Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery

BACKGROUND

We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications.

METHODS

We evaluated all TSA surgeries performed at 1 academic medical center from 7^th January, 2017 to 30^th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7^th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions.

RESULTS

One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5 years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97 days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27 days (P = 0.008, 95% CI: 0.33-2.20). In-hospital costs were reduced across all domains, including $1964.87 in variable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P = 0.011), with fewer readmissions (0% vs. 6%, P = 0.021).

CONCLUSIONS

A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.

In-Hospital Costs for Open versus Endoscopic Endonasal Approach for Craniopharyngioma Resection

OBJECTIVE

To determine the in-hospital cost implications of an expanded endoscopic endonasal approach (EEEA) for craniopharyngioma resection relative to the traditional open transcranial approach.

METHODS

All craniopharyngioma surgeries performed at a single institution over a period from January 1st 2001 to October 31th 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate regression analysis was performed using R software.

RESULTS

Thirty-six patients met study criteria, including 22 undergoing an open approach and 14 undergoing an EEEA. There was a significantly longer average length of stay among patients undergoing open resection (21.5 vs. 10.6 days, p = 0.024). The average total in-hospital cost of a patient undergoing an EEEA was $58979.3 compared to $89142.3 for an open approach (p = 0.127). On univariate regression analysis, the total in-hospital cost for a patient undergoing an open approach relative to an EEEA was $30163.0 (p = 0.127). The open approach was exclusively performed from study onset until April 2010 (16 patients). From April 2010 to August 2013, 6 open approaches and 5 EEEA were performed. The EEEA has been exclusively performed from August 2013 until the conclusion of our study period (9 patients).

CONCLUSIONS

There has been a shift toward surgical resection of craniopharyngioma via an EEEA approach for amenable tumors. Our study demonstrates that the EEEA has become the preferred surgical approach at our institution, and shows that the EEEA is associated with shorter postoperative length of stay and lower total in-hospital cost. Laryngoscope, 133:83-87, 2023.

In-Hospital Cost Comparison for Open Versus Endoscopic Endonasal Approach for Meningioma Resection

Objective

To determine the in-hospital cost implications of an endoscopic expanded endonasal approach (EEEA) for meningioma resection relative to the open transcranial approach.

Methods

All anterior skull base meningioma surgeries performed over a period from January 1st, 2015 to October 31th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using R software. All cost data were converted into August 2021-equivalent dollar amounts using the United States Bureau of Labor Statistics consumer price index.

Results

Thirty-five patients met study criteria, including 27 patients undergoing an open transcranial approach and 8 undergoing an EEEA. Average length of stay for patients undergoing an open approach was 9.3 days compared to 5.6 within the EEEA group ( P = .126). The average total in-hospital cost of patient undergoing an EEEA was $35417.1 compared to $46406.9 among patients undergoing an open transcranial approach ( P = .168). On univariate analysis, the cost of an open transcranial approach relative to the EEEA was $10989.8 ( P = .411).

Conclusions

The open transcranial approach remained the dominant surgical approach to anterior skull base meningiomas over our study time period. However, despite limited patient numbers the EEEA was associated with decreased total in-hospital costs.

In-Hospital Costs Associated With an Expanded Endonasal Approach to Anterior Skull Base Tumors

Objective:

To determine in-hospital costs associated with performing an EEA to anterior skull base pathology and to identify drivers of cost variability for patients undergoing endoscopic anterior skull base surgery.

Methods:

All endoscopic anterior skull base surgeries performed over a period from January 1st, 2015 to October 24th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using Stata software.

Results:

An EEA was associated with an average total in-hospital cost of $44 545. Compared to patients undergoing a transsphenoidal approach to pituitary tumor resection, EEA patients incurred higher in-hospital costs across all variables including a total cost increase of $15 921 (95% confidence interval $5720-26 122, P = .002). Univariate analysis of all endoscopic anterior skull base surgery patients showed a cost increase of $30 616 associated with post-operative cerebrospinal fluid (CSF) leak ($10 420-50 811, P = .004), $14 610 with post-operative diabetes insipidus (DI) ($4610-24 609, P = .004), and $11 522 with African-American patients relative to Caucasian patients ($3049-19 995, P = .008).

