Performance and Consistency of ChatGPT-4 Versus Otolaryngologists: A Clinical Case Series

OBJECTIVE

To study the performance of Chatbot Generative Pretrained Transformer-4 (ChatGPT-4) in the management of cases in otolaryngology-head and neck surgery.

STUDY DESIGN

Prospective case series.

SETTING

Multicenter University Hospitals.

METHODS

History, clinical, physical, and additional examinations of adult outpatients consulting in otolaryngology departments of CHU Saint-Pierre and Dour Medical Center were presented to ChatGPT-4, which was interrogated for differential diagnoses, management, and treatment(s). According to specialty, the ChatGPT-4 responses were assessed by 2 distinct, blinded board-certified otolaryngologists with the Artificial Intelligence Performance Instrument.

RESULTS

One hundred cases were presented to ChatGPT-4. ChaGPT-4 indicated a mean of 3.34 (95% confidence interval [CI]: 3.09, 3.59) additional examinations per patient versus 2.10 (95% CI: 1.76, 2.34; P = .001) for the practitioners. There was strong consistency (k > 0.600) between otolaryngologists and ChatGPT-4 for the indication of upper aerodigestive tract endoscopy, positron emission tomography and computed tomography, audiometry, tympanometry, and psychophysical evaluations. Primary diagnosis was correctly performed by ChatGPT-4 in 38% to 86% of cases depending on subspecialty. Additional examinations indicated by ChatGPT-4 were pertinent and necessary in 8% to 31% of cases, while the treatment regimen was pertinent in 12% to 44% of cases. The performance of ChatGPT-4 was not influenced by the human-reported level of difficulty of clinical cases.

CONCLUSION

ChatGPT-4 may be a promising adjunctive tool in otolaryngology, providing extensive documentation about additional examinations, primary and differential diagnoses, and treatments. The ChatGPT-4 is more effective in providing a primary diagnosis, and less effective in the selection of additional examinations and treatments.

Over 132 Years Ago, the Inaugural Immunotherapy Treated Its First Head and Neck Cancer Patient

Immunotherapy in oncology has a more extensive history than is commonly perceived. Rooted in the observations and experiences of multiple physicians in the late 19th century, immunological interventions are currently integral to the oncological therapeutic repertoire. This article seeks to delineate the evolution of cancer immunotherapy, tracing its inception in 1891 with the pioneering work of an American surgeon, William B. Coley, who achieved the first documented cure of a cancer case involving a malignant head and neck tumor. The narrative extends to encompass successive historical breakthroughs and prospective developments in this dynamic field.

Management of Bilateral Vocal Fold Paralysis: A Systematic Review

OBJECTIVE

To review the current literature about epidemiology, etiologies and surgical management of bilateral vocal fold paralysis (BVFP).

DATA SOURCES

PubMED, Scopus, and Cochrane Library.

REVIEW METHODS

A systematic review of the literature on epidemiology, etiologies, and management of adult patients with BVFP was conducted through preferred reporting items for systematic reviews and meta-analyses statements by 2 investigators.

RESULTS

Of the 360 identified papers, 245 were screened, and of these 55 were considered for review. The majority (76.6%) of BVFP cases are iatrogenic. BVFP requires immediate tracheotomy in 36.2% of cases. Laterofixation of the vocal fold was described in 9 studies and is a cost-effective alternative procedure to tracheotomy while awaiting potential recovery. Unilateral and bilateral posterior transverse cordotomy outcomes were reported in 9 and 7 studies, respectively. Both approaches are associated with a 95.1% decannulation rate, adequate airway volume, but voice quality worsening. Unilateral/bilateral partial arytenoidectomy data were described in 4 studies, which reported lower decannulation rate (83%) and better voice quality outcome than cordotomy. Revision rates and complications vary across studies, with complications mainly involving edema, granuloma, fibrosis, and scarring. Selective posterior cricoarytenoid reinnervation is being performed by more surgeons and should be a promising addition to the BVFP surgical armamentarium.

CONCLUSION

Depending on techniques, the management of BVFP may be associated with several degrees of airway improvements while worsened or unchanged voice quality. The heterogeneity between studies, the lack of large-cohort controlled randomized studies and the confusion with posterior glottic stenosis limit the draw of clear conclusion about the superiority of some techniques over others.

