Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: A review

Periodic fever,aphthous stomatitis,pharyngitis,and adenitis(PFAPA)syndrome is the most common periodic fever condition in children,with most cases appearing by the age of 5.Although PFAPA is generally a self-limited condition,it can have a major impact on a child’s quality of life,as well as that of their family.Recent research has continued to shed light on the genetic and immunologic factors that play a role in the pathogenesis of PFAPA.There also exists significant heterogeneity in treatment strategies,and progress has been made to develop evidence-based management strategies and establish a standard of care.This review will outline current knowledge regarding the pathogenesis of PFAPA,as well as treatment strategies and our clinical experience.

The effect of treatment package time in head and neck cancer patients treated with adjuvant radiotherapy and concurrent systemic therapy

Objectives:In patients with head and neck carcinoma,“treatment package time”(TPT)was proven to impact outcomes in cases receiving adjuvant radiotherapy alone.Its impact in patients receiving radiotherapy with concurrent systemic therapy has not been studied previously.The TPT influence on survival endpoints for patients treated with surgery followed by radiation and concurrent systemic therapy was analyzed.Methods:Institutional database to identify head and neck carcinoma cases treated with definitive surgery followed by concomitant chemo(bio)radiotherapy(CRT)was used.TPT was the number of days elapsed between surgery and the last day of radiation.%FINDCUT SAS macro tool was used to search for the cutoff TPT that was associated with significant survival benefit.Kaplan-Meier curves,log-rank tests as well as univariate and multivariate analyses were used to assess overall survival(OS)and recurrence free survival(RFS).Results:One hundred and three cases with a median follow up of 37 months were included in the study.Oropharyngeal tumors were 43%,oral cavity 40%and laryngeal 17%of cases.Concurrent systemic therapy included platinum and cetuximab in 72%and 28%,respectively.Optimal TPT was found to be<100 days with significantly better OS(P=0.002)and RFS(P=0.043)compared to TPT≥100 days.On multivariate analysis;TPT<100 days,extracapsular nodal extension,high-risk score,iymphovascular space and perineural invasion were independent predictors for worse OS(P<0.05).T4,extracapsular nodal extension and high-risk score were all significantly detrimental to RFS(P<0.05).Conclusions:Addition of concomitant systemic therapy to adjuvant radiotherapy did not compensate for longer TPT in head and neck squamous cell carcinoma.Multidisciplinary coordinated care must be provided to ensure the early start of CRT with minimal treatment breaks.

Management of pediatric peritonsillar and deep neck infections-cross-sectional retrospective analysis

Objective:Deep neck infections(DNI)are responsible for significant morbidity in children and healthcare expenditures.Few studies exist specifically addressing the clinical and epidemiologic characterization and management of DNI's in the pediatric population.Our goal was to analyse the demographic characteristics,clinical presentation,diagnostic and therapeutic approaches of peritonsillar and DNI in pediatric patients.Methods:The medical records of patients,aged up to 18 years,admitted for peritonsillar and DNI at our department,from 2011 to 2016,were retrospectively reviewed and compared with the literature available.Ninety-eight patients were enrolled.Results:The mean age was higher in patients with peritonsillar abscess and lower in patients with retropharyngeal and parapharyngeal infections.Admissions have significantly increased from 2011.There was a seasonal variation for DNI incidence,with a peak incidence in Summer and Spring.All patients included were treated as inpatient and received empirical intravenous antibiotic therapy and steroids regardless of drainage procedures.Incision and drainage was performed in 72 patients.The hospital length of stay was higher among patients with retropharyngeal abscess and in the group with complications.Only 2 patients developed complications during hospital stay.The most common microbiological pattern was monomicrobial and the most commonly isolated pathogens were Streptococcus Pyogenes,Streptococcus Mitisand anaerobic bacteria.Conclusions:Surgical incision and drainage followed by intravenous antibiotic and steroids proved to be successfull with low morbidity related to surgical approach.However,in selected cases,medical therapy may be an alternative to surgical management in uncomplicated infections.

Changes in otolaryngology application requirements and match outcomes:Are we doing any better?