Conclusions:

Patients who undergo endoscopic EEA for resection of anterior skull base tumors typically incur greater in-hospital costs than patients undergoing a standard TSA. Post-operative complications such as CSF leak and DI, as well as ethnicity, are significant drivers of cost-variability.

Economic Evaluation of Dupilumab versus Endoscopic Sinus Surgery for the Treatment of Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Dupilumab is a novel monoclonal antibody that recently received FDA approval for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). Endoscopic sinus surgery (ESS) has been the mainstay of treatment for patients refractory to initial medical therapy. Data comparing the cost-effectiveness of these treatments is scarce. The objective of this study is to compare the cost-effectiveness of dupilumab and ESS treatment for patients with CRSwNP refractory to medical therapy.

METHODS

A cohort-style Markov decision tree economic evaluation with 10-year time horizon was performed. The two comparative treatment strategies were dupilumab therapy or ESS followed by postoperative maintenance therapy. Patients with response to treatment continued with either maintenance or dupilumab therapy; patients with no response underwent ESS. The primary outcome measure was incremental cost per quality-adjusted life year (QALY) calculated from sino-nasal outcome test (SNOT-22) scores. Sensitivity analyses were performed including discounting scenarios and a probabilistic sensitivity analysis.

RESULTS

The dupilumab strategy cost $195,164 and produced 1.779 QALYs. The ESS strategy cost $20,549 and produced 1.526 QALYs. This implies an incremental cost of $691,691 for dupilumab for every one-unit increase in QALY compared with ESS. Probability sensitivity analysis indicated that ESS was more cost-effective than dupilumab in all iterations.

CONCLUSIONS

While dupilumab and ESS may demonstrate similar clinical effectiveness, ESS remains the most cost-effective treatment option and should remain standard of care for CRSwNP patients refractory to medical therapy. This article is protected by copyright. All rights reserved.

The Impact of COVID-19 on Otolaryngology Community Practice in Massachusetts

OBJECTIVES

Coronavirus disease 2019 (COVID-19) significantly affected many health care specialties, including otolaryngology. In response to governmental policy changes, many hospitals and private practices in Massachusetts canceled or postponed nonurgent office visits and elective surgeries. The objective of this study was to quantify the impact of COVID-19 on the provision and practice trends of otolaryngology services for 10 private practices in Massachusetts.

STUDY DESIGN

Retrospective review.

SETTING

Multipractice study for community practices in Massachusetts.

METHODS

Electronic billing records from 10 private otolaryngology practices in Massachusetts were obtained for the first 4 months of 2019 and 2020. Questionnaires from these otolaryngology practices were collected to assess financial and staffing impact of COVID-19.

RESULTS

The local onset of the COVID-19 pandemic had a significant decrease of 63% of visits in comparison to equivalent weeks in 2019. Virtual visits overtook in-person visits over time. A greater decline in operating room (OR) procedures than for office procedures was recorded. Ninety percent of practices reduced working hours, and 80% furloughed personnel. Seventy percent of practices applied for the Paycheck Protection Program (PPP).

CONCLUSION

COVID-19 has had a multifaceted impact on private otolaryngology practices in Massachusetts. A significant decline in provision of otolaryngology services aligned with the Massachusetts government's public health policy changes. The combination of limited personnel and personal protective equipment, as well as suspension of nonessential office visits and surgeries, led to decrease in total office visits and even higher decrease in OR procedures.

Drivers of In-Hospital Costs Following Endoscopic Transphenoidal Pituitary Surgery

OBJECTIVE

To characterize the patient and clinical factors that determine variability in hospital costs following endoscopic transphenoidal pituitary surgery.

METHODS

All endoscopic transphenoidal pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in this retrospective single-institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software.

