Patient Experience of Head and Neck Surgery With Free Flap Reconstruction

Importance

Major head and neck surgery with microvascular free tissue transfer reconstruction is complex, with considerable risk of morbidity. Little is known about patients' experiences, including decision-making prior to, and regret following, free flap surgery.

Objective

To characterize patient experiences and decision regret of patients undergoing head and neck reconstructive free flap surgery.

Design, Setting, and Participants

This mixed-methods cohort study comprising semistructured interviews was conducted June to August 2021 at a single tertiary academic cancer center. Participants underwent head and neck reconstructive surgery with microvascular free tissue transfer (flap) more than 3 months before recruitment (range, 3 months to 4 years). Interview transcripts were qualitatively analyzed for themes. Participants also completed a Decision Regret Scale questionnaire.

Exposure

Microvascular free flap surgery for head and neck reconstruction.

Main Outcomes and Measures

Thematic analysis of interviews, decision regret score.

Results

Seventeen participants were interviewed. Median (IQR) age was 61 (52-70) years. Overall, 7 participants were women (49%), and 10 of 17 were men (59%). The most common free flap was fibula (8/17, 47%). Three major themes with 9 subthemes were identified: theme 1 was the tremendous effect of preoperative counseling on surgical decision-making and satisfaction, with subthemes including (1) importance of clinical care team counseling on decision to have surgery; (2) emotional context colors preoperative understanding and retention of information; (3) expectation-setting affects satisfaction with preoperative counseling; and (4) desire for diversified delivery of preoperative information. Theme 2 was coexisting and often conflicting priorities, including (1) desire to survive above all else, and (2) desire for quality of life. Theme 3 was perception of surgery as momentous and distressing, including (1) surgery as a traumatic event; (2) centrality of mental health, emotional resolve, and gratitude to enduring surgery and recovery; and (3) sense of accomplishment in recovery. On the Decision Regret Scale, most participants had no regret (n = 8, 47%) or mild regret (n = 5, 29%); 4 had moderate-to-severe regret (24%).

Conclusions and Relevance

In this mixed-methods cohort study, patient experiences surrounding major head and neck reconstructive free flap surgery were described. Opportunities to improve support for this complex and vulnerable population, and to mitigate decision regret, were identified.

Primary Classic Kaposi Sarcoma of the Parotid Gland in an HIV-Negative Patient

This case report describes an HIV-negative man in his 60s of Mediterranean descent with hypertension, Hashimoto thyroiditis, nephrolithiasis, and gout who presented with a lump on the right side of his face and was subsequently diagnosed with Kaposi sarcoma.

Personal Social Networks and Care-Seeking for Head and Neck Cancer: A Qualitative Study

OBJECTIVES

To investigate the role of patients' personal social networks (SNs) in accessing head and neck cancer (HNC) care through patients' and health care workers' (HCWs) perspectives.

STUDY DESIGN

Qualitative study.

SETTING

Tertiary HNC centers at 2 academic medical centers, including 1 safety net hospital.

METHODS

Patients with newly diagnosed HNC, and HCWs caring for HNC patients, aged ≥18 years were recruited between June 2022 and July 2023. Semistructured interviews were conducted with both patients and HCWs. Inductive and deductive thematic analysis was performed with 2 coders (κ = 0.82) to analyze the data.

RESULTS

The study included 72 participants: 42 patients (mean age 57 years, 64% female, 81% white), and 30 HCWs (mean age 42 years, 77% female, 83% white). Four themes emerged: (1) Patients' SNs facilitate care through various forms of support, (2) patients may hesitate to seek help from their networks, (3) obligations toward SNs may act as barriers to seeking care, and (4) the SN composition and dedication influence care-seeking.

CONCLUSION

Personal SNs play a vital role in prompting early care-seeking among HNC patients. SN-based interventions could enhance care and improve outcomes for HNC patients.

Circulating tumor-tissue modified HPV DNA testing in the clinical evaluation of patients at risk for HPV-positive oropharynx cancer: The IDEA-HPV study

OBJECTIVES

While survival outcomes are favorable for Human Papillomavirus (HPV)-positive oropharyngeal squamous cell carcinomas (OPSCCs), early diagnosis may minimize treatment-related morbidity and mortality. This study evaluated circulating tumor tissue-modified viral (TTMV)-HPV DNA plasma testing to facilitate early diagnosis of HPV-positive OPSCCs.

METHODS

In this prospective exploratory cohort study, patients presenting to an Otolaryngology-Head and Neck Surgery clinic with unexplained signs or symptoms considered high-risk for HPV-positive OPSCC were recruited between March 2021-October 2022. Circulating TTMV-HPV DNA testing was performed, and results were shared with subjects and treating clinicians. Clinicians were surveyed regarding the perceived clinical utility of the test.

RESULTS

Thirty-nine subjects were included. Most subjects were women (N = 23, 59 %), white (N = 32, 82 %) and never-smokers (N = 20, 51 %) with median age 60 years. Circulating TTMV-HPV DNA was detected in 2/39 subjects, both subsequently diagnosed with HPV-positive OPSCC. Both were white men aged 70-80 years with a neck mass. One subject with undetectable TTMV-HPV DNA was also diagnosed with HPV-positive OPSCC through excisional neck mass biopsy. Other eventual diagnoses included 3 HPV-negative head and neck squamous cell carcinomas and 4 other malignancies. Testing was perceived as helpful in clinical decision-making for 26/38 (68 %) subjects, and useful for similar future patients for 32/37 (86 %) subjects.

CONCLUSION

Circulating TTMV-HPV DNA testing is feasible and holds potential as a diagnostic aid for HPV-positive OPSCC alongside standard clinical workup. Clinicians should be cognizant of its limitations, as a negative test does not necessarily indicate the absence of disease. Further studies to evaluate its utility are warranted.

Variations in Payer-Negotiated Prices for Head and Neck Reconstructive Surgery

OBJECTIVE

Little is known about pricing for reconstructive procedures of the head and neck. As of January 2021, the Centers for Medicare and Medicaid Services requires hospitals to disclose payer-negotiated prices for services, offering new insight into prices for privately insured patients.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Turquoise database.

METHODS

Payer-negotiated facility fees for 41 reconstructive surgeries were grouped by procedure type: primary closure, skin grafts, tissue rearrangement, locoregional flaps, or free flaps. Prices were normalized to account for local labor costs, then calculated as percent markup in excess of Medicare reimbursement. The mean percent markup between procedure groups was compared by the Kruskal-Wallis test. Subset analyses were performed to compare mean percent markup using a Student's t test. We also assessed price variation by calculating the ratio of 90th/10th percentile mean prices both across and within hospitals.