Objectives:Otolaryngology-specific requirements were piloted to minimize applicant and program burdens.We investigated the impact of introducing and then removing these requirements on Match outcomes.Methods:2014-2021 National Resident Matching Program?data were examined.The primary outcome was the impact of Otolaryngology Resident Talent Assessment(ORTA;prematch 2017,postmatch 2019)and Program-Specific Paragraph(PSP;implemented 2016,optional 2018)on applicant numbers and match rates.Secondary survey analysis assessed candidate perceptions of PSP/ORTA.Results:Applicant numbers declined significantly during PSP/ORTA(18.9%;p=0.001).With the optional PSP and postmatch ORTA,applicant numbers increased significantly(39.0%;p=0.002).Examined individually,mandatory PSP was associated with a significant decline in applicants(p=0.007),whereas postmatch ORTA was associated with significant increases in applicants(p=0.010).ORTA and PSP negatively impacted the decision to apply to otolaryngology in 59.8%and 51.3%of applicants,respectively.Conversely,match rate success improved significantly from 74.8%to 91.2%during PSP/ORTA(p=0.014),followed by a significant decline to 73.1%after PSP was made optional and ORTA moved to postmatch(p=0.002).Conclusions:ORTA and PSP correlated with decreased applicant numbers and increased match rate success.As programs seek ways to remove barriers to applying to otolaryngology,the potential consequences of an increasing pool of unmatched candidates must also be considered.

Olfactory and gustatory dysfunctions of COVID-19 patients in China:A multicenter study

Introduction:With the spread of the epidemic worldwide,an increasing number of doctors abroad have observed the following atypical symptoms of coronavirus disease 2019(COVID-19):olfactory or taste disorders.Therefore,clarifying the incidence and clinical characteristics of olfactory and taste disorders in Chinese COVID-19 patients is of great significance and urgency.Materials and Methods:A retrospective study was conducted,which included 229 severe acute respiratory syndrome coronavirus 2 confirmed patients,through face-to-face interviews and telephone follow-up.Following the completion of questionnaires,the patients participating in the study,were categorized according to the degree of olfactory and taste disorders experienced,and the proportion of each clinical type of patient with olfactory and taste disorders and the time when symptoms appeared were recorded.Results:Among the 229 patients,31(13.54%)had olfactory dysfunction,and 44(19.21%)had gustatory dysfunction.For the patients with olfactory dysfunction,6(19.35%)developed severe disease and became critically ill.Olfactory dysfunction appeared before the other symptoms in 21.43%of cases.The proportion of females with olfactory and gustatory dysfunction was higher than that of males(P<0.001).Conclusions:The incidence of olfactory and gustatory dysfunction was much lower than that reported abroad;the prognosis of patients with olfactory dysfunction is relatively favorable;olfactory and gustatory dysfunction can be used as a sign for early screening;females are more prone to olfactory and gustatory dysfunction.

Completion thyroidectomy:is timing important for transcervical and remote access approaches?

Completion thyroidectomy(CT)is employed after lobectomy when histopathological results mandates total removal of the gland as in case of well differentiated thyroid carcinoma(DTC).It is also employed as a second stage thyroid surgery when unfavorable events occur as in recurrent laryngeal nerve injury or when the surgeon finds out the case is beyond his/her expertise in an attempt to protect the contralateral side and allowing time for recovery or for an expert surgeon to help.

Association of gastroesophageal reflux disease and laryngeal cancer

Objective:Studies examining the association of reflux disease with the risk of developing laryngeal cancer have both proven and disproven the null hypothesis.Methods:This retrospective caseecontrol study examines the association of reflux in two populations exposed to similar risk factors,including tobacco,to the extent that end-organ malignant transformation has occurred.After IRB approval was obtained,a search of our hospital’s cancer center’s database was performed from 2000 to 2013.A retrospective chart review was then performed and the prevalence of gastroesophageal reflux disease among patients with laryngeal cancer(n Z 290)was determined.It was then compared to the prevalence of gastroesophageal reflux disease among patients presenting with lung cancer(n Z 2440)during the same time period.A multivariate logistic regression was performed to determine the association of reflux with laryngeal cancer.Results:Taking into consideration tobacco use,there was a strong association between male gender and occurrence of laryngeal cancer as opposed to lung cancer(OR Z 3.30;95%CI 2.53e4.36,P<0.001).There was a modest association between reflux and laryngeal cancer(OR Z 1.65;95%CI 1.19e2.25,P Z 0.003).However,there was no association between reflux and the propensity for carcinoma in specific laryngeal subsites(P Z 0.47).Conclusions:In this study examining a heterogeneous population with end-organ malignancy there was a modest association between reflux and laryngeal cancer.Further research is necessary to determine the biologic relevance of this finding.