RESULTS

The analysis included 190 patients and average length of stay was 4.71 days. Average total in-hospital cost was $28,624 (95% confidence interval $25,094-$32,155) with average total direct cost of $19,444 ($17,136-$21,752) and total indirect cost of $9181 ($7592-$10,409). On multivariate regression, post-operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474-$66,489, P = .002). Current smoking status was associated with an increased total cost of $20,189 ($6,638-$33,740, P = .004). Self-reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (-$12,760 to -$532, P = .033). Post-operative DI was associated with increased costs across all variables that were not statistically significant.

CONCLUSIONS

Post-operative CSF leak, current smoking status, and non-Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:760-764, 2021.

Clinical and Radiographic Characteristics of Sinonasal Posttransplant Lymphoproliferative Disorder and Invasive Fungal Sinusitis

BACKGROUND

Sinonasal posttransplant lymphoproliferative disorder (PTLD) is a serious but uncommon complication of solid organ and hematopoietic stem cell transplantation that can overlap in many features with invasive fungal sinusitis (IFS).

OBJECTIVE

To identify clinical, laboratory, and radiographic features that may help to differentiate sinonasal IFS and PTLD in the posttransplant population.

METHODS

We performed a retrospective chart review of patients with posttransplant sinonasal PTLD and IFS to evaluate for clinical, laboratory, and imaging characteristics.

RESULTS

A total of 4 patients with sinonasal PTLD and 10 posttransplant IFS patients were evaluated. A total of 2 of 4 PTLD patients presented with a symptom duration of greater than 3 months compared to none in the IFS group (p = 0.07). Mean absolute neutrophil count (ANC) was 2,976 per mm3 (range 2,488-3,462) in the PTLD group compared to 773 per mm3 (range 0.0-2,744) in the IFS group (p = 0.01). Both PTLD lesions with available diffusion-weighted imaging demonstrated diffusion restriction on magnetic resonance im-aging (MRI) compared to zero of the IFS lesions (p = 0.10). No PTLD lesions demonstrated mucosal infarcts compared to three of seven IFS lesions (p = 0.23).

CONCLUSION

IFS was associated with a significantly lower ANC at the time of diagnosis compared to PTLD. Additionally, three other measures trend towards association with their respective pathology. PTLD typically has a more chronic time course than IFS, diffusion restriction on MRI is predominantly associated with PTLD patients, and mucosal infarct on MRI is more suggestive of IFS. Additionally, all cases of sinonasal PTLD arose following solid organ transplantation. These factors may assist clinicians during diagnosis.

Endoscopic endonasal resection versus open surgery for pediatric craniopharyngioma: comparison of outcomes and complications

OBJECTIVE

Craniopharyngioma represents up to 10% of pediatric brain tumors. Although these lesions are benign, attempts at gross-total resection (GTR) can lead to serious complications. More conservative approaches have emerged but require adjuvant radiation. Endoscopic endonasal surgery (EES) aimed at GTR has the potential to result in fewer complications, but there has been limited comparison to open surgery. The authors performed a review of these two approaches within their institution to elucidate potential benefits and complication differences.

METHODS

The authors performed a retrospective review of pediatric patients undergoing resection of craniopharyngioma at their institution between 2001 and 2017. Volumetric analysis of tumor size and postoperative ischemic injury was performed. Charts were reviewed for a number of outcome measures.

RESULTS

A total of 43 patients with an average age of 8.2 years were identified. Open surgery was the initial intervention in 15 and EES in 28. EES was performed in patients 3-17 years of age. EES has been the only approach used since 2011. In the entire cohort, GTR was more common in the EES group (85.7% vs 53.3%, p = 0.03). Recurrence rate (40% vs 14.2%, p = 0.13) and need for adjuvant radiation (20.0% vs 10.7%, p = 0.71) were higher in the open surgical group, although not statistically significant. Pseudoaneurysm development was only observed in the open surgical group. Volumetric imaging analysis showed a trend toward larger preoperative tumor volumes in the open surgical group, so a matched cohort analysis was performed with the largest tumors from the EES group. This revealed no difference in residual tumor volume (p = 0.28), but the volume of postoperative ischemia was still significantly larger in the open group (p = 0.004). Postoperative weight gain was more common in the open surgical group, a statistically significant finding in the complete patient group that trended toward significance in the matched cohort groups. Body mass index at follow-up correlated with volume of ischemic injury in regression analysis of the complete patient cohort (p = 0.05).