ChatGPT-4 performance in rhinology: A clinical case series

KEYPOINTS

Chatbot Generative Pre-trained Transformer (ChatGPT)-4 indicated more than twice additional examinations than practitioners in the management of clinical cases in rhinology. The consistency between ChatGPT-4 and practitioner in the indication of additional examinations may significantly vary from one examination to another. The ChatGPT-4 proposed a plausible and correct primary diagnosis in 62.5% cases, while pertinent and necessary additional examinations and therapeutic regimen were indicated in 7.5%-30.0% and 7.5%-32.5% of cases, respectively. The stability of ChatGPT-4 responses is moderate-to-high. The performance of ChatGPT-4 was not influenced by the human-reported level of difficulty of clinical cases.

Personalized Treatments Based on Laryngopharyngeal Reflux Patient Profiles: A Narrative Review

OBJECTIVE

To review the current findings of the literature on the existence of several profiles of laryngopharyngeal reflux (LPR) patients and to propose personalized diagnostic and therapeutic approaches.

METHODS

A state-of-the art review of the literature was conducted using the PubMED, Scopus, and Cochrane Library databases. The information related to epidemiology, demographics, clinical presentations, diagnostic approaches, and therapeutic responses were extracted to identify outcomes that may influence the clinical and therapeutic courses of LPR.

RESULTS

The clinical presentation and therapeutic courses of LPR may be influenced by gender, age, weight, comorbidities, dietary habits and culture, anxiety, stress, and saliva enzyme profile. The clinical expression of reflux, including laryngopharyngeal, respiratory, nasal, and eye symptoms, and the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring profile of patients are important issues to improve in patient management. The use of more personalized therapeutic strategies appears to be associated with better symptom relief and cures over the long-term. The role of pepsin in LPR physiology is well-established but the lack of information about the role of other gastrointestinal enzymes in the development of LPR-related mucosa inflammation limits the development of future enzyme-based personalized diagnostic and therapeutic approaches.

CONCLUSION

Laryngopharyngeal reflux is a challenging ear, nose, and throat condition associated with poor therapeutic responses and a long-term burden in Western countries. Artificial intelligence should be used for developing personalized therapeutic strategies based on patient features.

Safety and Feasibility of Hypnosis-Induced Sleep Endoscopy in Obstructive Sleep Apnea Patients

BACKGROUND

Hypnosis was never used in sleep endoscopy assessment of obstructive sleep apnea syndrome (OSAS). The aim of the study was to assess the feasibility, safety, and patient satisfaction of hypnosis-induced sleep endoscopy (HISE).

METHODS

From January to July 2021, 24 adults with moderate-to-severe OSAS at the polysomnography were included in the HISE protocol. The following outcomes were evaluated by the otolaryngologist and the hypnotherapist: safety, feasibility, and performance. The patient outcomes were assessed through a patient-reported outcome questionnaire assessing hypnosis acceptance, stress, anxiety, nasofibroscopy examination pain, and discomfort.

RESULTS

Twenty-three patients completed the evaluations (16 males). The mean age of patients was 50.8 years. The nasofibroscopy was well-tolerated with low levels of stress during the HISE. Otolaryngologist adequately completed the VOTE scoring in 22 patients (95.7%). Hypnosis was ineffective in one patient because he felt pain during the nasofibroscopy procedure due to an important septal deviation. The hypnotherapist reported adequate satisfaction outcomes, with better results for trance compliance compared to other steps. There were no adverse effects or complications. The percentage of snoring was negatively associated with the level of consciousness during hypnosis (p = 0.012). The easiness of nasofibroscopy was positively associated with the levels of muscle relaxation (p = 0.036) and consciousness (P = 0.002).

CONCLUSION

HISE is an effective alternative approach for the work-up of OSAS. Future controlled studies are needed to compare HISE with drug-induced sleep endoscopy and assess the cost-effective outcomes of both approaches.

History of Otolaryngology: Globus Pharyngeus as "Globus Hystericus"

Globus pharyngeus is the uncomfortable sensation of a "lump in the throat," and at present it has many recognized pathophysiologic causes. However, until relatively recently, this condition was often labeled "globus hystericus" and was thought to be a manifestation of hysteria or anxiety. In this commentary, we briefly review the history surrounding the initial treatment of globus pharyngeus sensation as a hysterical condition rooted in anxiety/psychological causes; then, we briefly review the emerging evidence that roots globus pharyngeus sensation within a constellation of pathophysiologies that are related to pharyngoesophageal inflammation and irritation rather than psychological disorders.

