bluuebunny/crossref_metadata_2025 huggingface dataset:
Intraoperative Local Anesthesia for Reducing Pain following Tonsillectomy
Authors: Lin Rui J. , Naidoo Lalenthra , Burton Martin J. , Chadha Neil K.
Published: August 2013

Objectives:

Perform a Cochrane review to systematically appraise the available evidence of pain relief through the use of intra‐operative local anaesthetic (LA) administration to the tonsillar region in adults and children undergoing tonsillectomy.

Methods:

The study followed the rigorous systematic review and meta‐analysis methodology as developed by the Cochrane Collaboration. A comprehensive search strategy was applied to multiple databases for published and unpublished trials up to April 2012. Randomized, double‐blind, placebo‐controlled trials were eligible. Two reviewers independently extracted data and assessed trials for quality. Data analyses were performed using the RevMan 5.1 software.

Results:

Sixty‐six randomized controlled trials were included in the review. Eleven trials assessing peritonsillar infiltration of LA and seven trials that investigated topical application of LA were suitable for meta‐analysis. Peritonsillar LA infiltration was associated with significant reduction in pain up to 2 hours after surgery (mean difference ‐1.34 on a scale of ‐10 to 10; 95% CI ‐1.80 to ‐0.88; P< 0.00001). Topical LA application to the tonsillar fossa was also associated with significant pain reduction in the early post‐operative period (mean difference ‐0.66 on a scale of ‐1 to 1; 95% CI ‐1.06 to ‐0.27; P = 0.001). Intra‐operative LA was associated with a longer period of time without analgesic requests post‐operatively (mean difference 12 minutes; 95% CI 2.0 to 21.8; P = 0.020).

Conclusions:

Based on the available evidence, we would advocate routine intra‐operative application of LA, whether infiltrative or topical, for patients undergoing tonsillectomy.
Isolated Basilar Skull Fracture: Outcomes and Predictors of Readmission
Authors: McCutcheon Brandon A. , Orosco Ryan K. , Chang David C. , Maturo Stephen C. , Magit Anthony E.
Published: August 2013

Objectives:

Outcomes in pediatric and adult patients with isolated basilar skull fracture.

Methods:

Cases of isolated basilar skull fracture were identified in the California Office of Statewide Health Planning and Development (OSHPD) database. In‐hospital and 90‐day rates of meningitis and cerebrospinal fluid (CSF) leak were assessed. Determinants of 30‐day readmission were evaluated using multivariate logistic regression.

Results:

5,223 pediatric and 7,421 adult patients met inclusion criteria. Most patients had a length of stay greater than one day (64.3% pediatric and 77.5% adult). In‐hospital rates of meningitis (0.41% and 0.55%) and CSF leak (2.24% and 1.75%) were similar among children and adults, respectively. Rates of 90‐day meningitis (0.24% and 0.37%) and CSF leak (0.43% and 0.40%) were also similar. 30‐day readmission was 3.94% for children compared to 12.4% for adults. For pediatric and adult patients, extra‐axial hematoma (odds ratio [OR] 1.73 and 1.57) and comorbidities (OR 2.18 and 1.50) were associated with significant increases in 30‐day readmission (p<0.001). Loss of consciousness of greater than one hour (OR 2.45, p<0.001), and CSF leak (OR 2.80 p=0.002) was also associated with significant increases in pediatric readmissions. No association between length of stay and the likelihood of readmission was observed.

Conclusions:

Meningitis and CSF leaks following isolated basilar skull fractures are rare in both children and adults. This study found no association between length of stay and likelihood of readmission. This suggests that, in the absence of CSF leak or other complication, extended inpatient monitoring may be unwarranted as a means to reduce complications and readmissions.
Regional Differences in Gender Promotion and Scholarly Productivity
Authors: Mady Leila J. , Svider Peter F. , Kalyoussef Evelyne , Setzen Michael , Baredes Soly , Chandrasekhar Sujana S. , Eloy Jean A.
Published: August 2013

Objectives:

Identify whether there are regional differences in previously described gender disparities in scholarly productivity and faculty rank among academic otolaryngologists.

Methods:

Online faculty listings from 95 academic otolaryngology departments were searched to identify clinical faculty and further organize them by gender, academic rank, fellowship training status, and institutional location. The Scopus database was used to assess various bibliometrics of these otolaryngologists, including the h‐index, number of publications, and publication range (in years).

Results:

Analysis included 1,127 otolaryngologists, 916 men (81.3%) and 211 women (18.7%). Female faculty comprised 15.4% in the Midwest, 18.8% in the Northeast, 21.3% in the South, and 19.0% in the West (p=0.44). Overall, men obtained significantly higher senior academic ranks (Associate Professor or Professor) compared to women (59.8% vs. 40.2%, p<0.0001). Regional gender differences among senior faculty were found in the South (59.8% men vs. 37.3% women, p=0.0003) and in the Northeast (56.4% men vs. 24.1% women, p<0.0001) with concomitant gender differences in scholarly impact, as measured by the h‐index (South, p=0.0003; Northeast, p=0.0001). Among geographic subdivisions, female representation at senior ranks was lowest in the Mid‐Atlantic (21.9%), New England (17.1%), and West South Central (33.3%), while highest in the Pacific (60.0%) and Mountain (71.4%) regions. No regional gender differences were found in fellowship training patterns (p‐values>0.05).

Conclusions:

Gender disparities in academic rank and scholarly productivity exist regionally, most notably in the Northeast where women in otolaryngology are most underrepresented relative to men at senior academic ranks and in scholarly productivity.
Risk Factors for Unplanned Hospital Readmission in Otolaryngology Patients
Authors: Graboyes Evan M. , Liou Tzyy‐Nong , Kallogjeri Dorina , Nussenbaum Brian , Diaz Jason A.
Published: August 2013

Objectives:

Describe the risk factors that predict 30‐day unplanned readmission in hospitalized otolaryngology patients.