RESULTS

In total, 1324 hospitals (85% urban, 81% nonprofit, 49% teaching) were included. Median payer-negotiated fees showed an increasing trend with more complex procedures, ranging from $379.54 (interquartile range [IQR], $230.87-$656.96) for Current Procedural Terminology (CPT) code 12001 ("simple repair of superficial wounds ≤2.5 cm") to $5422.60 ($3983.55-$8169.41) for CPT code 20969 ("free osteocutaneous flap with microvascular anastomosis"). Median percent markup was highest for primary closure procedures (576.17% [IQR, 326.28%-1089.34%]) and lowest for free flaps (99.56% [37.86%-194.02%]). Higher mean percent markups were observed for rural, for-profit, non-Northeast, nonteaching, and smaller hospitals.

CONCLUSION

Wide variation in private payer-negotiated facility fees exists for head/neck reconstruction surgeries. Further research is necessary to better understand how pricing variation may correlate with out-of-pocket costs and quality of care.

Hospital-Negotiated Pricing of Cochlear Implants

Access to cochlear implantation can be restricted by financial burden, and little is known about the extent to which cochlear implant (CI) devices prices may vary between hospitals or manufacturers. We performed a cross-sectional analysis of private payer-negotiated prices for CI devices. In total, 161 hospitals were analyzed. Prices varied widely across hospitals and between payers. Despite clinical equipoise between manufacturers with regards to CI user outcomes, significant differences in prices were identified, with higher prices for MED-EL ($38,478 ± 2633) than for Cochlear Ltd. ($34,150 ± 2418, p < .001). Markup analysis for Cochlear Ltd. devices revealed a mean 58.5% ± 7.4% markup in excess of the company's average sales price ($24,649). Negotiated prices were also at least $5000 lower when all 3 brands were offered at the same center (p < .05). Further research examining the influence of patient outcomes and hospital volume on prices are needed.

Hospital Prices for Pediatric Tympanostomy Tube Placement and Adenotonsillectomy in 2021

OBJECTIVES

Hospital prices vary substantially for myringotomy with tympanostomy tube placement (M&T) and adenotonsillectomy (T&A). The Centers for Medicare and Medicaid Services recently implemented hospital price transparency requirements to help families make financially informed decisions about where to seek care. We sought to determine price availability and the extent of price variation for these procedures.

METHODS

We performed a cross-sectional analysis of the Turquoise Health Hospital Rates Data Platform, which extracts prices for facility fees from publicly available hospital chargemasters. We determined the proportion of hospitals serving pediatric patients that published payer-specific prices for M&T and T&A. We additionally characterized the extent of variation in payer-specific prices both across and within hospitals.

RESULTS

Approximately 40% (n = 909 of 2,266 hospitals) serving pediatric patients disclosed prices for M&T or T&A. Among disclosing hospitals, across-center ratios (adjusted for Medicare hospital wage indices) ranged from 11.0 (M&T; 10th percentile adjusted median price: $536.80 versus 90th percentile adjusted median price: $5,929.93) to 23.4 (revision adenoidectomy age >12 years; 10th percentile: $393.82 versus 90th percentile: $9,209.88). Median within-center price ratios for procedures ranged from 2.2 to 2.7, indicating that some private payers reimbursed the same hospital more than twice as much as other payers for the same procedure.

CONCLUSION

The majority of hospitals serving pediatric patients were non-compliant with federal requirements to disclose prices for M&T and T&A. Among disclosing hospitals, there was wide variation in payer-specific prices between and within institutions. Further research is necessary to understand whether disclosure of prices will enable families to make more financially informed decisions.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:948-955, 2023.

Variation in the Price of Head and Neck Surgical Oncology Procedures

Health care costs can present a significant strain on patients with head and neck cancer. It remains unclear how much prices may vary among hospitals providing care and what factors lead to differences in prices of surgical procedures. A cross-sectional analysis of private payer-negotiated prices was performed for 10 commonly performed head and neck surgical oncology procedures. In total, 896 hospitals disclosed prices for at least 1 common head and neck surgical oncology procedure. Wide variation in negotiated surgical prices was identified. Across-center ratios ranged from 6.2 (partial glossectomy without primary closure) to 22.8 (excision of tongue lesion without closure). For-profit hospital ownership structure and geographic region outside of the northeast United States were associated with increased prices. For example, private payer-negotiated prices for direct laryngoscopy with biopsy were on average $2083 greater at for-profit hospitals when compared with nonprofit hospitals ($5215 vs $3132, P < .001). Further research comparing prices and outcomes is needed.

Hospital-Administered Cancer Therapy Prices for Patients With Private Health Insurance

Importance

The federal Hospital Price Transparency final rule, which became effective in 2021, requires hospitals to publicly disclose payer-specific prices for drugs. However, little is known about hospital markup prices for parenterally administered therapies.

Objective

To assess the extent of price markup by hospitals on parenterally administered cancer therapies and price variation among hospitals and between payers at each hospital.

Design, Setting, and Participants

A cross-sectional analysis was conducted of private payer-specific negotiated prices for the top 25 parenteral (eg, injectable or infusible) cancer therapies by Medicare Part B spending in 2019 using publicly available hospital price transparency files. Sixty-one National Cancer Institute (NCI)-designated cancer centers providing clinical care to adults with cancer were included. The study was conducted from April 1 to October 15, 2021.

Exposures

Estimated hospital acquisition costs for each cancer therapy using participation data from the federal 340B Drug Pricing Program.

Main Outcomes and Measures

The primary outcome was hospital price markup for each cancer therapy in excess of estimated acquisition costs. Secondary outcomes were the extent of across-center price ratios, defined as the ratio between the 90th percentile and 10th percentile median prices across centers, and within-center price ratios, defined as the ratio between the 90th percentile and 10th percentile prices between payers at each center.

Results

Of 61 NCI-designated cancer centers, 27 (44.3%) disclosed private payer-specific prices for at least 1 top-selling cancer therapy as required by federal regulations. Median drug price markups across all centers and payers ranged between 118.4% (sipuleucel-T) and 633.6% (leuprolide). Across-center price ratios ranged between 2.2 (pertuzumab) and 15.8 (leuprolide). Negotiated prices also varied considerably between payers at the same center; median within-center price ratios for cancer therapies ranged from 1.8 (brentuximab) to 2.5 (bevacizumab).