Association between laryngopharyngeal reflux, gastroesophageal reflux and recalcitrant chronic rhinosinusitis: A systematic review

OBJECTIVE

To investigate the association between laryngopharyngeal reflux (LPR), gastroesophageal reflux disease (GERD) and recalcitrant chronic rhinosinusitis (CRS).

DATA SOURCES

PubMed, Cochrane Library and Scopus.

REVIEW METHODS

Three investigators searched the specified databases for studies investigating the relationship between LPR, GERD and recalcitrant CRS with or without polyposis. The following outcomes were investigated with PRISMA criteria: age; gender; reflux and CRS diagnosis; association outcomes and potential treatment outcomes. The authors performed a bias analysis of papers and provided recommendations for future studies.

RESULTS

A total of 17 studies investigated the association between reflux and recalcitrant CRS. According to pharyngeal pH monitoring, 54% of patients with recalcitrant CRS reported hypo or nasopharyngeal acid reflux events. The number of hypo- and nasopharyngeal acid reflux events was significantly higher in patients compared to healthy individuals in 4 and 2 studies, respectively. Only one study did not report intergroup differences. The proportion of GERD was significantly higher in CRS patients compared to controls, with a prevalence ranging from 32% to 91% of cases. No author considered nonacid reflux events. There was significant heterogeneity in the inclusion criteria; definition of reflux and association outcomes, limiting the ability to draw clear conclusions. Pepsin was found in sinonasal secretions more frequently in CRS patients than controls.

CONCLUSION

Laryngopharyngeal reflux and GERD may be contributing factors of CRS therapeutic resistance, but future studies are needed to confirm the association considering nonacid reflux events.

A Therapeutic Approach to Primary Hyperparathyroidism: A Collaborative Evaluation Between Endocrinology and Surgery

Introduction Primary hyperparathyroidism (PHPT) is a disorder in which one or more parathyroid glands overproduce parathyroid hormone, leading to hypercalcemia. It may present with symptoms like constipation, abdominal pain, psychiatric complaints as well as signs of nephrolithiasis, and osteoporosis that may need surgical treatment. PHPT is often underdiagnosed and undertreated. Our study aimed to review hypercalcemia in a single center to evaluate for undiagnosed PHPT. Methods A group of 546 patients from Southwest Virginia was selected using the EMR Epic (Epic Systems, Verona, USA) who had a diagnosis of hypercalcemia in the previous six months. Charts were manually reviewed, and patients were excluded based on the lack of hypercalcemia as well as previous testing of parathyroid hormone (PTH) levels. One hundred and fifty patients were excluded because of a lack of documented hypercalcemia. Letters were sent to the patients advising the patients to discuss whether a PTH would be indicated with their primary care provider (PCP). These patients' charts were re-examined six months later and a determination of whether a PTH level was performed as well as any referrals explicitly for hypercalcemia or PHPT was done. Results A total of 20 (5.1%) patients had a new PTH test during the time assessed. Of these patients, five received referrals to surgical treatment and six received referrals to endocrinology for treatment (no patients received referrals to both). Of those who obtained a PTH level, 50% of them had significantly elevated PTH levels consistent with the diagnosis of primary hyperparathyroidism. An additional 45% had levels of parathyroid hormone that were in the normal range but or most likely inappropriately normal for the concurrent level of calcium. Only one patient (5%) had a suppressed PTH level. Conclusion The impact of an intervention on clinician evaluation and treatment of patients with hypercalcemia has been previously tested and shown to be beneficial. In this study, the method of directly sending a letter to patients yielded clinically significant results, with 20 patients out of 396 (5.1%) having a PTH level tested. A majority had an overt or suspected parathyroid disease, and out of them, 11 underwent referral for treatment.