Methods:

We conducted a retrospective review of all otolaryngology admissions for the one year period between January 1, 2011, and December 31, 2011, at a single academic medical center with a broad and heterogeneous otolaryngology practice. A univariate logistic regression and then a forward stepwise logistic regression model were performed to identify risk factors for unplanned readmission to the hospital within thirty days of discharge from the otolaryngology service.

Results:

1271 patients met inclusion criteria. The 30‐day unplanned readmission rate for patients discharged from otolaryngology was 7.3% (93/1271). There were twenty variables that were significant on univariate analysis. The risk factors for readmission after the forward stepwise logistic regression model were new total laryngectomy (Odds Ratio (OR) 5.5) (95% Confidence Interval (CI) 2.1; 14.6), prior unplanned readmission from any service at the academic center (OR 3.1) (95% CI 1.9; 5.1), current illicit drug use (OR 3.4) (95% CI 1.8, 6.4), preoperative non‐steroidal immunosuppression (OR 3.4) (95% CI 1.4; 8.4), discharge to an extended care facility or skilled nursing facility (OR 3.4) (95% CI 1.6; 7.1), and discharge to home with home healthcare (OR 2.3) (95% CI 1.2; 4,4). The c‐index for the regression model was 0.73.

Conclusions:

Otolaryngology patients have unique risk factors that predict unplanned readmission within 30‐days of discharge. These data identify specific patient characteristics and care processes that can be targeted with quality improvement interventions to decrease readmissions.
Three‐Dimensional, Virtual Reality Vestibular Rehabilitation for Ménière's Disease‐Induced Chronic Imbalance Problem
Authors: Yeh Shih‐Ching , Wang Pa‐Chun , Su Mu‐Chun , Chang Chia‐Huang , Fang Te‐Yung
Published: August 2013

Objectives:

Patients with Ménière's disease (MD) may suffer from chronic imbalance problem that cannot be cured by surgery or medication. For these patients, vestibular rehabilitation is another treatment option. Three‐dimensional (3D), virtual reality (VR) technology may be applied to facilitate rehabilitation exercise. In this study we report outcomes of 3D, VR rehabilitation for patients with MD‐related chronic vestibular dysfunction.

Methods:

A VR‐based rehabilitation system was developed. The system consists of the Kinect Xbox for full‐body interaction, 3D‐ready projector with shutter‐glasses for stereo imaging, Wii Fit pressure pad (for tracing the center of gravity sway and statokinesigrams [SKG], in cm2), and Unity game engine for leveled‐difficulty design. The modified Cawthorne‐Cooksey exercises (MCCE) was adapted into this system; the MCCE scores were compared following intervention. 50 MD patients with chronic balance were recruited for this prospective, longitudinal, uncontrolled clinical study. Patients followed the instructions of MCCE to complete at least 6 sessions of vestibular rehabilitation within a 4‐week period.

Results:

All patients experienced improvement of balance function performing daily activities and were overall positive about the training protocol. After intervention, the fast components of postural sway and SKG (P < 0.05) were reduced. The MCCE scores significantly improved (66.6 to 74.6, P < 0.05). We found age (Î2 = ‐0.52, P < 0.05) and number of training sessions (Î2 = 2.53X, P < 0.05) were significant predictors for clinical improvement.

Conclusions:

Vestibular rehabilitation can assist MD patients who cannot benefit from medication and surgery. The data support the applicability of 3D, VR technology in the field of vestibular rehabilitation.
Using Cumulative Summation to Draw Otolaryngology Trainees’ Learning Curves in Tonsillectomy
Authors: Awad Zaid , Unadkat Samit , Ziprin Paul , Tolley Neil S. , Taghi Ali S. , Darzi Ara
Published: August 2013

Objectives:

Assess the applicability of cumulative summation (CUSUM) in 1) showing trainees progress, 2) achieving competency, and 3) highlighting concerns in tonsillectomy surgery.

Methods:

We followed 9 otolaryngology junior trainees in their first 6‐12 months in the specialty between 2011‐2013. Tonsillectomy is the most common operation that introduces trainees to operative otolaryngology. Two outcome measures were used: operative time and post‐operative bleeding. These were then compared to experienced surgeons (>100 tonsillectomies). For time CUSUM, the mean and standard deviation of the experts’ performance was used as the factor to draw the curve applying the formula (Cn=0, Cn‐1+Xn‐k) on consecutive procedures. k=0.2 to allow for 20% incidence of overrunning. For bleeding CUSUM, any post‐operative bleed was regarded a negative outcome and k=0.05 to allow for 5% incidence.

Results:

Trainees performed 14‐35 tonsillectomies each (ongoing). The average time for experts over 150 procedures was 23min (SD:11). Trainees’ operative time was higher (38min, SD:16, P<0.01). Xn=0 if the time was within 1SD of the experts (34min) and 1 if higher. Trainees’ time CUSUM plateaued after a variable number of cases (20‐30) while that of experts remained low. For bleeding CUSUM, Xn=1 if reported and 0 if not. Bleeding was rare and did not reflect the same pattern.

Conclusions:

CUSUM using time can be used to monitor performance and draw learning curves for tonsillectomy. Bleeding is a rare complication and hence needs larger numbers to show improvement. The flexibility of the CUSUM makes it adaptable to any outcome. It allows early detection of poor performance to instigate intervention.
Analysis and Review of Outcomes for Cutaneous Squamous Cell Carcinoma Involving the Parotid
Authors: Zimmerman Terence , Sweeny Larissa , Carroll William R. , Day Kristine E. , Rosenthal Eben L.
Published: August 2013

Objectives:

An in depth analysis of outcomes following parotidectomy for a cutaneous squamous cell carcinoma.