Magnetic resonance spectroscopy findings of brain olfactory areas in patients with COVID-19-related anosmia:A preliminary comparative study

Objectives:2019 novel coronavirus disease(COVID-19)infection is commonly associated with olfactory dysfunctions,but the basic pathogenesis of these complications remains controversial.This study seeks to evaluate the value of magnetic resonance spectroscopy(MRS)in determining the molecular neurometabolite alterations within the main brain olfactory areas in patients with COVID-19-related anosmia.Methods:In a cross-sectional study,seven patients with persistent COVID-19-related anosmia(mean age:29.57 years)and seven healthy volunteers(mean age:27.28 years)underwent MRS in which N-acetyl-aspartate(NAA),choline(Cho),creatine(Cr),and their ratios were measured in the anterior cingulate cortex,dorsolateral prefrontal cortex,orbitofrontal cortex(OFC),insular cortex,and ventromedial prefrontal cortex.Data were analyzed using TARQUIN software(version 4.3.10),and the results were compared with an independent sample t-test and nonparametric Mann-Whitney test based on the normality of the MRS data distribution.Results:The mean duration of anosmia before imaging was 8.5 months in COVID-19-related anosmia group.MRS analysis elucidated a significant association between MRS findings within OFC and COVID-19-related anosmia(P_(disease)<0.01),and NAA was among the most important neurometabolites(P_(interaction)=0.006).Reduced levels of NAA(P<0.001),Cr(P<0.001)and^(NAA)/Cho ratio(P=0.007)within OFC characterize COVID-19-related anosmia.Conclusions:This study emphasizes that MRS can be illuminating in COVID-19-related anosmia and indicates a possible association between central nervous system impairment and persistent COVID-19-related anosmia.

Papillary thyroid carcinoma:A bibliometric analysis of the top 100 cited articles

Objectives:To describe the current trends and key themes that are shaping the literature surrounding papillary thyroid carcinoma.Methods:The Thomson Reuters Web of Science citation database was used to identify manuscripts relevant to papillary thyroid carcinoma.These were then subdivided into title,author,journal,publication date,theme,and manuscript types.Themes were then identified.Results:A total of 1506 manuscripts were returned.The mean citation number was 163(range 885–74),with the highest citation rate of 73.5.The highest impact factor was JAMA(impact factor of 56.27).85%were original research,10%review articles,and 5%were guidelines.The highest number of manuscripts were published in South Korea(21%).Conclusions:This bibliometric analysis describes the most influential papers published in the topic of papillary thyroid carcinoma.Historic key themes have been endocrinology and metabolism,followed by surgical management and oncology(subdivided into surgery,pathology,radiology and public health/epidemiology).South Korea leads the world with the largest number of publications in this field;with an incidence rate of papillary thyroid carcinoma that is significantly higher than most parts of the world.Despite concerns with overdiagnosis,a collaborative radiological team skilled in ultrasonography of the neck appears to be of great value to the workup of thyroid cancers.

Facial nerve monitoring in parotid gland surgery:Design and feasibility assessment of a potential standardized technique

Background:Even though the use of nerve monitoring during parotid gland surgery is not the gold standard to prevent damage to the nerve,it surely offers some advantages over the traditional approach.Different from thyroid surgery,where a series of steps in intraoperative nerve monitoring have been described to confirm not only the integrity but—most importantly—the function of the recurrent laryngeal nerve,in parotid gland surgery,a formal guideline to follow while dissecting the facial nerve has yet to be described.Methods:A five‐year retrospective study was done reviewing the intraoperative records of patients who underwent parotid gland surgery under neural monitoring.The operative findings regarding the neuromonitoring process,particularly in regard to the amplitude of two main branches,were revised.A literature search was done to search for guidelines to follow when a facial nerve loss of signal is encountered.Results:Fifty‐five patients were operated on using the Nim 3 Nerve Monitoring System(Medtronic);31 were female patients,and 47 patients had benign lesions.Minimum changes were observed in the amplitude records after a comparison was made between the first and the last stimulation.There were only three articles discussing the term loss of signal during parotid gland surgery.Conclusion:Today,no sufficient attention has been given to the facial nerve monitoring process during parotidectomy.This study proposes a formal guideline to follow during this procedure as well as an instruction to consider when a loss of signal is observed to develop a uniform technique of facial nerve stimulation.

