentin were significantly associated with reduced PEG use. This analysis may help refine the indications for prophylactic PEG placement.

Background There is a rare need for postoperative non‐invasive positive pressure ventilation (NIPPV) following microvascular reconstruction of the head and neck. In midface reconstruction, the free flap vascular pedicle is especially vulnerable to the compressive forces of positive pressure delivery. Case A 60 year old female with Amyotrophic Lateral Sclerosis (ALS) presented with squamous cell carcinoma of the anterior maxilla, for which she underwent infrastructure maxillectomy and fibula free flap reconstruction. To avoid tracheotomy, the patient was extubated postoperatively and transitioned to NIPPV immediately utilizing a full‐face positive pressure mask with a soft and flexible sealing layer. The patient was successfully transitioned to NIPPV immediately after extubation. The free flap exhibited no signs of vascular compromise postoperatively, and healed very well. Conclusion Postoperative non‐invasive positive pressure ventilation can be successfully applied following complex microvascular midface reconstruction to avoid tracheotomy in select patients without vascular compromise of the free flap.