Methods:

Retrospective review (2003‐2012).

Results:

Forty‐nine percent of 218 patients presented with a primary lesion (n = 107), and 51% presented with a recurrence (n = 111). Parotid lymph nodes were positive in 52% of patients; 81% had a concurrent neck dissection, and 28% had cervical lymph node metastases. Eighteen percent had both positive parotid and cervical lymph nodes. The majority of margins were negative (49%), with 19% being < 2mm. Preoperative radiation therapy did not decrease the incidence of cervical (P = 0.27) or parotid (P = 0.37) lymph node involvement, perineural invasion (P = 0.08), positive margins (P = 0.31), facial nerve sacrifice (P = 0.43), or rate of recurrence (P = 0.87). The overall 2‐ and 5‐year survival rates were 0.71 and 0.58. Overall 5‐year survival was lower for patients presenting with recurrent (0.49) vs. primary disease (0.69; P = 0.04). In addition, decreased overall 5‐year survival rates were associated with cervical lymph involvement (0.47 vs. 0.62; P = 0.01) and preoperative radiation therapy (0.39 vs. 0.67; P = 0.037). Interestingly, there was no difference in overall survival when stratified by parotid lymph node involvement (P = 0.85), margin status (P = 0.67), perineural invasion (P = 0.42), temporal bone resection (P = 0.14), facial nerve sacrifice (P = 0.92), or type of parotid operation performed (P = 0.51).

Conclusions:

In this patient population, cervical, but not parotid, lymph node involvement was associated with poor outcomes. Furthermore, radiation therapy prior to a definitive operation resulted in worse outcomes and did not decrease the incidence lymph node metastases.
Analysis of Racial Survival Disparities in Head and Neck Cancer by Site of Primary Tumor
Authors: Stokes William A. , Lentsch Eric J.
Published: August 2013

Objectives:

Head and neck cancer carries a significant survival disparity by race and site of primary tumor. We performed survival analysis to determine how racial survival disparities differ by site.

Methods:

We selected 34,182 patients from the Surveillance, Epidemiology, and End Results (SEER) database with head and neck cancer (HNC) diagnosed from 2004‐2009. Eighty‐three point nine percent were white, 11.4% black, 4.28% Asian or Pacific Islander, and 0.36% American Indian. All patients with >1 primary and primaries outside the upper aero‐digestive tract were excluded. American Joint Committee on Cancer (AJCC) staging in SEER was recorded with stages I and II as early stage, and stages III and IV as late stage. Hazardous ratio were calculated with and without stage as covariates.

Results:

Stage independent: hazard ratio (HR) for black vs. white survival was 1.637 (95% confidence interval [CI] = 1.455‐1.842, P <.001) for mouth, 2.402 (95% CI = 2.182‐2.644, P <.001) for oropharynx, 1.382 (95% CI = 1.275‐1.530, P =<.001) for larynx, and 1.563 (95% CI = 01.337‐1.827, P = <.001) for hypopharynx. Stage dependent: HR of 1.297 (95% CI = 1.152‐1.460, P = <.001) for mouth, 2.349 (95% CI = 2.134‐2.586, P <.001) for oropharynx, 1.124 (95% CI = 1.014‐1.246, P =. 025) for larynx, and 1.541 (95% CI = 1.318‐1.802, P =<.001) for hypopharynx.

Conclusions:

We found racial survival disparities in HNC for all sites, with differing reasons by location. The mouth and larynx's disparity is significantly affected by stage at presentation, but primaries of the oropharynx are not. Therefore, poor tumor recognition is a major reason for black survival disparities in early diagnostic areas. However, in inferior upper aero‐digestive tract lesions the disparity is not due to a difference in tumor recognition and likely stems from differences in treatment or risk factors such as human papillomavirus status.
Are We Following Treatment Guidelines for Papillary Thyroid Carcinoma? Cost Implications: A SEER‐Medicare Study
Authors: Abemayor Elliot , Razfar Ali , St. John Maie
Published: August 2013

Objectives:

The National Comprehensive Cancer Network (NCCN) guidelines are evidence‐based management algorithms for papillary thyroid carcinoma (PTC). We sought to determine whether actual practice patterns coincide with these guidelines and whether management outside NCCN guidelines affected Medicare costs.

Methods:

Surveillance, Epidemiology, and End Results (SEER) Medicare linked data were examined to determine treatment patterns for 4,582 patients with PTC from 1988‐2007 that met our inclusion criteria. Indications for lobectomy, total thyroidectomy, and postoperative radioactive iodine ablation (RAI) were based on NCCN guidelines, including tumor size, extrathyroidal extension, positive lymph nodes, and aggressive histology. The cost related to PTC treatments was Medicare payments linked directly to each treatment's claim code.

Results:

Seventy‐six percent underwent total thyroidectomy, and 34% underwent thyroid lobectomy. According to NCCN guidelines, 90% received appropriate surgical management. Of patients with aggressive features based on NCCN guidelines, 33.4% should have received RAI. Based on intermediate tumor size, positive lymph nodes, and aggressive histology, 37.7% would have benefited from RAI. Of patients with tumors less than 1 cm and no ETE, 42% should not have received postoperative RAI. Patients undergoing thyroid lobectomy cost Medicare $50,175, while total thyroidectomy cost $54,455 (P = 0.293). Postoperative RAI cost Medicare approximately $47,652 yearly.