Innovations in otorhinolaryngology in the age of COVID-19: A systematic literature review

Objective: Otolaryngologists are at increased occupational risk of Coronavirus Disease 2019 (COVID-19) infection due to exposure from respiratory droplets and aerosols generated during otologic, nasal, and oropharyngeal examinations and procedures. There have been a variety of guidelines and precautions developed to help mitigate this risk. While many reviews have focused on the personal protective equipment (PPE) and preparation guidelines for surgery in the COVID-19 era, none have focused on the more creative and unusual solutions designed to limit viral transmission. This review aims to fill that need.Data Sources: PubMed, Ovid/Medline, and ScopusMethods: A comprehensive review of literature was performed on September 28, 2020 using PubMed, Ovid/Medline, and Scopus databases. All English-language studies were included if they proposed or assessed novel interventions developed for Otolaryngology practice during the COVID-19 pandemic. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.Results: A total of 41 papers met inclusion criteria and were organized into 5 categories ("General Recommendations for Otolaryngologic Surgery’, "Equipment Shortage Solutions’, "Airway Procedures’, "Nasal Endoscopy and Skull Base Procedures’, and "Otologic Procedures’). Articles were summarized, highlighting the innovations created and evaluated during the COVID-19 pandemic. Creative solutions such as application of topical viricidal agents, make-shift mask filters, three-dimensional (3-D) printable adapters for headlights, aerosol containing separation boxes, and a variety of new draping techniques have been developed to limit the risk of COVID-19 transmission.Conclusions: Persistent risk of COVID-19 exposure remains high. Thus, there is an increased need for solutions that mitigate the risk of viral transmission during office procedures and surgeries, especially given that most COVID-19 positive patients present asymptomatically. This review examines and organizes creative solutions that have been proposed and utilized in the otolaryngology. These solutions have a potential to minimize the risk of viral transmission in the current clinical environment and to create safer outpatient and operating room conditions for patients and healthcare staff.

The outcomes of hypoglossal nerve stimulation in the management of OSA: A systematic review and meta-analysis

Objectives:Obstructive sleep apnea (OSA) is a prevalent disease with significant health impacts.While first line therapy is CPAP,long-term compliance is low and device misuse is common,highlighting the need for alternative therapies.Upper airway surgery is one alternative,but substantial side effects hamper efficacy.A new alternative is an implantable hypoglossal nerve stimulator (HNS).These devices utilize neuromodulation to dilate/reinforce the airway and reduce side effects associated with traditional surgery.Several recent trials investigated the efficacy of these devices.The purpose of this study was to perform meta-analysis of available HNS studies investigating treatment of OSA to analyze objective and subjective outcomes and side effects.Methods:A comprehensive literature search of PubMed and Scopus was performed.Two independent reviewers examined clinical trials investigating HNS in treatment of sleep apnea in adults.Studies with objective and subjective endpoints in sleep were included for analysis.Adverse events from trials were also recorded.Results:Across 16 studies,381 patients were analyzed.At 6 months (p =0.008),mean SAQLI improved by 3.1 (95%CI,2.6-3.7).At 12 months (p < 0.0001),mean AHI was reduced by 21.1 (95%Cl,16.9-25.3),mean ODI was reduced by 15.0 (95%CI,12.7-17.4),mean ESS was reduced by 5.0 (95%CI,4.2-5.8),mean FOSQ improved by 3.1 (95%CI,2.6-3.4).Pain (6.2%:0.7-16.6),tongue abrasion (11.0%:1.2-28.7),and internal (3.0%:0.3-8.4)/external device (5.8%:0.3-17.4) malfunction were common adverse events.Conclusions:HNS is a safe and effective treatment for CPAP refractory OSA.Further study comparing HNS to other therapies is required.