CONCLUSIONS

EES was associated with similar, if not better, extent of resection and significantly less ischemic injury than open surgery. Pseudoaneurysms were only seen in the open surgical group. Weight gain was also less prevalent in the EES cohort and appears be correlated with extent of ischemic injury at time of surgery.

The impact of expanded endonasal skull base surgery on midfacial growth in pediatric patients

OBJECTIVE

Surgical resection of skull base tumors in children is increasingly accomplished through an expanded endonasal approach (EEA). We aim to evaluate the potential effect of the EEA on midfacial growth as a result of iatrogenic damage to nasal growth zones.

METHODS

We performed a retrospective review of children undergoing craniopharyngioma resection via an open transcranial or EEA. Pre- and postoperative magnetic resonance imaging was evaluated for growth in four midfacial measurements based on established cephalometric landmarks: anterior midface height, posterior midface height, palatal length, and sella-nasion distance. Statistical analysis was conducted using a mixed-effects linear regression model.

RESULTS

Twenty-two patients underwent an EEA (n = 12) or open transcranial approach (n = 10) for tumor resection with 3 years of imaging follow-up. There was no difference in midfacial growth between groups for each measurement. Compared to the open group, patients undergoing EEA demonstrated relative anterior midface height growth of -0.42 mm (P = 0.880), posterior midface height growth of -0.44 mm (P = 0.839), palatal length growth of 0.35 mm (P = 0.894), and sella-nasion distance growth of -2.16 (P = 0.365).

CONCLUSION

We found no difference in midfacial growth measurements between patients undergoing craniopharyngioma resection via an EEA and the open transcranial route after 3 years of imaging follow-up. Preliminary results on midfacial growth demonstrate that the EEA is a safe alternative to traditional transcranial approaches for the pediatric population. Further investigation with larger sample size and longer duration of follow-up is warranted to more thoroughly investigate the long-term implications of the EEA to the skull base.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:338-342, 2020.

Nasopharyngeal Angiofibroma: A Forgotten Entity in Older Patients

Introduction:

Nasopharyngeal angiofibroma (NA) characteristically affects adolescent men. Although benign, these tumors can cause local destruction and surgical resection is warranted.

Objective:

We present a case of a 62-year-old man with nasal congestion and epistaxis, found to be a right NA on pathology. We also present a review of the available NA staging systems.

Findings:

In this case of NA, imaging revealed an aggressive, hypervascular mass in the nasal cavity with involvement of the middle cranial fossa and cavernous sinus. The patient underwent complete endoscopic surgical resection following vascular embolization.

Conclusions:

Although it is rare, NA should not be disregarded in the elderly population.

Lack of Sphenoid Pneumatization Does Not Affect Endoscopic Endonasal Pediatric Skull Base Surgery Outcomes

OBJECTIVES/HYPOTHESIS

Currently, due to the rarity of pathology, there are limited data surrounding outcomes of pediatric skull base surgery. Traditionally, surgeons have proceeded with caution when electing endonasal endoscopic transsellar/transplanum approaches to the skull base in pediatric patients due to poor sphenoid pneumatization. In this study, we review outcomes of endoscopic pediatric skull base surgery based on sphenoid pneumatization patterns.

STUDY DESIGN

Retrospective chart review.

METHODS

A review of all cases of pediatric (age < 18 years) craniopharyngioma managed via an endoscopic endonasal approach at a tertiary academic medical center.

RESULTS

A total of 27 patients were included in the analysis. The median age was 8 years. Nineteen (70%) patients were male. Presellar, sellar/postsellar, and conchal sphenoid pneumatizations were found in 6, 11, and 10 patients, respectively. There was no significant association between sphenoid pneumatization pattern and extent of resection (gross vs. subtotal, P = .414), postoperative cerebrospinal fluid (CSF) leak (P = .450), intraoperative estimated blood loss (P = .098), total operative time (P = .540), and length of stay (P = .336). On multivariate analysis, after accounting for age, sex, preoperative cranial nerve involvement, and cavernous sinus invasion, there remained no significant association between sphenoid pneumatization pattern and extent of resection (P = .999) and postoperative CSF leak (P = .959).