Conclusions:

Ninety percent of patients received appropriate surgical management. However, 40% of patients did not receive appropriate postoperative RAI management. As the incidence of PTC rises, the use of evidence‐based guidelines can reduce cost attributed to Medicare.
Barriers to Same‐Day Discharge of Total and Completion Thyroidectomy Patients
Authors: Rutledge Jonathan W. , Siegel Eric R. , Bodenner Don , Stack Brendan C.
Published: August 2013

Objectives:

Thyroid surgery has traditionally been performed as an inpatient procedure due to the risk of postoperative hematoma and hypocalcaemia, but it is evolving into a safe outpatient procedure in selected patients. However, there is little in the literature about which patients require prolonged observation after planned same day surgery.

Methods:

A retrospective chart review was performed on patients from 2005 to 2012. We analyzed patients who underwent total thyroidectomy, completion thyroidectomy, or revision total thyroidectomy who were kept overnight or longer at a tertiary care center.

Results:

Two hundred thirty‐one cases qualified and planned for same day surgery. Eighty‐six patients were not discharged (37%). Twenty‐three of 86 patients were admitted for parathyroid hormone (PTH) <10. Eighty‐three percent of patients admitted had drains placed at the time of surgery, and most had their drains removed postoperative day (POD) 1 prior to discharge. Twelve patients required conversion to inpatient (14%). Eighty‐two point six percent of overnight observation patients were discharged home POD 1, and 96.5% were discharged by POD 2. Only one patient required readmission for hypocalcemia after observation and discharge.

Conclusions:

Intraoperative PTH <10 was the most frequent factor (27%) precluding same day discharge followed by admission for social/financial/transportation reasons (23%), large dead space (14%), multiple medical comorbidities (13%), multiple surgical reasons (11%), stridor (6%), pain management (4%), and intractable nausea due to general anesthetic (2%). Hypocalcemia and postoperative bleeding still remain obstacles to outpatient thyroid surgery; however, the use of rapid PTH, calcium prophylaxis, and power instrumentation facilitates same day surgery. Experienced clinical decision making can effectively stratify which patients require prolonged observation.
Central Node Dissection: Comparison of Standard Open to Minimally Invasive Video‐Assisted Approach
Authors: Steward David L. , Hensler Matthew S.
Published: August 2013

Objectives:

Compare outcomes of primary concomitant thyroidectomy with central neck dissection by standard open vs. minimally invasive video‐assisted (MIVA) approach in patients with low risk thyroid carcinoma.

Methods:

A retrospective chart review was performed using CPT code 60502 for patients undergoing central neck dissection from February 2005 through June 2012. Revision cases were excluded. Primary outcomes included lymph node yield, complications, and recurrence.

Results:

One hundred eighty‐five patients were identified, with 134 as open cases and 51 as MIVA. Of the open cases, 87 were primary, 46 were revision, and 1 had insufficient data. Of the MIVA cases, 49 were primary, and 2 were revision. Of the 136 eligible patients, mean age was 46 years in both groups (range 14‐97). The MIVA group was more likely female (88% vs. 68%, P < 0.01), T1 (80% vs. 42%, P < 0.001), and N0 (57% vs. 37%, P < 0.001). Nodal yield was lower in the MIVA group (5.0 vs. 6.7, P = 0.04), but was similar in unilateral cases (4.9 vs. 5.5, P = 0.58). Transient recurrent laryngeal nerve injury was similar (4.1% vs. 5.8%, P = 0.67); however, transient hypoparathyroidism defined by postanesthesia care unit parathyroid hormone < 15 pg/ml was lower in the MIVA group (29.8% vs. 49.3%, P = 0.03). Recurrence rates were similar (2.0% vs. 6.0%, P = 0.29).

Conclusions:

Primary concomitant central neck dissection with MIVAT may result in a slightly lower nodal yield but with reduced transient hypoparathyroidism, likely from less aggressive dissection in the presence of less advanced disease. MIVAT with central neck dissection appears a safe alternative to the standard open approach for low risk thyroid carcinoma.
Confocal Laser Endomicroscopy in Precancerous Lesions of the Head and Neck
Authors: Nathan Cherie‐Ann O. , Mehta Vikas , Lian Timothy S. , Chaudhery Shubhnum
Published: August 2013

Objectives:

Distinguishing precancerous lesions from invasive carcinoma is a challenge due to field cancerization. Extensive biopsies are required to determine histology and sampling errors result in inaccurate diagnosis. The probe based confocal laser endomicroscopy (pCLE) is an emerging technology of real time microscopic imaging of mucosal surfaces at the cellular level. It has been studied extensively in the lung and gastrointestinal tract but not the head and neck.

Methods:

We performed a study on awake patients with 15 precancerous and cancerous lesions of the oral cavity. After intravenous injection of fluorescein, a 1.8‐mm gastroflex probe helped visualize normal mucosa, carcinoma, and precancer to assess image quality on various grades of dysplasia. The histology from biopsies of visualized areas was compared to optical images.

Results:

The dorsal surface of the tongue was not well visualized due to the keratinized filiform papillae. The remaining non‐keratinized subsites, buccal mucosa, floor of mouth, and ventral tongue were well visualized. Although leukoplakia was widespread, only some areas demonstrated suspicious microarchitecture, including abnormal vasculature and disruption of membranes. This correlated with final histology. Flat, well‐organized scale‐like cells were noted in normal mucosa. In patients with carcinoma in situ there were increased ectatic blood vessels. In high grade dysplasia there was complete disorganization of the epithelium and fluorescein leakage with an abrupt change to the so called “black cells.”

Conclusions:

The pCLME has significant potential in determining areas more likely to progress to carcinoma, resection margins in head and neck squamous cell carcinoma patients plagued with field cancerization, and response to chemopreventive agents.
Correlation of Critical Score Models with Outcomes after Tracheostomy in Critically Ill Patients
Authors: Hotaling Jeffrey M. , Canar W. Jeffrey , Bier‐Laning Carol M.
Published: August 2013

Objectives:

Understand the utility in using the validated outcome prediction models (Sequential Organ Failure Assessment [SOFA] and Logistic Organ Dysfunction System [LODS]) as additional information in making surgical decisions in the specific population of critically ill patients undergoing tracheotomy.