Conclusions and Relevance

Most NCI-designated cancer centers did not publicly disclose payer-specific prices for cancer therapies as required by federal regulation. The findings of this cross-sectional study suggest that, to reduce the financial burden of cancer treatment for patients, institution of public policies to discourage or prevent excessive hospital price markups on parenteral chemotherapeutics might be beneficial.

Neoadjuvant and Adjuvant Nivolumab and Lirilumab in Patients with Recurrent, Resectable Squamous Cell Carcinoma of the Head and Neck

PURPOSE

Surgery often represents the best chance for disease control in locoregionally recurrent squamous cell carcinoma of the head and neck (SCCHN). We investigated dual immune-checkpoint inhibition [anti-PD-1, nivolumab (N), and anti-KIR, lirilumab (L)] before and after salvage surgery to improve disease-free survival (DFS).

PATIENTS AND METHODS

In this phase II study, patients received N (240 mg) + L (240 mg) 7 to 21 days before surgery, followed by six cycles of adjuvant N + L. Primary endpoint was 1-year DFS; secondary endpoints were safety, pre-op radiologic response, and overall survival (OS). Correlatives included tumor sequencing, PD-L1 scoring, and immunoprofiling.

RESULTS

Among 28 patients, the median age was 66, 86% were smokers; primary site: 9 oral cavity, 9 oropharynx, and 10 larynx/hypopharynx; 96% had prior radiation. There were no delays to surgery. Grade 3+ adverse events: 11%. At the time of surgery, 96% had stable disease radiologically, one had progression. Pathologic response to N + L was observed in 43% (12/28): 4/28 (14%) major (tumor viability, TV ≤ 10%) and 8/28 (29%) partial (TV ≤ 50%). PD-L1 combined positive score (CPS) at surgery was similar regardless of pathologic response (P = 0.71). Thirteen (46%) recurred (loco-regional = 10, distant = 3). Five of 28 (18%) had positive margins, 4 later recurred. At median follow-up of 22.8 months, 1-year DFS was 55.2% (95% CI, 34.8-71.7) and 1-year OS was 85.7% (95% CI, 66.3-94.4). Two-year DFS and OS were 64% and 80% among pathologic responders.

CONCLUSIONS

(Neo)adjuvant N + L was well tolerated, with a 43% pathologic response rate. We observed favorable DFS and excellent 2-year OS among high-risk, previously treated patients exhibiting a pathologic response. Further evaluation of this strategy is warranted.See related commentary by Sacco and Cohen, p. 435.

Private Payer-Negotiated Prices for Outpatient Otolaryngologic Surgery

In January 2021, the Centers for Medicare & Medicaid Services began requiring hospitals to publish price transparency files listing all prices negotiated with payers. We performed a cross-sectional analysis of payer-negotiated prices for commonly performed outpatient otolaryngology surgery at all hospitals scored by the US News & World Report in otolaryngology. We compared prices among hospitals (across-center ratios) and among payers at the same hospital (within-center ratios). Price disclosure rates were low overall for otolaryngologic surgery (maximum, 26.7% for bronchoscopy). Across-center ratios ranged from 3.5 (adjacent tissue transfer/rearrangement <10 cm²; raw median price range, $1384-$7047) to 18.6 (cochlear implant placement; raw median price range, $2417-$60,255). Median within-center ratios ranged between 2.7 (intraoperative navigation) and 5.4 (total thyroidectomy). Although price variation may signal opportunities for cost savings, patients may have limited ability to comparison shop due to hospital nondisclosure. Further investigation is necessary to examine the factors affecting price variation for otolaryngologic procedures.

Cancer of the Oropharynx and the Association with Human Papillomavirus

Squamous cell carcinoma of the oropharynx (OPC) consists of human papillomavirus (HPV)-negative disease caused by tobacco and alcohol use, and HPV-positive disease caused by the sexually transmitted infection HPV. These entities have unique but overlapping risk factors, epidemiologic trends, staging systems, and survival outcomes. HPV-positive tumor status confers a significant survival benefit compared with HPV-negative disease. OPC treatment entails a combination of surgery, radiation, and chemotherapy. Ongoing trials will determine whether treatment of HPV-related disease may be safely deintensified to decrease morbidity. Emerging HPV-related biomarkers are under study as tools to inform screening, diagnosis, treatment, and surveillance for HPV-positive OPC.

Socioeconomic and Demographic Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the Affordable Care Act

Importance

Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC.

Objective

To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC.

Design, Setting, and Participants

A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018.

Main Outcomes and Measures

Changes in the percentage of patients with insurance.

Results

A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36).

Conclusions and Relevance

There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.

Cost-effectiveness analysis of using the heat and moisture exchangers compared with alternative stoma covers in laryngectomy rehabilitation: US perspective

BACKGROUND

This study aims to evaluate the cost-effectiveness of using heat and moisture exchangers (HMEs) vs alternative stoma covers (ASCs) following laryngectomy in the United States.

METHODS

A cost-effectiveness and budget impact analysis were conducted including uncertainty analyses using real-world survey data with pulmonary events and productivity loss.

RESULTS

HME use was more effective and less costly compared with ASCs. Quality-adjusted life years were slightly higher for HME-users. Total costs per patient (lifetime) were $59 362 (HME) and $102 416 (ASC). Pulmonary events and productivity loss occurred more frequently in the ASC-users. Annual budget savings were up to $40 183 593. Costs per pulmonary event averted were $3770.

CONCLUSIONS

HME utilization in laryngectomy patients was cost-effective. Reimbursement of HME devices is thus recommended. Utilities may be underestimated due to the generic utility instrument used and sample size. Therefore, we recommend development of a disease-specific utility tool to incorporate in future analyses.

State Medicaid expansion status, insurance coverage and stage at diagnosis in head and neck cancer patients

OBJECTIVES

Only one in three head and neck cancer (HNC) patients present with early-stage disease. We aimed to quantify associations between state Medicaid expansions and changes in insurance coverage rates and stage at diagnosis of HNC.

METHODS

Using a quasi-experimental difference-in-differences (DID) approach and data from 26,330 cases included in the Surveillance, Epidemiology, and End Results program (2011-2015), we retrospectively examined changes in insurance coverage and stage at diagnosis of adult HNC in states that expanded Medicaid (EXP) versus those that did not (NEXP).