CONCLUSIONS

Sphenoid pneumatization pattern does not appear to affect outcomes in endoscopic skull base surgery in the pediatric population. Importantly, lack of sphenoid pneumatization does not impede gross total resection or increase complications. Thorough knowledge of the anatomy during the endoscopic approach is critical to optimize outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:832-836, 2019.

Accuracy of Self-reported Diagnosis of Chronic Rhinosinusitis

Large cohort studies of chronic rhinosinusitis (CRS) prevalence often include patients who have been inappropriately diagnosed with the disease. In this investigation, new patients presenting to a tertiary rhinology practice completed a screening questionnaire that included questions about self-reported CRS status, demographic information, and symptomatology. Treating rhinologists evaluated patients according to clinical practice guideline criteria for CRS; 91 patients were ultimately diagnosed with CRS. The sensitivity of self-report for CRS was 84%; the specificity was 82%; and the estimated negative predictive value ranged from 97% to 99%. Prior sinus surgery or oral steroid use correlated with CRS self-report, and a concurrent self-report of nasal polyps or nasal steroid use improved the positive predictive value of CRS self-report. Self-report of CRS status may represent an effective and relatively inexpensive screening mechanism for CRS in large cohort studies, particularly when combined with other associated diagnostic features that improve performance parameters of self-report.

The impact of nasal airflow on sinus mucosa: A radiographic review

BACKGROUND

Chronic rhinosinusitis (CRS) is a disease of widespread prevalence and high morbidity. Many suggest that the introduction of toxins and allergens via nasal airflow plays a significant role in the development of CRS. In patients who have undergone total laryngectomy, nasal airflow is disrupted, providing an opportunity to examine the role of nasal airflow in sinonasal pathology.

METHODS

All patients who received a total laryngectomy between 2002 and 2012 with preoperative and postoperative computed tomography (CT) scans were retrospectively reviewed. The Lund-Mackay (LM) score for each sinus was recorded for both scans. The assessment of differences in pre-operative and post-operative LM scores was analyzed utilizing paired t-tests.

RESULTS

56 patients underwent total laryngectomy and had both preoperative and postoperative CT scans. There were no significant differences in the LM scores between pre-operative and post-operative scans within each sinus (frontal sinus, p = 1.0; anterior ethmoid sinus, p = 0.77; posterior ethmoid sinus, p = 0.45; maxillary sinus, p = 0.90; sphenoid sinus, p = 0.63; ostiomeatal complex, p = 0.78) or in the total LM scores (p = 0.97). Furthermore, patients with pre-operative sinonasal mucosal thickening (total LM score > 0) showed no significant change in their total LM score post-operatively (p = 0.13).

CONCLUSION

In total laryngectomy patients, studies demonstrate that a disruption in nasal airflow is correlated to altered sinonasal physiology and decreased subjective symptoms. However, our study shows that the disruption of nasal airflow results in no significant change in radiographic evidence of sinonasal mucosal thickening.

Alcohol-induced respiratory symptoms improve after aspirin desensitization in patients with aspirin-exacerbated respiratory disease

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is characterized by chronic eosinophilic rhinosinusitis, nasal polyps, asthma, and respiratory sensitivity to aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). In addition to sensitivity to aspirin and NSAIDs, the majority of patients with AERD have been reported to have respiratory intolerance associated with the consumption of alcohol.

METHODS

A multicenter prospective cohort study was performed. Patients with AERD confirmed by aspirin challenge were eligible to participate. Those who described themselves as able to tolerate alcohol consumption were excluded. Patients underwent aspirin desensitization following endoscopic sinus surgery. A questionnaire was distributed to patients before and after desensitization to determine pre-desensitization and post-desensitization symptoms associated with alcohol ingestion.