Methods:

Retrospective chart review of 94 consecutive critically ill patients at a tertiary care Veterans Administration hospital who underwent isolated tracheotomy between January 2006 andJune 2011. Data were collected from the medical charts. Outcome measurements included decannulation, ventilatory status after tracheotomy, and date of death. SOFA and LODS scores were calculated and Students T test was used for statistical analysis.

Results:

Mortality was expectedly high. Twenty‐two point 3 percent of patients died while still inpatients, and 53.2% died within 180 days of tracheotomy. The average time to ventilator independence was 20.1 days, and 28.7% of patients were decannulated. The LODS score was more powerful, showing a significant association with ventilator status 14 days after tracheotomy, death while an inpatient, and death within 90 days of tracheotomy (all P < 0.05). The SOFA score only showed a significant association with death while an inpatient (P < 0.05).

Conclusions:

This work is the first reported use of the validated LODS and SOFA outcome prediction models in the subset of critically ill patients undergoing tracheotomy. While this patient population is known to have a high mortality rate, the use of objective measurements such as LODS can be useful to help guide clinical decision making, counsel surrogate decision makers, and allocate resources.
Costs of Outpatient Thyroid Surgery from the University Heathcare Consortium
Authors: Marino Matthew , Spencer Horace , Hohmann Samuel F. , Bodenner Don , Stack Brendan C.
Published: August 2013

Objectives:

Compare the cost of outpatient and inpatient thyroidectomy at US academic medical centers.

Methods:

Discharge data were collected from the first quarter of 2009 through the fourth quarter of 2012 from the University Health System Consortium (UHC) on over 50,000 patients. The UHC database, compiled from over 100 academic health centers and their 200 affiliated hospitals, was searched based on diagnosis codes for outpatient and inpatient thyroid procedures. The Agency for Healthcare and Research Quality (AHRQ) chronic conditions were collected in addition to demographic, length of stay (LOS), and cost data. Comparisons were made between inpatient and outpatient thyroidectomy stratified by number of chronic conditions.

Results:

The cost of outpatient thyroidectomy was consistently less than that for inpatient thyroidectomy. More outpatient thyroidectomies were performed on patients with 0 or 1 chronic condition, while more inpatient thyroidectomies were performed on patients with 2 or greater chronic conditions. When stratifying by number of chronic conditions, the cost of outpatient thyroidectomy remained stable independent of the number of additional conditions. However, the cost of inpatient thyroidectomy rose linearly with an increased number of chronic conditions.

Conclusions:

Outpatient thyroid surgery is associated with less cost when compared with inpatient thyroid surgery, and the difference in cost rises with number of chronic conditions present. The transition to outpatient thyroid surgery may provide significant cost‐savings, particularly in those patients with chronic conditions. However, certain chronic conditions may preclude patients from undergoing outpatient surgery.
Endoscopic Transnasal Approach to the Infratemporal and Upper Parapharyngeal Tumors: Indications and Outcomes
Authors: Turri‐Zanoni Mario , Battaglia Paolo , Gallo Stefania , Sica Eleonora , Ferreli Fabio , Bignami Maurizio , Castelnuovo Paolo
Published: August 2013

Objectives:

Describe the endoscopic transnasal approach to the infratemporal fossa (ITF) and upper parapharyngeal region (UPR), and analyze the indications and outcomes of this surgical technique in the management of the tumors localized in this critical area.

Methods:

Retrospective review of patients with benign and malignant tumors arising in or extending to the ITF and UPR, treated from 2002 to 2012 at a single institute. The tumors were surgically resected using an endoscopic transnasal transmaxillary transpterygoid approach, combined with a posterior septotomy to improve the controlateral maneuverability of surgical instruments.

Results:

Thirty‐one consecutive patients with benign tumors (20 juvenile nasopharyngeal angiofibromas, 2 extracranial trigeminal schwannomas, 2 meningiomas, and 1 cavernous hemangioma) and malignancies (2 adenoid‐cystic carcinoma, 1 mucoepidermoid carcinoma, 1 squamous‐cell carcinoma, 1 adenocarcinoma, and 1 recurrence of chondrosarcoma after chemo‐radiation therapy) were treated with curative intent. A gross‐total resection was achieved in 28/30 patients. Major complications were observed in 1 case (intra‐operative internal carotid artery blowout), and minor complications (postoperative palate and/or cheek numbness) were observed in 4 cases. Postoperatively, the 5 primitive malignancies received intensity‐modulated radiotherapy. Mean follow‐up was 30 months for malignancies and 54 months for benign tumors. All patients are now alive without recurrences, with stable intracranial persistence of disease in 2 cases (1 meningioma and 1 adenoid‐cystic carcinoma).

Conclusions:

The purely endoscopic transnasal technique may provide a minimally‐invasive and safe approach to resect selected tumors involving the ITF and UPR. Larger case series and longer follow‐up are needed to validate the reproducibility and efficacy of this technique.
Exploring SEER‐Medicare for Changes in Frequency of Different Treatments for Laryngeal Cancer
Authors: Jean Raymond A. , Kallogjeri Dorina , Strope Seth , Piccirillo Jay F.
Published: August 2013

Objectives:

Explore the change in frequency of different treatment modalities and its association with change in 5‐year survival rate over a 15‐year period among Medicare enrollees with squamous‐cell carcinoma of the larynx (SCCL).

Methods:

Retrospective data analysis of the SEER‐Medicare dataset of elderly patients diagnosed with SCCL between 1992 and 2007. Main treatment modalities were identified, and the change in frequency by year of cancer diagnosis was explored. Multivariate Cox regression was used to calculate the adjusted 5‐year survival by year of diagnosis.