RESULTS

There was a significant increase in Medicaid coverage in EXP (+1.6 percentage point (PP) versus) vs. NEXP (-1.8 PP) states (3.36 PP, 95% CI = 1.32, 5.41; p = 0.001), and this increase was mostly among residents of low income and education counties. We also observed a reduction in uninsured rates among HNC patients in low income counties (-4.17 PP, 95% CI = -6.84, -1.51; p = 0.002). Overall, early stage diagnosis rates were 28.3% (EXP) vs. 26.7% (NEXP), with significant increases in early stage diagnosis post-Medicaid expansion among young adults, 18-34 years (17.2 PP, 95% CI - 1.34 to 33.1, p = 0.034), females (7.54 PP, 95% CI = 2.00 to 13.10, p = 0.008), unmarried patients (3.83 PP, 95% CI = 0.30-7.35, p = 0.033), and patients with lip cancer (13.5 PP, 95% CI = 2.67-24.3, p = 0.015).

CONCLUSIONS

Medicaid expansion is associated with improved insurance coverage rates for HNC patients, particularly those with low income, and increases in early stage diagnoses for young adults and women.

Change in stage of presentation of head and neck cancer in the United States before and after the affordable care act

OBJECTIVE/HYPOTHESIS

Early diagnosis and stage at presentation, two prognostic factors for survival among patients with head and neck cancer (HNC), are significantly impacted by a patient's health insurance status. We aimed to assess the impact of the Patient Protection and Affordable Care Act (ACA) on stage at presentation across socioeconomic and demographic subpopulations of HNC patients in the United States.

STUDY DESIGN

Retrospective data analysis.

METHODS

The National Cancer Database, a hospital-based cancer database (2011-2015), was queried for adults aged 18-64 years and diagnosed with a malignant primary HNC. The outcome of interest was change in early-stage diagnoses between 2011-2013 (pre-ACA) and 2014-2015 (post-ACA) using logistic regression models.

RESULTS

A total of 91,137 HNC cases were identified in the pre-ACA (n = 53,726) and post-ACA (n = 37,411) years. Overall, the odds of early-stage diagnoses did not change significantly post-ACA (aOR = 0.97, 95 % CI 0.94, 1.00; p = 0.081). However, based on health insurance status, HNC patients with Medicaid were significantly more likely to present with early-stage disease post-ACA (aOR = 1.12, 95 % CI 1.03, 1.21; p = 0.007). We did not observe increased odds of early-stage presentation for other insurance types. Males were less likely to present with early-stage disease, pre- or post-ACA.

CONCLUSIONS

We demonstrate a significant association between ACA implementation and increased early-stage presentation among Medicaid-enrolled HNC patients. This suggests that coverage expansions through the ACA may be associated with increased access to care and may yield greater benefits among low-income HNC patients.

National Trends in Surgical Resection of Vestibular Schwannomas

OBJECTIVE

To characterize the national trend for surgical resection of vestibular schwannoma (VS) and to assess changes in demographics, length of stay (LOS), discharge patterns, and hospital charges.

STUDY DESIGN

Population-based inpatient registry analysis.

SETTING

National Inpatient Sample and SEER database (Surveillance, Epidemiology, and End Results).

PATIENTS AND METHODS

Retrospective review of the US National Inpatient Sample and the SEER database from 2001 to 2014 of all patients who underwent resection of VS.

RESULTS

A total of 24,380 VS resections were performed. While the annual incidence of VS remained stable at 1.38 per 100,000, surgical volume declined by 36.1%, from 2807 in 2001 to 1795 in 2014 (R² = 0.58). Total hospital charges more than doubled, from $52,475 in 2001 to $115,164 in 2014 ($4478 per year, R² = 0.96). While most procedures were performed at large-sized hospitals, this decreased from 89% in 2002 to 75.8% in 2014. Average LOS remained stable at 5.2 days during the study period. The number of discharges to a nursing facility increased from 113 (5.5%) in 2002 to 245 (13.6%) in 2014 (P = .0002).

CONCLUSION

VS resection has evolved in the United States. While the incidence remained stable, surgical volume decreased by 36%, and hospital charges more than doubled. More cases are being performed at smaller hospitals. Although LOS did not vary significantly, there is an increase in nonroutine discharges. These data may guide future research in resource utilization in neurotology.

Predicting length of stay in head and neck patients who undergo free flap reconstruction

OBJECTIVE

Understanding factors that affect postoperative length of stay (LOS) may improve patient recovery, hasten postoperative discharge, and minimize institutional costs. This study sought to (a) describe LOS among head and neck patients undergoing free flap reconstruction and (b) identify factors that predict increased LOS.

METHODS

A retrospective cohort was performed of 282 head and neck patients with free flap reconstruction for oncologic resection between 2011 and 2013 at a tertiary academic medical center. Patient demographics, tumor characteristics, and surgical and infectious complications were characterized. Multivariable regression identified predictors of increased LOS.

RESULTS

A total of 282 patients were included. Mean age was 64.7 years (SD = 12.2) and 40% were female. Most tumors were located in the oral cavity (53.9% of patients), and most patients underwent radial forearm free flap (RFFF) reconstruction (RFFF-73.8%, anterolateral thigh flap-11.3%, and fibula free flap-14.9%). Intraoperative complications were rare. The most common postoperative complications included nonwound infection (pneumonia [PNA] or urinary tract infection [UTI]) (15.6%) and wound breakdown/fistula (15.2%). Mean and median LOS were 13 days (SD = 7.7) and 10 days (interquartile range = 7), respectively. Statistically significant predictors of increased LOS included flap take back (Beta coefficient [C] = +4.26, P < .0001), in-hospital PNA or UTI (C = +2.52, P = .037), wound breakdown or fistula (C = +5.0, P < .0001), surgical site infection (C = +3.54, P = .017), and prior radiation therapy (C = +2.59, P = .004).

CONCLUSION

Several perioperative factors are associated with increased LOS. These findings may help with perioperative planning, including the need for vigilant wound care, optimization of antibiotics prophylaxis, and institution-level protocols for postoperative care and disposition of free flap patients.

LEVEL OF EVIDENCE

2b; retrospective cohort.

Outcomes and prognostic factors in parotid gland malignancies: A 10-year single center experience

OBJECTIVES

To describe a 10-year single center experience with parotid gland malignancies and to determine factors affecting outcomes.

STUDY DESIGN

Retrospective review.

METHODS

The institutional cancer registry was used to identify patients treated surgically for malignancies of the parotid gland between January 2005 and December 2014. Clinical and pathologic data were collected retrospectively from patient charts and analyzed for their association with overall survival (OS) and disease-free survival (DFS).