Injection of Platelet Rich Plasma in the Olfactory Cleft for COVID-19 Patients With Persistent Olfactory Dysfunction: Description of the Technique

In this paper, we described technique of platelet rich plasma injection into the olfactory cleft in a 22-year-old female with 24-month post-COVID-19 anosmia. The technique starts with the blood extraction and the isolation of PRP through a 10-min centrifugation. The supernatant was injected in nasal regions after a local anesthesia through a 0° rigid optic. Several points of .2-.5 mL were performed in the nasal septum in regard of the head of the middle turbine and in the head of the middle turbine in both sides. The baseline threshold, discrimination, and identification scores were 1, 8, and 0, and the Olfactory Disorder Questionnaire score was 51, respectively. The injection of PRP in olfactory cleft was done without complication and mild pain. The patient perception of recovery of smell sense occurred at 3-week post-injection. From this time, the smell sense progressively improved to the 2-month consultation. At 2-month post-injection, the TDI scores reached 16, 16, and 16 (48), while the Olfactory Disorder Questionnaire was 73. The injection of PRP into the olfactory cleft appears to be a safe and easiness new approach that may improve the recovery of smell sense. Future controlled studies are needed.

Post-Laryngectomy Voice Prosthesis Changes by Speech-Language Pathologists: Preliminary Results

Background: In the present study, we assess the feasibility and success outcomes of voice prosthesis (VP) changes when performed by a speech-language pathologist (SLP). Methods: Patients treated with total laryngectomy (TL) from January 2020 to December 2020 were prospectively recruited from our medical center. Patients benefited from tracheoesophageal puncture. The VP changes were performed by the senior SLP and the following data were collected for each VP change: date of placement; change or removal; VP type and size; reason for change or removal; and use of a washer for periprosthetic leakage. A patient-reported outcome questionnaire including six items was proposed to patients at each VP change. Items were assessed with a 10-point Likert-scale. Results: Fifty-two VP changes were performed by the senior SLP during the study period. The mean duration of the SLP consultation, including patient history, examination and VP change procedure, was 20 min (range: 15–30). The median prosthesis lifetime was 88 days. The main reasons for VP changes were transprosthetic (n = 34; 79%) and periprosthetic (n = 7; 21%) leakages. SLP successfully performed all VP changes. He did not change one VP, but used a periprosthetic silastic to stop the periprosthetic leakages. In two cases, SLP needed the surgeon’s examination to discuss the following indication: implant mucosa inclusion and autologous fat injection. The patient satisfaction was high according to the speed and the quality of care by the SLP. Conclusions: The delegation of VP change from the otolaryngologist–head and neck surgeon to the speech-language pathologist (SLP) may be achieved without significant complications. The delegation of VP change procedure to SLP may be interesting in some rural regions with otolaryngologist shortages.

Clinical Update Findings about pH-Impedance Monitoring Features in Laryngopharyngeal Reflux Patients

Purpose: The diagnosis of laryngopharyngeal reflux (LPR) is commonly based on non-specific symptoms and findings and a positive response to an empirical therapeutic trial. The therapeutic response is, however, unpredictable, and many patients need pH-impedance monitoring to confirm the diagnosis. Methods: A review of the recent literature was conducted in PubMED, Scopus, and Embase about the pH-study features of LPR patients. A summary of last evidence was proposed. Results: The awareness of otolaryngologists about indications and interpretation of pH-impedance monitoring is low. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) is the most reliable examination determining the type and composition of hypopharyngeal reflux events (HRE) and the LPR features. The use of HEMII-pH is important to confirm the diagnosis in selected patients because non-specificity of symptoms and findings. There are no international consensus guidelines for the LPR diagnosis at the HEMII-pH. However, most studies supported the occurrence of >1 acid/weakly acid/nonacid HRE as diagnostic threshold. HREs are more frequently gaseous, weakly/nonacid compared with reflux events of gastroesophageal reflux. HREs occurred as daytime and upright, which does not support the value of double proton pump inhibitors or bedtime alginate. Oropharyngeal pH-monitoring is another approach reporting different sensitivity and specificity outcomes from HEMII-pH. The use of Ryan score for the LPR diagnosis at the oropharyngeal pH monitoring may be controversial regarding the low consideration of alkaline HREs. Conclusions: The awareness of otolaryngologists about HEMII-pH indication, features, and interpretation is an important issue regarding the high prevalence of LPR in outpatients consulting in otolaryngology. The HEMII-pH findings may indicate a more personalized treatment considering type and occurrence time of HREs.