Results:

There were 5159 cases of primary SCCL diagnosed between 1992 and 2007. The majority of patients were male (4033, 78%), Caucasian (4466, 87%), and between 66 and 75 years of age (2873, 56%). Stage distribution at diagnosis was local 3241 (63%), regional 1060 (20%), and distant 608 (12%). Between 1992 and 2007, there was a significant trend for increased use of chemo‐radiation therapy (5% to 15%, P = 0.0255) and a significant trend for decreased use of combined surgery and radiation (47% to 32%, P < 0.0001). No treatment was identified for 474 (9%) patients. There was a significant increase in 5‐year survival rate by year of diagnosis (42.2% in 1992 to 46.7% in 2005, P < 0.0001), which was negatively correlated only to changes in incidence of radiation‐only treatment (Spearman rho = ‐0.6).

Conclusions:

Between 1992 and 2007, there were significant increases in the frequency of use of chemoradiation and concomitant decrease in combined surgery and radiation for SCCL among Medicare beneficiaries. The implications of these trends will be discussed.
Fluorescence‐Guided Thyroidectomy in a Transgenic Murine Model of Papillary Thyroid Carcinoma
Authors: Orosco Ryan K. , Weissbrod Philip A. , Nashi Nadia , Bouvet Michael , Tsien Roger Y. , Nguyen Quyen T.
Published: August 2013

Objectives:

A transgenic murine model for thyroid cancer was used to evaluate the effectiveness of molecularly targeted ratiometric activatable cell‐penetrating peptides (RACPPs) for surgical navigation. We will analyze the implementation of fluorescence guided surgery in this model and discuss future applications.

Methods:

Thirteen transgenic BRAFV600E mice were studied prospectively. Seven were injected with RACPP, and 4 were injected with saline (controls). Pre‐ and postoperative laryngoscopy was used to assess vocal cord function. Total thyroidectomy was performed with microscopic white‐light visualization. Fluorescence imaging of the post‐thyroidectomy field was performed, and fluorescent tissue was removed for pathology. One surgeon carried out all procedures. Data underwent blinded review by a board certified pathologist and a laryngologist.

Results:

There were 7 successful fluorescence guided surgical procedures and four successful controls. Average operative times were 15.8 (RACPP) and 14 minutes (controls). RACPPs improved thyroid tumor visualization with an average intensity ratio of 9.1, versus 1.5 with white‐light alone. Intact function was present in 12 of 12 vocal cords in the study group and 1 of 2 vocal cords of the controls. Postoperatively, 5 RACPP animals showed fluorescent signal, but on histology there was no tumor. Thyroid tumor was present in the final surgical beds of 3 animals, 2 RACPP animals, and 1 control.

Conclusions:

In this transgenic murine model of papillary thyroid cancer, RACPPs improved surgical visualization without compromising post‐resection vocal cord function. There was no proven benefit for completeness of resection. Surgical molecular guidance with RACPPs warrants further study.
Functional and Oncologic Outcomes of Hypopharyngeal Cancer by Treatment Modality
Authors: Momin Suhael , Khan Mumtaz
Published: August 2013

Objectives:

1) Describe functional and oncologic outcomes of patients with hypopharyngeal cancer treated with various treatment modalities. 2) Recognize advantages and limitations of different management options for hypopharyngeal cancer.

Methods:

A retrospective chart review was completed to include all patients with a diagnosis of hypopharyngeal cancer between 1998‐2012. The primary outcome measure was overall survival, with secondary outcome measures including disease free survival, feeding tube dependence, and tracheostomy dependence. Tumor stage at presentation and history of previous or subsequent malignancy were also included. Data were grouped by primary treatment modality (surgical vs non‐surgical). Kaplan Meier curves were generated. Student's t test and Chi‐square test were also used.

Results:

One hundred and eight patients with hypopharyngeal cancer were included. Patients were 79% male, with an average age of 61.9 years and average follow‐up of 36 months. Sixty‐four were treated with non‐surgical modalities, and 44 were treated with surgery with or without adjuvant therapy. Initial analysis demonstrated more locoregional recurrences in those treated without surgery. Among those patients, loco‐regional recurrence occurred in 40% vs 20% of those managed surgically (P = 0.04). Of those patients initially treated non‐surgically, 11 (19%) progressed to require total laryngectomy. Long term feeding tube dependence was not significantly different between treatment modalities (34% surgical vs 30% non‐surgical, P = 0.62).

Conclusions:

Hypopharyngeal cancer remains a challenging clinical problem. In early analysis of our data, rates of locoregional recurrence are higher in patients treated non‐surgically. There is no difference in long‐term feeding‐tube dependence.
Hardware Failure after Osseous Free Flap Reconstruction
Authors: Magnuson Scott , Day Kristine E. , Carroll William R. , Rosenthal Eben L.
Published: August 2013

Objectives:

Understand the underlying reasons for hardware failure after osseous free flap reconstruction.

Methods:

A retrospective chart review of 224 patients undergoing 241 vascularized osseous mandibular reconstructions between the years of 2004‐2012 was conducted with a minimum of 6 months follow‐up.

Results:

There were 33 (14.7%) patients who underwent removal of the support implant with the most common reason being infection, exposure, or both. The average length of time to removal was 16.3 months, with a bimodal distribution: the majority of removals occurred within the first year, and the second group occurred in the third year. Of patients who had the hardware removed after 3 months, there were 12 (36.4%) who had malunion at the time of removal. In those patients, the inciting factor was resolved upon removal for 18.2% (n = 6) of cases.