RESULTS

Two hundred patients were identified. Mean age at surgery was 57.8 years, and mean follow-up time was 52 months. One hundred two patients underwent total parotidectomy, while 77 underwent superficial parotidectomy, and 21 underwent deep lobe resection. Seventy patients (35%) required facial nerve (FN) sacrifice. Acinic cell carcinoma was the most common histologic type (22%), followed by mucoepidermoid carcinoma (21.5%) and adenoid cystic carcinoma (12.5%). Twenty-nine patients (14.5%) experienced recurrences, with mean time to recurrence of 23.6 months (range: 1-82 months). Five- and 10-year OS were 81% and 73%, respectively. Five- and 10-year DFS were 80% and 73%, respectively. In univariate analyses, age > 60, histologic type, positive margins, high grade, T-stage, node positivity, perineural invasion, and FN involvement were predictors of OS and DFS. In the multivariate analysis, histology, positive margins, node positivity, and FN involvement were independent predictors of OS and DFS.

CONCLUSIONS

Our single-center experience of 200 patients suggests that histology, positive margins, node positivity, and FN involvement are independently associated with outcomes in parotid malignancies.

LEVEL OF EVIDENCE

4.

Insurance status, stage of presentation, and survival among female patients with head and neck cancer

OBJECTIVES

Incidence trends and outcomes of head and neck cancer (HNC) among female patients are not well understood. The objective of this study was to estimate incidence trends and quantify the association between health insurance status, stage at presentation, and survival among females with HNC.

STUDY DESIGN

Retrospective cohort study.

METHODS

The Surveillance, Epidemiology, and End Results database (2007-2014) was queried for females aged ≥18 years diagnosed with a malignant primary head and neck cancer (HNC) (n = 18,923). Incidence trends for stage at presentation were estimated using Joinpoint regression analysis. The association between health insurance status and stage at presentation on overall and disease-specific survival was estimated using Fine and Gray proportional hazards models.

RESULTS

Incidence of stage IV HNC rose by 1.24% from 2007 to 2014 (annual percent change = 1.24, 95% CI 0.30, 2.20). Patients with Medicaid (adjusted odds ratio [aOR] = 1.59, 95% confidence interval [CI] 1.45, 1.74) and who were uninsured (aOR = 1.73, 95% CI 1.47, 2.04) were more likely to be diagnosed with advanced stage (stages III/IV) HNC. Similarly, patients with Medicaid (adjusted hazard ratio [aHR] = 1.47, 95% CI 1.38, 1.56) and who were uninsured (aHR =1.45, 95% CI 1.29, 1.63) were more likely to die from any cause compared to privately insured patients. Medicaid (aHR = 1.34, 95% CI 1.24, 1.44) and uninsured (aHR = 1.41, 95% CI 1.24, 1.60) patients also had a greater hazard of HNC-specific deaths compared to privately insured patients.

CONCLUSIONS

Incidence of advanced-stage presentation for female HNC patients in the United States has increased significantly since 2007, and patients who are uninsured or enrolled in Medicaid are more likely to present with late stage disease and die earlier.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:385-391, 2020.

The role of elective neck dissection in patients with adenoid cystic carcinoma of the head and neck

OBJECTIVE

To investigate the frequency and outcomes of elective neck dissection (END) for adenoid cystic carcinoma (ACC) of the head and neck.

METHODS

The National Cancer Database was queried for a cohort study of patients with ACC of the major salivary glands, nasal cavity/nasopharynx, hard/soft palate, tongue, floor of mouth, larynx, and oral cavity who underwent primary surgical resection from 2004 to 2014. Multivariable logistic regression was used to identify predictors of END and occult nodal metastasis. Overall survival (OS) was estimated using the Kaplan-Meier method and modeled with Cox proportional hazards regression.

RESULTS

Among 2,807 patients with ACC treated surgically, 636 (22.7%) underwent END. Patients with ACC of the salivary glands and tongue most frequently underwent END; patients with hard/soft palate (odds ratio [OR] 0.06, P < 0.001) and nasal cavity/nasopharynx (OR 0.05, P < 0.001) ACC rarely underwent END compared to patients with major salivary gland cancer. Increasing tumor (T) stage (T4 vs. T1, OR 3.02, P < 0.001) was associated with END. Patients with advanced T3 to T4 ACC of the major salivary glands demonstrated extended OS associated with END (5-year OS 78.1% vs. 70.4%, P = 0.041) on Kaplan-Meier analysis and with END with adjuvant radiation therapy (hazard ratio 0.55, P = 0.027) using Cox proportional hazards regression. Elective neck dissection for T4 ACC of the salivary glands (21.3%) and tongue (25.5%) most consistently revealed occult nodal metastasis.

CONCLUSION

Elective neck dissection for ACC of the major salivary glands or tongue is most likely to reveal occult nodal metastasis. Elective neck dissection is associated with extended OS for advanced-stage ACC of the major salivary glands.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2094-2104, 2019.

Laryngeal fracture presentation and management in United States emergency rooms

OBJECTIVES/HYPOTHESIS

There are limited data on laryngeal fracture presentation and management in US emergency departments (EDs). We aimed to characterize patients who are diagnosed with laryngeal fractures in the ED and identify management patterns.

STUDY DESIGN

Retrospective review of the Nationwide Emergency Department Sample (NEDS) from 2009 to 2011.

METHODS

The NEDS was queried for patient visits with a primary diagnosis of open or closed laryngeal fracture (International Classification of Diseases, Ninth Revision codes 807.5 and 807.6). Patient demographics, comorbidities, ED management, and hospital characteristics were extracted.

RESULTS

There were 3,102 ED visits with a diagnosis of laryngeal fracture during the study period. Mean patient age was 40.9 years (range, 3-93 years). The majority of patients were male (85.5%) and sustained a closed (vs. open) fracture (91.4%), with an overall mortality rate of 3.8%. The majority of patients were treated for more than one injury during the same visit (76.2%). Most patients were evaluated at a trauma hospital (53.9%), and most patients were admitted to the hospital (71.9%). Emergent intubation or tracheostomy was rarely reported (2.6% and 0.1% of all cases), and a minority of patients underwent fiberoptic flexible laryngoscopy in the ED (1.9%). Laryngeal fractures occurred more frequently during summer months (28.2%). Mean charge for the entirety of the ED stay was $4,957.34.

CONCLUSIONS

Laryngeal fracture is rare and frequently associated with other injuries. The frequency of emergent airway procedure, imaging, and flexible fiberoptic laryngoscopy is lower than expected, raising concerns about appropriate workup and management or recognition of injury in the ED setting.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2341-2346, 2019.