COVID-19 Pandemic and its Impact on the Management of Head and Neck Cancer in the Spanish Healthcare System

Introduction  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has represented a major challenge for healthcare systems worldwide, changing the habits of physicians. A reorganization of healthcare activity has been necessary, limiting surgical activity to essential cases (emergencies and oncology), and improving the distribution of health resources.

Objective  To analyze the impact of the COVID-19 pandemic on head and neck cancer surgery management in Spain.

Methods  A cross-sectional study, through an anonymous and voluntary online survey distributed to 76 Spanish otorhinolaryngology departments.

Results  A total of 44 centers completed the survey, 65.9% of which were high-volume. A total of 45.5% of them had to stop high-priority surgery and 54.5% of head and neck surgeons were relocated outside their scope of practice. Surgeons reported not feeling safe during their usual practice, with a decrease to a 25% of airway procedures. A total of 29.5% were “forced” to deviate from the “standard of care” due to the epidemiological situation.

Conclusions  Approximately half of the departments decreased their activity, not treating their patients on a regular basis, and surgeons were reassigned to other tasks. It seems necessary that the head and neck surgeons balance infection risk with patient care. The consequences of the reported delays and changes in daily practice should be evaluated in the future in order to understand the real impact of the pandemic on the survival of head and neck cancer patients.

Cognitive Impairment and Delirium in Older Patients Undergoing Major Head and Neck Surgery

The study objective was to measure the prevalence and predictors of cognitive impairment (CI) and delirium. Adults undergoing major head and neck cancer surgery completed the Clock Draw Test to screen for CI, defined as a score of 0 or 1. Postoperative delirium was recorded. Predictors of delirium and length of stay were assessed by univariate logistic regression and the latter with multivariate linear regression. Overall 274 patients were included, of which 47% had a Clock Draw Test score of 0 or 1. Post-operative delirium occurred in 17 (6%). CI was a predictor of postoperative delirium (odds ratio, 3.9; 95% CI, 1.2-12; P = .02). Postoperative delirium was a predictor of increased length of stay (adjusted odds ratio, 1.30; 95% CI, 1.07-1.57; P = .0073) on multivariate regression while baseline Clock Draw Test result was not a predictor on univariate regression (P = .98). Screening for CI can help predict delirium and facilitate targeted interventions in the postoperative period.

High-definition three-dimensional exoscope for head and neck reconstruction: Prospective analysis of 27 consecutive patients

PURPOSE

To analyze the advantages and disadvantages of a three-dimensional (3D) operating exoscope (OE) in head and neck free flap reconstruction.

METHODS

Twenty-seven consecutive patients (females: 8; mean age: 57.0) were included. After each procedure, both surgeon and nurse were asked to fill out a tailored questionnaire on a three-point Likert scale including 12 items.

RESULTS

All microvascular anastomoses were successfully completed, and no related complications were detected with a final free flap survival rate of 100% (mean follow-up of 5.6 months, SD: 3.1 months). The ergonomics, the ease of use, and the possibility to share the view among all the OR members were the best-rated items by the surgeons, while the luminance of the surgical field and the eye strain determined by the 3D glasses can still be improved.

CONCLUSION

Further comparative clinical studies are needed to clarify its real value in substitution to a conventional operating microscope.

Evaluation of the Braden scale in predicting surgical outcomes in older patients undergoing major head and neck surgery

BACKGROUND

Being able to predict negative postoperative outcomes is important for helping select patients for treatment as well for informed decision-making by patients. Frailty measures are often time and resource intensive to use as screening measures, whereas the Braden scale, a commonly used measure to assess patients at risk of developing pressure ulcers after surgery, may be a potential tool to predict postoperative complication rates and longer length of stay (LOS) in patients undergoing major head and neck cancer surgery.

METHODS

A retrospective analysis of Braden scale scores was performed on a prospectively collected cohort of patients undergoing major head and neck surgery recruited between December 2011 and April 2014. The association of Braden scale score with the primary outcomes of complications and LOS was analyzed using logistic regression and linear regression models on univariate analysis (UVA), respectively. Multivariate analysis (MVA) was performed based on a backward stepwise selection algorithm.