Conclusions:

Removal of the supporting hardware most commonly occurs from infection or exposure in the first year. In the majority of cases, the bone is well healed and the problem resolves with removal.
Human Papillomavirus and p16 in Oropharyngeal Cancer and Their Relationship to Tobacco Use
Authors: Saunders James , Losavio Phillip , Gattuso Paolo , Lamzabi Ihab , Fogg Louis , Petruzzelli Guy J.
Published: August 2013

Objectives:

Over the last decade, there has been a vast amount of research establishing the link between human papillomavirus (HPV) and oropharyngeal cancer. It has been hypothesized now that two distinct forms of oropharynx cancer exist: HPV associated disease and carcinogen induced. Correlation between oncologic outcomes and HPV status is ongoing. The objective of this study is to investigate the relationship between HPV markers and carcinogen status.

Methods:

Clinical data were collected both retrospectively and prospectively for 151 patients with squamous cell carcinoma of the oropharynx. Main clinical outcome measures included tobacco status (pack‐years and CMS tobacco groupings) and alcohol use history. All tumors were evaluated for p16 by monoclonal antibody immunohistochemistry assay. HPV DNA was detected by in‐situ hybridation probes for low and high risk subtypes. Statistical analysis was done by Pearson's Chi‐Squared analysis for tobacco use.

Results:

Patients with p16+ tumors or HPV+ tumors had significantly lower tobacco exposure (P <. 001, P =. 001 respectively) with p16 having higher significance. These relationships were enhanced in both circumstances when taking both HPV DNA and p16 positive status into account in combination.

Conclusions:

This study demonstrates that HPV+/p16+ tumors show the strongest correlation with low tobacco exposure. It has been hypothesized that p16+, HPV ‐ tumors may represent a distinct subset of oropharynx cancers, with p16 having its own unique clinical relevancy. Further studies should be done to evaluate whether there is a difference in outcome measures for p16+, HPV ‐ tumors relative to p16+, HPV+ tumors.
The Impact of Tumor Volume on Treatment Outcomes for T4a Laryngeal Cancers
Authors: Hsin Li‐Jen , Fang Tuan‐Jen
Published: August 2013

Objectives:

Investigates the impact of tumor volume on treatment outcomes for T4a laryngeal cancer patients.

Methods:

A retrospective chart review was conducted from October 2002 to September 2010. Sixty‐two T4a laryngeal cancer patients treated with laryngectomy or concurrent chemo‐radiotherapy (CRT) were enrolled. Tumor volume was calculated using imaging software and was correlated with the survival data.

Results:

In the CRT group, the 5‐year overall survival (OS) and progression‐free survival (PFS) were significantly lower in those patients whose tumor was larger than 14 cm3 (20.7% vs. 52.6%, P = 0.008; 35.5% vs. 63.4%, P = 0.008). For patients whose tumor volume was larger than 14 cm3, laryngectomy provided a significantly higher 5‐year OS (72.7% vs. 20.7%, P = 0.039) than CRT.

Conclusions:

Patients with T4a laryngeal tumors larger than 14 cm3 had a poorer treatment outcome after CRT than total laryngectomy. Thus, laryngectomy is preferable for this subset of patients.
Microbiological Sampling of Common Otolaryngological Office Equipment: What Lessons Can We Learn?
Authors: Bhatt Jay M. , Verma Sunil P.
Published: August 2013

Objectives:

Analyze whether standard decontamination protocols were effective in cleaning integral components of common otolaryngological office equipment, including flexible fiberoptic laryngoscopes, detachable light cables, and otoscope handles.

Methods:

A random microbiological sampling of 6 flexible fiberoptic laryngoscopes including the eye piece and the driver handle, 3 light cables, and 5 otoscope handles was performed. All equipment was sampled in the middle of a busy office session. Samples were then subjected to standard aerobic growth culture analysis.

Results:

From a total of 20 samples collected, 7 (35%) demonstrated contamination with bacterial organisms. 4 of the 20 sample sites (20%) exhibited human contamination, 2 of which were from light cables, 1 from a laryngoscope eye piece, and 1 from an otoscope handle.

Conclusions:

This microbiological evaluation of common office instruments demonstrates that there are numerous potential contaminates which may be present in the office setting. These include flexible laryngoscope eyepieces, light cables, and otoscopes, which are commonly overlooked in the cleaning protocols of a standard otolaryngology clinic.
Hypocalcemia after Total and Completion Thyroidectomy: Analysis of 100 Consecutive Patients
Authors: Gurunathan Ramesh K. , McCadden Luke , McBride Greg , Nadig Shrinath
Published: August 2013

Objectives:

Evaluate incidence of hypocalcemia (time‐course) after thyroid surgery in 100 consecutive cases who underwent total/completion thyroidectomy.

Methods:

Retrospective case note analysis of 100 cases from 2009 ‐2012. We assessed ionic calcium preoperatively and postoperatively at 6‐24‐48 hours, 1 week, 6 weeks and 6 months. Serum parathormone level 24 hours post‐surgery (and later if persistent hypocalcaemia), patient demographics, details of surgery, duration of stay, histopathological diagnosis were also analyzed.

Results:

79/100 patients were female, 21 male. Mean age was 55 (range 14‐87). 74/100 had total thyroidectomy and 26 had completion. Preoperative mean calcium was 2.39 (range 2.1‐3.86) and at 6 hours post‐operatively dropped to 2.1 (1.84‐2.53), 24 hours 2.16 (1.6‐2.5), 48 hours 2.24 (1.7‐2.7) and 1 week 2.3 (1.74‐2.67) and stabilized at 6 weeks and 6 months 2.3 (1.9‐2.66). 18/100 patients had hypocalcemia (below 1.99) and parathormone at 24 hours post‐operation measured below 5. Delayed hypocalcemia was seen in 4 of 18 patients (after 24‐48 hours) and 2 of them had parathyroid adenoma with pre‐op high calcium. Persistent hypocalcemia at 6 weeks was seen in 7/18 patients and at 6 months in 5/18 patients (necessitating long term calcium/Vitamin D supplement) despite parathormone levels measuring above 5 (mean:7 range:2‐20). Of 18 patients who had hypocalcemia, 10 had surgery for malignancy (with level‐6 neck dissection), 2 had Graves disease, and 2 had Hashimoto's thyroiditis.