Opioid prescription patterns and use among patients undergoing endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Opioid-related deaths in the United States have increased 200% since 2000, in part due to prescription diversion from patients who had a surgical procedure. The purpose of this study was to characterize provider prescription patterns and assess patient-reported opioid use after endoscopic sinus surgery (ESS).

STUDY DESIGN

Retrospective chart review.

METHODS

Patients who underwent ESS between May 2017 and May 2018 were included. Opioid prescription, operative details, and postoperative opioid use data were extracted. The Massachusetts Prescription Awareness Tool (MassPAT) was queried to determine if patients filled their prescription.

RESULTS

One hundred fifty-five patients were included. Nearly all patients received an opioid prescription (94.8%). An average of 15.6 tablets was prescribed per patient. Among 116 patients with MassPAT data, 91.4% filled their prescription. Among 67 patients who reported the number of tablets they had used at the time of first follow-up appointment, 73.1% reported taking no opioids. Mean number of tablets prescribed was significantly greater among patients who underwent primary versus revision surgery (16.5 vs. 13.5, P = .0111) and those who had splints placed (21.5 vs. 15.1, P = .0037). Predictors of opioid use included concurrent turbinate reduction (58.3% vs. 14.3%, P < .0001) and concurrent septoplasty (45.5% vs. 21.6%, P = .039).

CONCLUSIONS

Nearly all patients who underwent ESS were prescribed an opioid, and nearly all patients filled their prescription. However, the vast majority of patients did not require any opioid medication for postoperative pain control. As the opioid epidemic continues to persist, these findings have immediate relevance to current prescribing patterns and pain management practices.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1046-1052, 2019.

Postoperative care in an intermediate-level medical unit after head and neck microvascular free flap reconstruction

Objective

The need for intensive care unit (ICU) admission and mechanical ventilation after head and neck microvascular free flap reconstructive surgery remains controversial. Our institution has maintained a longstanding practice of immediately taking patients off mechanical ventilation with subsequent transfer to intermediate, non-ICU level of care with specialized otolaryngologic nursing. Our objective was to describe postoperative outcomes for a large cohort of patients undergoing this protocol and to examine the need for routine ICU transfer.

Materials and Methods

We performed a retrospective review of 512 consecutive free flaps treated with a standard protocol of immediate postoperative transfer to an intermediate-level care unit with specialized otolaryngology nursing. Outcome measures included ICU transfer, ventilator requirement, flap failure, postoperative complications, and length of stay. Predictors of ICU transfer were identified by multivariable logistic regression.

Results

The vast majority of patients did not require intensive care. Only a small fraction (n = 18 patients, 3.5%) subsequently transferred to the ICU, most commonly for respiratory distress, cardiac events, and infection. The most common complications were delirium/agitation (n = 55; 10.7%) and pneumonia (n = 51; 10.0%). Sixty-five cases (12.7%) returned to the OR, most commonly for hematoma/bleeding (n = 41; 8.0%) and anastomosis revision (n = 20; 3.9%). Heavy alcohol consumption and greater number of medical comorbidities were significant predictors of subsequent ICU transfer.

Conclusions

Among head and neck free flap patients, routine cessation of mechanical ventilation and transfer to intermediate-level care with specialized ENT nursing was found to be safe with infrequent subsequent ICU transfer and low complication rates. Routine transfer to intermediate-level care in this population may prevent unnecessary ICU utilization and facilitate the delivery of high-value, disease-centered care.

Level of Evidence

3b.

Value of SPECT/CT for Sentinel Lymph Node Localization in the Parotid and External Jugular Chain

OBJECTIVE

Preoperative single-photon emission computed tomography/computed tomography (SPECT/CT) imaging may aid in the localization of sentinel lymph nodes (SLNs) in cutaneous head and neck malignancy and has been rigorously evaluated for deep cervical lymph nodes. The purpose of this study was to assess the sensitivity, specificity, and positive predictive value (PPV) of SPECT/CT for preoperative localization of nodal basins superficial to the sternocleidomastoid muscle, with comparison to deep nodal basins of the neck.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

SPECT/CT images obtained preoperatively for patients undergoing SLN biopsy for cutaneous head and neck malignancy between June 2015 and June 2016 were reviewed by a blinded nuclear medicine physician and head and neck surgeon. SPECT/CT imaging was compared to intraoperatively determined SLN location via gamma probe. Sensitivity, specificity, and positive and negative predictive values were determined and compared for superficial (external jugular [EJ] and parotid) nodes vs level II nodes.

RESULTS

Fifty-three patients were included in the study. Most had cutaneous melanoma (69.8%). The PPV of EJ/parotid node identification by SPECT/CT imaging was 85.7%, specificity was 88.9%, and sensitivity was 69.2%. Comparatively, the PPV for level II nodes was 76.9%, specificity was 50%, and sensitivity was 85.7%. No significant difference in SPECT/CT predictive value was identified between EJ/parotid and level II node identification ( P > .05).

CONCLUSION

SPECT/CT imaging has strong specificity and positive predictability for preoperative localization of SLN superficial to the sternocleidomastoid muscle in cutaneous head and neck malignancy. SPECT/CT imaging may be a useful radiographic aid for preoperative SLN mapping in this patient population.

Transfusion in Head and Neck Cancer Patients Undergoing Pedicled Flap Reconstruction

OBJECTIVE

Blood product utilization is monitored to prevent unnecessary transfusions. Head-and-neck pedicled flap reconstruction transfusion-related outcomes were assessed.

METHODS

One hundred and thirty-six pedicled flap patients were reviewed: 64 supraclavicular artery island flaps (SCAIF), 57 pectoralis major (PM) flaps, and 15 submental (SM) flaps. Outcome parameters included flap-related complications, medical complications, length of stay (LOS), and flap survival. Multivariable logistic regression analyses were performed. Multivariable logistic regression analyses were performed to adjust for relevant pre- and perioperative factors.

RESULTS

Of all head-and-neck pedicled flap patients included in our analyses (n = 136), 40 (29.4%) received blood transfusions. The average pretransfusion hematocrit (Hct) was 24.3% ± 0.5%, with 2.65 ± 0.33 units transfused and a posttransfusion Hct increase of 5.0% ± 0.6%. Transfusion rates differed with PM (47.4%), SCAIF (17.2%), and SM (13.3%) flaps (P < 0.005). Patients undergoing PM reconstruction trended toward higher transfusion requirements (PM 2.89 ± 0.47 units, SC 2.18 ± 0.28 units, and SM 2.00 ± 0.0 units), with transfusion occurring later in the postoperative course (4.9 ± 1.3 days vs. 2.4 ± 0.1 days for all other flaps; P = 0.08). Infection, dehiscence, fistula, or medical complications were not different. Transfusion thresholds of Hct < 21 versus Hct < 27 exhibited no difference in LOS, flap-survival, or medical/flap-related complications.