RESULTS

There were 232 patients with a mean (SD) Braden scale score of 14.9 (2.8) with a range from 9 to 23. The Braden scale (β = -.07 per point; 95% CI -0.09, -0.04, P < .001) was an independent predictor of increased LOS on UVA, but not on MVA when adjusted for other variables. For overall complications, as well as type of complication, the Braden scale score was not a significant predictor of complications on either UVA or MVA.

CONCLUSION

In the sample population, the Braden scale did not demonstrate an ability to predict negative outcomes in head and neck surgery patients.

LEVEL OF EVIDENCE

Level 2b individual cohort study.

Thyroid Storm in Head and Neck Emergency Patients

Background: Thyroid storm is a rare but life-threatening emergency that prompts urgent intervention to halt its potentially disastrous outcomes. There is not much literature available on thyroid storm in head neck trauma and non-thyroid/parathyroid head neck surgery. Due to rarity of thyroid storm in head and neck trauma/surgery patients, its diagnosis becomes challenging, is often misdiagnosed and causes delay in the diagnosis and management. Therefore, the aim of this work was to compile, analyze and present details to develop a consensus and augment available literature on thyroid storm in this group of patients. Materials and methods: A comprehensive literature search of the last 30 years was performed on PUBMED/MEDLINE, EMBASE, CINAHL and Science Citation Index for thyroid storm using MeSH words and statistical analyses were performed. Results: Seven articles describing seven cases of thyroid storm were reviewed. All patients required medical management and one patient (14.3%) required adjunctive surgical management. Burch and Wartofsky Diagnostic criteria for thyroid storm were used in diagnosis of 42% patients. Time of diagnosis varied from immediately upon presentation to formulating a retrospective diagnosis of having a full-blown thyroid storm at 4 days post presentation. It was misdiagnosed and unthought of initially in majority of these cases, (71.4%) were not diagnosed in the first day of hospital stay. Conclusion: Early recognition of thyroid storm in head and neck patients markedly reduce morbidity/mortality. Albeit unexpected, it should be ruled out in any symptomatic head and neck trauma or post-surgery patient.

Evaluation and validation of Physiological and Operative Severity Score for the enumeration of mortality and morbidity and Portsmouth-POSSUM scores in predicting morbidity and mortality in patients undergoing head and neck cancer surgeries

BACKGROUND

Identification of risk factors for perioperative complications helps in the prognostication. We wanted to determine whether Physiological and Operative Severity Score for the enumeration of mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) can be used in patients undergoing head and neck oncosurgery.

METHODS

We conducted a retrospective analysis of 1265 patients after they had major head and neck oncosurgeries. Demographic, surgical and outcome data was collected. We separately analyzed data for patients who had undergone cancer surgery for oral cavity, pharynx, and larynx. We calculated the POSSUM and P-POSSUM scores.

RESULTS

POSSUM scoring system had moderate discrimination (AUC = 0.61) and good calibration (P = .36) for the entire study cohort and in the subgroup. Since there were no deaths in the entire cohort, we were not able to check predictive ability of the scores, for mortality.

CONCLUSIONS

We found that POSSUM had moderate discrimination and good calibration for morbidity prediction in head and neck cancer surgeries, as well as for the selected subgroup.

Free flap microvascular anastomosis in head and neck reconstruction using a 4K three-dimensional exoscope system (VITOM 3D)

The aim of this study was to evaluate the feasibility of microvascular anastomosis using a 4K three-dimensional exoscope system (VITOM 3D) in 10 consecutive cases of free flap head and neck reconstructive surgery. This was a clinical human study of free flap microvascular anastomosis using a VITOM 3D exoscope in 10 consecutive patients undergoing reconstruction after ablative surgery for head and neck carcinoma. Microvascular anastomoses were performed successfully using the exoscope in all patients, without any need for the conventional microscope. Arterial anastomoses were all end-to-end. Venous anastomoses were end-to-end in eight cases and end-to-side with the internal jugular vein in two cases. This study demonstrates the technical feasibility of microvascular anastomosis using a 4K three-dimensional exoscope system (VITOM 3D) in a series of 10 cases.

Antibiotic prophylaxis in clean head and neck surgery: A prospective randomised controlled trial

OBJECTIVE

Antibiotic prophylaxis is not indicated for clean head and neck surgery. However, its role in revision cases is not known. The objective was to prospectively test whether antibiotics are useful in this patient group.