RESULTS

Forty-five patients were enrolled and 37 patients completed the study. The most common pre-desensitization symptoms were nasal congestion (95.6%), rhinorrhea (46.7%), and wheezing (40%). Improvement in the ability to tolerate alcohol was noted in 86.5% of participants (95% confidence interval [CI], 75.5% to 97.5%) and 70.3% of participants (95% CI, 55.5% to 85.0%) described desensitization to be "very helpful" or "extremely helpful" for their ability to tolerate alcohol.

CONCLUSION

The majority of patients with AERD who experience respiratory symptoms with alcohol consumption describe improvement in this domain following aspirin desensitization.

Costs in Pituitary Surgery: Racial, Socioeconomic, and Hospital Factors

Objective  To investigate the influence of patient demographic factors and hospital factors on cost and length of stay in patients undergoing pituitary surgery. Design/Setting  A retrospective cross-sectional study of the 2008 to 2012 Nationwide/National Inpatient Sample. Participants  Patient demographics and hospital characteristics for patients undergoing pituitary surgery were compared between white, black, and Hispanic patients. Main Outcome Measures  Variables associated with increased cost and increased length of hospital stay were ascertained and compared against each racial and ethnic group via multiple linear regression analysis. Results  Of 8,812 patients who underwent pituitary surgery, 5,924 (67.2%) patients were white, 1,590 (18.0%) were black, and 1,296 (14.7%) were Hispanic. Patient variables found to be significantly different between racial groups via univariate analysis were age, chronic conditions, gender, income, and primary payer. Hospital variables found to be significantly different were location/teaching status, region, and ownership. Hospitalization cost was significantly lower for whites (-$3,082, 95% confidence interval [CI] -$3,961 to -$2,202) and significantly higher for both blacks ($1,889, 95% CI $842-$2,937) and Hispanics ($2,997, 95% CI $1,842-$4,152). Length of hospital stay was also significantly lower in whites (-1.01, 95% CI -1.31 to -0.72) and significantly higher for both blacks (0.65, 95% CI 0.30 to 1.00) and Hispanics (0.96, 95% CI 0.57-1.35). Conclusions  Racial and ethnic factors contribute to differences in hospital utilization and cost for patients undergoing pituitary surgery. Further investigations are necessary to uncover the sources of these disparities in an effort to provide safer and more affordable care to all patients.

Leiomyosarcoma of the head and neck: A 17-year single institution experience and review of the National Cancer Data Base

BACKGROUND

Leiomyosarcoma is a rare neoplasm of the head and neck. The purpose of this study was to present our single-institution case series of head and neck leiomyosarcoma and a review of cases in the National Cancer Data Base (NCDB).

METHODS

Patients with head and neck leiomyosarcoma at the University of Pennsylvania and in the NCDB were identified. Demographic characteristics, tumor factors, treatment paradigms, and outcomes were evaluated for prognostic significance.

RESULTS

Nine patients with head and neck leiomyosarcoma from the institution were identified; a majority had high-grade disease and cutaneous leiomyosarcoma, with a 5-year survival rate of 50%. Two hundred fifty-nine patients with leiomyosarcoma were found in the NCDB; macroscopic positive margins and high-grade disease were associated with poor prognosis (P < .01), and positive surgical margins were related to adjuvant radiation (P < .001).

CONCLUSION

Head and neck leiomyosarcoma presents at a high grade and is preferentially treated with surgery. Several demographic and tumor-specific factors are associated with outcomes and prognosis.

Outcomes after complete endoscopic sinus surgery and aspirin desensitization in aspirin-exacerbated respiratory disease

BACKGROUND

In this study we assessed patient outcomes after complete endoscopic sinus surgery (ESS) and aspirin desensitization for patients with aspirin-exacerbated respiratory disease (AERD).

METHODS

A retrospective chart review was conducted for patients with aspirin challenge-proven AERD who underwent complete ESS followed by aspirin desensitization. Outcomes assessed included need for revision surgery and quality-of-life measures using the 22-item Sino-Nasal Outcomes Test (SNOT-22). Data were collected preoperatively, postoperatively prior to desensitization, and then at intervals post-desensitization through 30 months after aspirin desensitization. A longitudinal linear mixed-effects model was used for data analysis.