Conclusions:

Extensive surgery with neck dissection, elderly patients and peri‐glandular fibrosis predict high risk for post‐operative hypocalcemia. Patients should be warned about risk of delayed hypocalcemia occurring late (after 48 hrs) and seek immediate medical attention.
Immunohistochemical Expression of E‐Cadherin, Survivin and VEGF in Nonexophytic Nasopharyngeal Carcinoma
Authors: Tay Joshua K. , Jeevanandam Madana , Petersson Frederik , Loh Kwok‐Seng
Published: August 2013

Objectives:

E‐cadherin, survivin and vascular endothelial growth factor (VEGF) have been suggested to be prognostic markers for nasopharyngeal carcinoma (NPC). Patients with biopsy‐proven NPC sometimes present with a normal‐appearing nasopharynx (nonexophytic NPC). These patients have been reported to have higher risk of N3 and M1 disease. The authors aim to compare the immunohistochemical expression of the above markers for nonexophytic and exophytic NPC.

Methods:

From 2003 to 2011, 30 patients with nonexophytic NPC were diagnosed in a single institution. Thirty patients diagnosed with exophytic NPC were selected for comparison, matched for age, gender and TNM stage. Expressions of E‐cadherin, survivin and VEGF in tumor tissues were investigated by immunohistochemistry. Expression levels were evaluated by a pathologist blinded to the clinical data, using a semiquantitative scoring scheme.

Results:

The majority of nonexophytic NPC patients had late stage disease (Stage I: 13.3%, II: 23.3%, III: 33.3%, IV: 30%), even though 67% had T1 disease of the nasopharynx. A borderline significant result was obtained for cytoplasmic E‐cadherin, with positive expression in 12% of nonexophytic NPC patients compared to 35.7% of exophytic NPC patients (P =. 059). There was no difference in overall expression of survivin and VEGF between both groups (P =. 612 and P =. 653 respectively, Mann‐Whitney U test).

Conclusions:

Reduced cytoplasmic E‐cadherin suggests downregulation and provides a possible explanation for the higher risk of nodal and distant metastasis in nonexophytic NPC. The evaluation of other immunohistochemical markers should be considered to explain this phenomenon.
Incidence of Occult Nodal Disease in Patients Treated with Salvage Laryngectomy with Radiologically Negative Neck
Authors: Ojo Rosemary B. , Freiser Monika , Saint‐Victor Sandra , Bollig Craig , Mantravadi Avinash V. , Sargi Zoukaa B.
Published: August 2013

Objectives:

The National Comprehensive Cancer Network guidelines address neck dissection in the setting of primary tumor treatment but do not provide a clear guideline for negative nodal disease in recurrent advanced laryngeal cancer. We often extrapolate the indication of neck dissection for recurrent disease based on the guidelines of primary disease. It is controversial whether there is a survival benefit for patients with clinically and radiologically negative (N0) necks to receive a neck dissection versus conservative management. This study aims to determine survival outcomes and incidence of post‐operative complications in patients who underwent neck dissection at the time of salvage laryngectomy with clinically and radiologically negative neck.

Methods:

Single institution case series at a tertiary care university hospital. We identified 424 cases of total laryngectomy between 2000‐2010. We reviewed the subset of N0 patients who had salvage laryngectomy and divided them into neck dissection versus conservative management. We reviewed demographic variables, final pathological stage of dissected neck specimen, and post‐operative course and survival.

Results:

Patients who had a neck dissection at salvage laryngectomy with clinically N0 disease as compared to those treated conservatively may have no significant difference in survival; there may be a significant difference in the complication rate and perioperative mortality rate between the two groups.

Conclusions:

The data reviewed in this large series of patients will be useful for clinicians to determine the survival and complications that are frequently experienced by patients following neck dissection with salvage laryngectomy in the setting of previous radiation.
Incidence of Synchronous Bilateral Tonsillar Carcinoma in a Cohort of T1/T2 Primary Tonsil Cancer
Authors: Saunders James , Losavio Phillip , Petruzzelli Guy J.
Published: August 2013

Objectives:

The most recent review of bilateral synchronous tonsillar carcinoma published in 2012 identified 12 previously described cases in the literature. It has been estimated that there is a 10% incidence of contralateral nodal metastasis from tonsillar carcinoma. However, the true incidence of bilateral synchronous occult disease is unknown. This study aims to describe the incidence of bilateral tonsillar carcinoma in early stage disease.

Methods:

The study design consisted of a retrospective cohort study of 120 patients with T1 or T2 primary tonsillar squamous cell carcinoma treated between 1995 to 2012. All patients were treated with primary radical surgical therapy and had the contralateral tonsil removed at the time of surgery. Data was extracted from an institutional review board approved department database. All cases were reviewed for evidence of an occult tumor in the contralateral tonsil.

Results:

Out of 120 patients, 3 patients were identified to have an occult primary cancer in the contralateral tonsil. This resulted in a 2.5% incidence of disease in this cohort of patients. Compared to the incidence of tonsillar carcinoma in the general population 2.1 x 10‐5, (95% CI: 2 x 10‐5, 2.2 x 10‐5) this is significantly elevated.

Conclusions:

This is the first study attempting to establish the incidence of bilateral tonsillar carcinoma in a large cohort of early stage tonsillar carcinoma patients. Given the increasing use of transoral robotic surgery to treat these patients, it is important to be aware that there is likely a small but slightly elevated risk of contralateral occult disease.