DESIGN

This was a prospective, double-blind, randomised, placebo-controlled study.

SETTING

A single-centre study in a tertiary care centre.

PARTICIPANTS

The patients were selected from a referred sample of adult patients (>18 years old) who were planned to undergo revision clean head and neck surgery and who had no preoperative indication for prophylactic antibiotics (eg previous radiation therapy, tracheostomy, active infection, immunosuppression). A total of 59 patients were approached for the study. After exclusion, 53 were available for final analysis.

INTERVENTION

The intervention group received a single-dose cefazolin, while the control group received placebo.

MAIN OUTCOMES

The primary end-point was the combined rate of surgical wound infection, bacteremia and sepsis. The secondary end-points were length of hospital stay and drug-induced adverse reactions.

RESULTS

A total of 53 patients were randomised to 2 groups: 31 to antibiotics group and 22 to control group. There was no difference between the groups in baseline characteristics. The primary end-point occurred in both groups at the same rate. There was no difference in secondary end-point rate, as well.

CONCLUSION

Prophylactic antibiotics appear to have no benefit in revision, clean head and neck surgery. Further studies in larger populations and other settings are needed. (ClinicalTrials.gov number NCT01980082, clinicaltrials.gov/ct2/show/NCT01980082).

Prediction of mortality and morbidity in head and neck cancer patients 80 years of age and older undergoing surgery

OBJECTIVES

To determine postoperative complications and mortality rates in octogenarian and older head and neck cancer patients undergoing ablative surgical resections and to identify factors associated with postoperative morbidity and mortality.

METHODS

Retrospective cohort study investigating risk factors for 30-day serious complication risk and 90-day mortality risk for patients aged 80 years and older who underwent ablative head and neck oncologic surgical procedures at an academic tertiary care center between 2005 and 2015.

RESULTS

Of the 219 patients who underwent 241 surgeries, 74 patients experienced serious complications within 30 days and 25 died within 90 days of surgery. American Society of Anesthesiologists (ASA) score of 4 or greater, and operating room (OR) time ≥6 hours were independently associated with serious complications, whereas age ≥90 years, overall severe comorbidity score, presence of preoperative dysphagia, and large extent of resection were associated with increased risk of death in 90 days. Models to predict risk of 30-day serious complications and 90-day mortality were then developed.

CONCLUSION

Patient and surgical treatment factors predict risk of serious complications and mortality in patients aged 80 years and older undergoing ablative head and neck surgery. Predictive models may guide preoperative discussion with patients.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:871-877, 2018.

An audit and feedback system for effective quality improvement in head and neck surgery: Can we become better surgeons?

BACKGROUND

An evaluation system was established for measuring physician performance. This study was designed to determine whether an initial evaluation with surgeon feedback improved subsequent performance.

METHODS

After an evaluation of an initial cohort of procedures (2004-2008), surgeons were given risk-adjusted individual feedback. Procedures in a postfeedback cohort (2009-2010) were then assessed. Both groups were further stratified into high-acuity procedure (HAP) and low-acuity procedure (LAP) groups. Negative performance measures included the length of the perioperative stay (2 days or longer for LAPs and 11 days or longer for HAPs); perioperative blood transfusions; a return to the operating room within 7 days; and readmission, surgical site infections, and mortality within 30 days.

RESULTS

There were 2618 procedures in the initial cohort and 1389 procedures in the postfeedback cohort. Factors affecting performance included the surgeon, the procedure's acuity, and patient comorbidities. There were no significant differences in the proportions of LAPs and HAPs or in the prevalence of patient comorbidities between the 2 assessment periods. The mean length of stay significantly decreased for LAPs from 2.1 to 1.5 days (P = .005) and for HAPs from 10.5 to 7 days (P = .003). The incidence of 1 or more negative performance indicators decreased significantly for LAPs from 39.1% to 28.6% (P < .001) and trended downward for HAPs from 60.9% to 53.5% (P = .081).

CONCLUSIONS

Periodic assessments of performance and outcomes are essential for continual quality improvement. Significant decreases in the length of stay and negative performance indicators were seen after feedback. Therefore, an audit and feedback system may be an effective means of improving quality of care and reducing practice variability within a surgical department.