CONCLUSION

Transfusion is not associated with surgical or medical morbidity following head and neck pedicled flap reconstruction. There were no differences in outcomes between transfusion triggers of Hct < 21 versus Hct < 27, suggesting that a more conservative transfusion trigger may not precipitate adverse patient complications. Our data recapitulate findings in free flap patients and warrant further investigation of transfusion practices in head and neck flap reconstruction.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:E409-E415, 2018.

Association of Treatment for Critical Limb Ischemia with Gender and Hospital Volume

Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10–707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83–0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17–0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69–0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09–1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation.

Association of Treatment for Critical Limb Ischemia with Gender and Hospital Volume

Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10-707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83-0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17-0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69-0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09-1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation.

Online Teaching Tool for Sinus Surgery: Trends toward Mobile and Global Education

Objective

Online resources may provide an ideal forum for expert presentation of surgical techniques. The purpose of this study was to investigate utilization patterns of a sinus surgery website, SinusVideos.com, to gain insight into the needs of viewers.

Study Design

Retrospective analysis.

Setting

Surgical teaching website.

Subjects and Methods

The website’s anonymized analytic database was queried from 2009 to 2014. Quantified data included user demographics, geographic location, viewing device, page visits, and time spent on the website.

Results

A total of 428,691 website pages were viewed during the study period. Growth in viewership was observed each successive year since the site was launched. The mean time spent viewing webpages was 96.1 seconds for desktop computer users, 98.0 for tablet users, and 103.8 for mobile users. The percentage of mobile devices used to view the site increased significantly between 2009 and 2014 (2.1% vs 25.4%, respectively; P < .0001). The website’s viewership expanded globally, with a significant increase in site views from outside North America over this same period (18.4% vs 51.7%, P < .0001).

Conclusion

The observed increase in global participation and mobile device usage may reflect new areas of growth for surgical education.

Resident responses to after-hours otolaryngology patient phone calls: An overlooked aspect of residency training?

OBJECTIVES/HYPOTHESIS

Otolaryngology residents are often responsible for triaging after-hours patient calls. However, residents receive little training on this topic. Data are limited on the clinical content, reporting, and management of otolaryngology patient calls. This study aimed to characterize the patient concerns residents handle by phone and their subsequent management and reporting.

STUDY DESIGN

Retrospective review.

METHODS

Five hundred consecutive after-hours patient calls in a tertiary pediatric hospital were reviewed. Data collected included patient and caller demographics, clinical concerns, surgical history, recommendations, and subsequent emergency department (ED) visits.

RESULTS

On average, 3.7 calls occurred per shift, 2.8 on weekday and 5.9 on weekend shifts. Mean patient age was 6.6 years. Mothers (71%) called most frequently. The majority of calls were postoperative (64.2%). Of postoperative calls, most occurred within 3 days of surgery (52.3%). Most calls were for surgical site bleeding (19.9%). Residents recommended ED evaluation for 17.2% of calls, of which 20.9% returned to the primary institution ED. ED evaluation was recommended more frequently for postoperative patients (P = .040), particularly following adenotonsillectomy (51.2%) or surgical site bleeding (18.6%). With respect to documentation, 32.8% of medical record numbers were absent, 11.8% had name errors, and 2.2% of patients could not be identified.

CONCLUSIONS

This is the first study to analyze the management and reporting of patient calls by otolaryngology residents. A wide array of clinical concerns are triaged by phone conversations. The study has implications for both resident and patient education.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:E163-E170, 2018.

Perioperative Deep Vein Thrombosis Risk Stratification: A Comparative Analysis of Free and Pedicled Flap Patients

Patients with head and neck cancer who undergo reconstructive surgery are at risk for deep venous thrombosis (DVT), but the risk profile for patients undergoing major flap reconstruction is highly variable. Herein, we report our findings from a retrospective analysis of head and neck cancer patients (n = 517) who underwent free (n = 384) or pedicled (n = 133) flap reconstructive operations at a major tertiary care center from 2011 to 2014. DVTs developed perioperatively in 9 (1.7%) patients. Compared with pedicled flap patients, free flap patients had a longer mean operative time (421.4 ± 4.4 vs 332.7 ± 10.7 min, P < .0001), but the DVT incidence did not differ significantly between free and pedicled flap patients (1.6% vs 2.2%, respectively, P = .28). These data suggest that perioperative DVT risk in head and neck oncology patients may be largely similar regardless of the reconstructive strategy pursued.

Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy

IMPORTANCE

The optimal reconstruction of total glossectomy defects with or without total laryngectomy is controversial. Various pedicled and free tissue flaps have been advocated, but long-term data on functional outcomes are not available to date.

OBJECTIVES

To compare various total glossectomy defect reconstructive techniques used by multiple institutions and to identify factors that may lead to improved long-term speech and swallowing function.

DESIGN, SETTING, AND PARTICIPANTS

A multi-institutional, retrospective review of electronic medical records of patients undergoing total glossectomy at 8 participating institutions between June 1, 2001, and June 30, 2011, who had a minimal survival of 2 years.

INTERVENTION

Total glossectomy with or without total laryngectomy.

MAIN OUTCOMES AND MEASURES

Demographic and surgical factors were compiled and correlated with speech and swallowing outcomes.

RESULTS

At the time of the last follow-up, 45% (25 of 55) of patients did not have a gastrostomy tube, and 76% (42 of 55) retained the ability to verbally communicate. Overall, 75% (41 of 55) of patients were tolerating at least minimal nutritional oral intake. Feeding tube dependence was not associated with laryngeal preservation or the reconstructive techniques used, including flap suspension, flap innervation, or type of flap used. Laryngeal preservation was associated with favorable speech outcomes, such as the retained ability to verbally communicate in 97% of those not undergoing total laryngectomy (35 of 36 patients) vs 44% (7 of 16) in those undergoing total laryngectomy (P < .001), as well as those not undergoing total laryngectomy achieving some or all intelligible speech in 85% (29 of 34 patients) compared with 31% (4 of 13) undergoing total laryngectomy achieving the same intelligibility (P < .001).