Postoperative mometasone irrigations improve quality of life in skull base tumor patients

Objectives:The use of topical corticosteroids to manage postoperative sinonasal symptoms after endoscopic skull base surgery (ESBS) has not been well studied.We quantified long‐term impact of postoperative steroid irrigations (SIs) on quality of life of patients after ESBS.Methods:Retrospective review of patients at the University of Pennsylvania undergoing ESBS from 2010 to 2019.Data on patient demographics and postoperative treatment with nasal saline irrigation twice daily with and without dissolved steroids (mometasone or budesonide) was collected.Preoperative,and 1‐,3‐,6‐,12‐,18‐,and 24‐month postoperative Sino‐Nasal Outcome Test (SNOT‐22) scores were assessed.Results:A total of 727 patients were assessed (53.4% males),with 479 patients in the no SI group and 248 patients in the SI group.Preoperative SNOT‐22 scores did not differ significantly (P = 0.19).1‐,3‐,6‐,12‐,18‐,and 24‐month post‐op SNOT‐22 scores did not significantly differ between groups.However,mometasone irrigations resulted in significantly lower postoperative 2‐year SNOT‐22 scores compared to budesonide (P < 0.01) and saline (P = 0.03).Conclusions:Though corticosteroid irrigations are routine in managing inflammatory sinus disease,their role in postoperative management after ESBS for tumors is unclear.Our findings suggest that mometasone irrigation may be effective at improving postoperative quality of life in patients after ESBS.

Facial nerve palsy following parotid gland surgery:A machine learning prediction outcome approach

Introduction:Machine learning (ML)‐based facial nerve injury (FNI) forecasting grounded on multicentric data has not been released up to now.Three distinct ML models,random forest (RF),K‐nearest neighbor,and artificial neural network (ANN),for the prediction of FNI were evaluated in this mode.Methods:A retrospective,longitudinal,multicentric study was performed,including patients who went through parotid gland surgery for benign tumors at three different university hospitals.Results:Seven hundred and thirty‐six patients were included.The most compelling aspects related to risk escalation of FNI were as follows:(1) location,in the mid‐portion of the gland,near to or above the main trunk of the facial nerve and at the top part,over the frontal or the orbital branch of the facial nerve;(2) tumor volume in the anteroposterior axis;(3) the necessity to simultaneously dissect more than one level;and (4) the requirement of an extended resection compared to a lesser extended resection.By contrast,in accordance with the ML analysis,the size of the tumor (>3 cm),as well as gender and age did not result in a determining favor in relation to the risk of FNI.Discussion:The findings of this research conclude that ML models such as RF and ANN may serve evidence‐based predictions from multicentric data regarding the risk of FNI.Conclusion:Along with the advent of ML technology,an improvement of the information regarding the potential risks of FNI associated with patients before each procedure may be achieved with the implementation of clinical,radiological,histological,and/or cytological data.

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Transoral flexible laryngoscope biopsy:Safety and accuracy

Objective:To determine the accuracy of transoral flexible laryngoscope (TFL) biopsy and also to identify the safety as office based procedure in terms of complications.Methods:This is a diagnostic study;the type of intervention is outpatient department based biopsy of laryngeal lesions.All patients seen in ENT outpatient department of Lyari General Hospital with suspicious lesions of Larynx were referred for Transoral Flexible Laryngoscopy Biopsy under local anesthesia.The specimens were sent for histopathology.The patients with benign pathology or carcinoma in situ were referred for direct laryngoscopy and biopsy.The sensitivity and specificity were calculated and the frequencies of complications were monitored to determine the complication rate.Results:During the course of study a total of 47 patients underwent TFL biopsy in office settings.Out of these patients 16 patients were referred for direct laryngoscopy biopsy.The study population included 32 men and 15 women with ages ranging from 28 to 52 years and mean of (39 ± 6) years.Among 43 patients squamous cell carcinoma was the final diagnosis in 31 patients.In the rest of 12 patients' dysplasia and benign lesion was the diagnosis in 9 and 3 patients respectively.These 12 patients underwent direct laryngoscopy biopsy and 10 of them diagnosed with invasive carcinoma rest had benign lesions.Hence the specificity was 75.6% and sensitivity was 100%.None of the patients developed any serious complication.Conclusions:All patients with a suspicious lesion diagnosed by TFL biopsy as being benign or carcinoma in situ should have direct laryngoscopy for verification of the findings.But the results positive for carcinoma are reliable.In addition,this is a safe procedure.

