bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.