CONCLUSIONS AND RELEVANCE

In patients with total glossectomy, feeding tube dependence was not associated with laryngeal preservation or the reconstructive technique, including flap innervation and type of flap used. Laryngeal preservation was associated with favorable speech outcomes such as the retained ability to verbally communicate and higher levels of speech intelligibility.

Increased Resident Research over an 18-Year Period

Objectives

(1) To evaluate changes in the resident publications over time, including before and after duty hour restrictions, and (2) to identify factors statistically associated with publications during residency.

Study Design

Retrospective review of bibliometric data.

Subjects and Methods

Residents who graduated from an otolaryngology residency program from 1996 to 2013 were evaluated. Thomson Reuters Web of Science was searched to determine the number of indexed peer-reviewed publications before and after implementation of resident duty hour restrictions in 2003. Resident demographics, PhD degrees, training tracks, and postgraduation plans were collected to determine factors associated with publication rate using multivariable regression analysis.

Results

During the studied period, 75 residents completed otolaryngology residency training and published a total of 294 papers, averaging 3.92 publications per resident during training. After work hour restrictions were implemented, the mean number of publications increased from 1.21 to 5.10 ( P < .0001). First author publications, clinical publications, and basic science publications all increased ( P < .001). In regression analysis, T32 grants (β = 6.98, standard error [SE] = 1.87, P = .0004) and the time period after duty hour restrictions were introduced (β = 4.72, SE = 1.73, P = .0083) were positively associated with resident publications. Gender, PhD degree, and pursuit of fellowship training were not associated with increased publications ( P > .05).

Conclusion

There has been a significant increase in resident publications over time, coinciding with the implementation of work hour restrictions. T32 grants were most predictive of increased resident publications, while PhD degrees were not significantly associated.

Analysis of an online match discussion board: improving the otolaryngology-head and neck surgery match

OBJECTIVE

"The Match" has become the accepted selection process for graduate medical education. Otomatch.com has provided an online forum for Otolaryngology-Head and Neck Surgery (OHNS) Match-related questions for over a decade. Herein, we aim to delineate the type of posts on Otomatch to better understand the perspective of medical students applying for OHNS residency.

STUDY DESIGN

Retrospective review of an OHNS Match-related online forum.

SUBJECTS AND METHODS

Subjects were contributors to an OHNS Match-related online forum. Posts on Otomatch between December 2001 and April 2014 were reviewed. The title of each thread and number of views were recorded for quantitative analysis. Each thread was organized into 1 of 6 major categories and 1 of 18 subcategories. National Resident Matching Program (NRMP) data were utilized for comparison.

RESULTS

We identified 1921 threads corresponding to over 2 million page views. Over 40% of threads were related to questions about specific programs, and 27% were discussions about interviews. Views, a surrogate measure for popularity, reflected different trends. The majority of individuals viewed posts on interviews (42%), program-specific questions (20%), and how to rank programs (11%). There was an increase in viewership tracked with a rise in applicant numbers based on NRMP data.

CONCLUSION

Our study provides an in-depth analysis of a popular discussion forum for medical students interested in the OHNS Match process. The most viewed posts are about interview dates and questions regarding specific programs. We provide suggestions to address unmet needs for medical students and potentially improve the Match process.

Epidemiology of otologic diagnoses in United States emergency departments

OBJECTIVES/HYPOTHESIS

Otologic complaints may place a significant burden on emergency departments (EDs) in the United States; however, few studies have comprehensively examined this discrete patient population. We aimed to identify utilization of EDs by patients with primary otologic complaints.

STUDY DESIGN

Retrospective analysis of the Nationwide Emergency Department Sample (NEDS) from 2009 through 2011.

METHODS

The NEDS database was queried for patient encounters with a primary otologic diagnosis based on International Classification of Diseases, Ninth Revision codes (380-389). Weighted estimates for demographics, diagnostic characteristics, socioeconomic status, and trends over time were extracted. Predictors of mortality and admission were determined by multivariable logistic regression.

RESULTS

A weighted total of 8,611,282 visits between 2009 and 2011 were attributed to otologic diagnoses, representing 2.21% of all ED visits. Stratified by patient age, otologic diagnoses encompassed 1.01% and 6.79% of all adult and pediatric ED visits, respectively. The majority of patients were treated and released (98.17%). The average age of patients presenting with an otologic complaint was 17.9 years (standard error = 0.23). Overall, 62.7% of patients who presented with an otologic complaint were 0 to 17 years old. The most common diagnoses among all age groups included otitis media not otherwise specified (NOS) (60.6%), infected otitis externa NOS (11.8%), and otalgia NOS (6.8%).

CONCLUSIONS

We provide a comprehensive overview of otologic complaints that are an overlooked diagnostic category in public health research. NEDS data demonstrate a significant number of visits related to otologic complaints, especially in the pediatric population, that are nonemergent.

LEVEL OF EVIDENCE

4

Subspecialty emergency room as alternative model for otolaryngologic care: implications for emergency health care delivery

PURPOSE

A dedicated otolaryngology emergency room (ER) represents a specialized surgical evaluation and treatment setting that may be an alternative triage pathway for acute otolaryngologic complaints. We aim to characterize practice patterns in this setting and to provide insight into the epidemiology of all-comer, urgent otolaryngologic complaints in the United States.

METHODS AND METHODS

Electronic medical records were reviewed for all patients who registered for otolaryngologic care and received a diagnosis in the Massachusetts Eye and Ear Infirmary ER between January 2011 and September 2013. Descriptive analysis was performed to characterize utilization and diagnostic patterns. Predictors of inpatient admission were identified using multivariable regression. Geocoding analysis was performed to characterize catchment area.

RESULTS

A total of 12,234 patient visits were evaluated with a mean age of 44.7. Auditory and vestibular problems constituted the most frequent diagnoses (50.0%). The majority of patients were discharged home (92.3%). Forty-three percent of patients underwent a procedure in the ER; the most common procedure was diagnostic nasolaryngoscopy (52%). Predictors of inpatient admission were post-operative complaint (odds ratio [OR] 7.3, P<0.0001), arrival overnight (OR 3.3, P<0.0001), and laryngeal complaint (OR 2.4, P<0.0001). Patients traveled farther for evaluation of hearing loss (11 miles) and less for common diagnoses including impacted cerumen (7.1 miles) (P<0.0001).

CONCLUSION

In this report, we investigate practice patterns of a dedicated otolaryngology emergency room to explore an alternative to standard acute otolaryngologic health care delivery mechanisms. We identify key predictors of inpatient admission. This study has implications for emergency health care delivery models.