Visual working memory span in adults with cochlear implants： Some preliminary findings

Objective:Neurocognitive functions,specifically verbal working memory (WM),contribute to speech recognition in postlingual adults with cochlear implants (CIs) and normal-hearing (NH) listener shearing degraded speech.Three hypotheses were tested:(1) WM accuracy as assessed using three visual span measures-digits,objects,and symbols-would correlate with recognition scores for spectrally degraded speech (through a CI or when noise-vocoded);(2) WM accuracy would be best for digit span,intermediate for object span,and lowest for symbol span,due to the increasing cognitive demands across these tasks.Likewise,response times,relating to processing demands,would be shortest for digit span,intermediate for object span,and longest for symbol span;(3) CI users would demonstrate poorer and slower performance than NH peers on WM tasks,as a result of less efficient verbally mediated encoding strategies associated with a period of prolonged auditory deprivation.Methods:Cross-sectional study of 30 postlingually deaf adults with CIs and 34 NH controls.Participants were tested for sentence recognition in quiet (CI users) or after noise-vocoding (NH peers),along with WM using visual measures of digit span,object span,and symbol span.Results:Of the three measures of WM,digit span scores alone correlated with sentence recognition for CI users;no correlations were found using these three measures for NH peers.As predicted,WM accuracy (and response times) were best (and fastest) for digit span,intermediate for object span,and worst (and slowest) for symbol span.Cl users and NH peers demonstrated equivalent WM accuracy and response time for digit span and object span,and similar response times for symbol span,but contrary to our original predictions,Cl users demonstrated better accuracy on symbol span than NH peers.Conclusions:Verbal WM assessed using visual tasks relates weakly to sentence recognition for degraded speech.CI users performed equivalently to NH peers on most visual tasks of WM,but they outperformed NH peers on symbol span accuracy.This finding deserves further exploration but may suggest that CI users develop alternative or compensatory strategies associated with rapid verbal coding,as a result of their prolonged experience of auditory deprivation.

Preferences in stapes surgery among American otological society otologists

Objective:Stapes surgery is technically challenging,yet its methodology is not standardized.We aim to elucidate preferences in stapes surgery among American Otological Society(AOS)otologists and determine if any common practice patterns exist.Study design:Cross-sectional study via emailed questionnaire.Setting:Surgery centers.Subjects and methods:Members of the AOS were an emailed a survey to quantify variables including surgical volume,anesthetic preference,laser use,type of procedure,footplate sealing technique,antibiotic use,and trainee participation.Results:Most otologists(71%)performed 2 to 5 stapes surgeries per month under general anesthesia(69%)with stapedotomy(71%)as the preferred procedure.Most(56%)used the rosette method of laser stapedotomy with manual pick debris removal for footplate fenestration.Either the handheld potassium titanyl phosphate(KTP)laser(40%)or handheld carbon dioxide(CO2)laser(33%)was used.The heat-activated memory hook(51%)was the preferred prosthesis.Footplate sealing method was variable,as was antibiotic use among respondents.Trainee participation was limited,as 42%of otologists allowed residents to place the prosthesis,and fewer allowed residents to crimp the prosthesis,and laser or drill the footplate.Surgeons with higher surgical volume(≥6 surgeries per month)demonstrated the following statistically significant correlations:footplate fenestration with laser in a rosette pattern and pick for debris removal(rs=-0.365,P=0.014)and trainee participation with fellows only(rs=0.341,P=0.022).Conclusions:Trends in various surgical decisions showed a lack of consensus in all aspects of stapes surgery.

Free tissue reconstruction of the anterior skull base:A review

Objective:There has been a significant shift from open craniofacial resection of the anterior skull base to endoscopic approaches that accomplish the same outcomes in tumor ablation.However,when open resection is required,free flap reconstruction is often necessary to provide sufficient well-vascularized tissue for optimal wound healing as well as providing adequate tissue bulk for cosmesis.This articleaims to providea focused review of free flaps most commonly used in anterior skull base reconstruction.Methods:This is a state-of-the-art review based on expert opinion and previously published reviews and journal articles,queried using PubMed and Google Scholar.Results&conclusion:Anterior skull base reconstruction via free tissue transfer is imperative in limiting complications and promoting healing,particularly with large defects,post-radiation,and in at-risk patients.The type of free flap utilized for a particular anterior skull base reconstruction should be tailored to the patient and nature of the disease.This review offers insight into the numerous reconstructive options for the free flap surgeon.