RESULTS

Thirty-four patients met the inclusion criteria for this study. Thirty-two patients successfully completed aspirin desensitization and were subsequently followed for 30 months after desensitization. Two patients were unable to complete desensitization. Five patients discontinued aspirin maintenance therapy due to gastrointestinal and respiratory side effects. Within the follow-up period, there were only 3 (9.4%) revision sinus surgeries. Notably, 1 of these revision cases occurred in a patient who had discontinued aspirin maintenance therapy. After surgical treatment and prior to desensitization patients had significant reductions in SNOT-22 scores. Our results demonstrate that total SNOT-22 scores remained statistically unchanged from immediate post-desensitization throughout the 30-month follow-up period.

CONCLUSION

Complete sinus surgery followed by timely aspirin desensitization and maintenance therapy is an effective combination in the long-term management of sinus disease in patients with AERD.

18FDG PET/CT in Routine Surveillance of Asymptomatic Patients following Treatment of Sinonasal Neoplasms

Objective Sinonasal neoplasms have a high rate of recurrence following treatment, and current guidelines support the use of a variety of surveillance techniques. Recent work demonstrates that performance parameters of surveillance modalities may differ with sinonasal tumors in particular when compared with head and neck tumors overall. This study aims to characterize the value of ¹⁸fluorodeoxyglucose (¹⁸FDG) positron emission tomography/computed tomography (PET/CT) as a screening tool in asymptomatic patients. Study Design Retrospective cohort study. Setting Hospital of the University of Pennsylvania and Pennsylvania hospital. Methods Records of asymptomatic patients without suspicious endoscopy or suspicious imaging other than PET during the first 3 years following definitive treatment for sinonasal malignancy were screened and analyzed for inclusion in the cohort. Disease recurrence was determined by biopsy following suspicious PET evaluation. Results PET/CT scans (n = 111) were performed for 45 disease-free asymptomatic patients with no evidence of disease on endoscopy, and 6.3% were suspicious and prompted biopsy during this period, revealing 3 cases of disease recurrence. Overall specificity for PET/CT alone was 96.3% (95% CI, 90.7%-99.0%), with a negative predictive value of 99% (95% CI, 94.8%-100%). All recurrences were detected between 7 and 12 months, and all patients with true recurrence diagnosed by PET/CT had extrasinonasal involvement of tumor at the time of surgery. Conclusion We examined performance parameters of ¹⁸FDG PET/CT in asymptomatic patients with no evidence of disease on endoscopy during the posttreatment period for sinonasal malignancy. The ability of PET/CT to detect recurrences that may be missed by structural imaging or endoscopy makes it a valuable tool for clinicians.

Accuracy of computer-assisted navigation: significant augmentation by facial recognition software

BACKGROUND

Over the past 20 years, image guidance navigation has been used with increasing frequency as an adjunct during sinus and skull base surgery. These devices commonly utilize surface registration, where varying pressure of the registration probe and loss of contact with the face during the skin tracing process can lead to registration inaccuracies, and the number of registration points incorporated is necessarily limited. The aim of this study was to evaluate the use of novel facial recognition software for image guidance registration.

METHODS

Consecutive adults undergoing endoscopic sinus surgery (ESS) were prospectively studied. Patients underwent image guidance registration via both conventional surface registration and facial recognition software. The accuracy of both registration processes were measured at the head of the middle turbinate (MTH), middle turbinate axilla (MTA), anterior wall of sphenoid sinus (SS), and nasal tip (NT).

RESULTS

Forty-five patients were included in this investigation. Facial recognition was accurate to within a mean of 0.47 mm at the MTH, 0.33 mm at the MTA, 0.39 mm at the SS, and 0.36 mm at the NT. Facial recognition was more accurate than surface registration at the MTH by an average of 0.43 mm (p = 0.002), at the MTA by an average of 0.44 mm (p < 0.001), and at the SS by an average of 0.40 mm (p < 0.001). The integration of facial recognition software did not adversely affect registration time.

CONCLUSION

In this prospective study, automated facial recognition software significantly improved the accuracy of image guidance registration when compared to conventional surface registration.

Risk stratification for outpatient parathyroidectomy and predictors of postoperative complications

INTRODUCTION

The mainstay of treatment for primary hyperparathyroidism is surgery. Hypocalcemia after parathyroidectomy is common and poses a significant challenge, leading to increased patient morbidity and health care costs. While several groups have found predictor factors for hypocalcemia, none have created a risk stratification model. Here, we recognize important factors and optimal cut-off values that can allow risk stratification of patients.

METHODS

A single-institution retrospective chart review of 339 patients that underwent parathyroidectomy from 2009 to 2012 was conducted. Pre-operative, intra-operative, and post-operative data were collected. A non-routine outcome was defined as post-operative admission, outpatient hypocalcemia-related complication, or inpatient hypocalcemia-related complication. The preoperative or intraoperative factors of patients that experienced a non-routine outcome were compared to those that did not. Optimal cut-off values were determined for preoperative and intraoperative factors and a risk stratification method was created.

RESULTS

A total of 39 patients experienced a non-routine outcome including 24 postoperative admissions, 2 inpatient hypocalcemia-related complications, and 17 outpatient hypocalcemia-related complications. Patients with a non-routine outcome displayed a trend toward preoperative hypercalcemia (calcium >11.0mg/dL) than not (p=0.0543). The median preoperative parathyroid hormone (PTH) level was significantly higher among patients with a non-routine outcome (p=0.0037). Furthermore, the median percent decrease in PTH at 20min intraoperatively among patients with a non-routine outcome was significantly higher compared to those that did not (p=0.0421). The optimal cut-off value for preoperative PTH was 129pg/mL and for median percent decrease in intraoperative PTH at 20min was 90.7% for predicting a non-routine outcome. A risk stratification model was created based on these data.

CONCLUSION

Our analysis reveals that patients with larger intraoperative decrease in PTH levels (greater than 90.7% drop at 20min), higher preoperative hypercalcemia (greater than 11mg/dL), and higher preoperative PTH levels (greater than 129pg/mL) are more likely to experience a non-routine outcome during outpatient parathyroidectomy. Patients can be risk stratified based on this criteria.

Clinical characteristics and outcomes of oropharyngeal carcinoma related to high-risk non-human papillomavirus16 viral subtypes

BACKGROUND

The majority of human papillomavirus (HPV)-related oropharyngeal carcinomas (OPCs) are associated with HPV genotype 16; however, OPC can be associated with other high-risk non-HPV16 genotypes.

METHODS

This was a retrospective analysis of patients with high-risk non-HPV16 OPC treated at a single tertiary institution. Sociodemographic and clinical information was obtained by chart review. HPV genotype was determined by polymerase chain reaction (PCR). Baseline data and outcomes were compared between HPV16 and high-risk non-HPV16 groups.

RESULTS

High-risk non-HPV16 genotypes accounted for 9% of HPV-related OPC. Of the 27 total high-risk non-HPV16 OPCs, HPV35 was most prevalent (48%). High-risk non-HPV16 OPC presented at a slightly higher age (p = .021) and higher clinical T classification (p = .008) compared to HPV16 OPC, but there was no significant survival difference.

CONCLUSION

Clinical characteristics of high-risk non-HPV16 OPC were largely consistent with those of HPV16 OPC. Additional multi-institutional studies will be required to demonstrate conclusively that the favorable prognosis of patients with HPV16 applies to all high-risk HPV types. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1330-1337, 2016.

Intraoral midline mandibulotomy improves laryngeal access for transoral resection of laryngeal cancer

Intraoral midline mandibulotomy is a technique that can be used to increase exposure for transoral endoscopic laser microsurgery (TLS). We describe the case of a 51 year old male with persistent T1 glottic carcinoma. At initial diagnosis, he had been referred for curative radiotherapy as laryngeal access was not sufficient for TLS. For treatment of his recurrence, we describe the technique of performing a midline mandibular osteotomy to improve access to the larynx allowing for safe and effective transoral endoscopic laser microsurgery. Surgical access to the larynx was greatly improved, and we were able to perform TLS in a case that would have otherwise not been amenable to TLS. An intraoral midline mandibulotomy can improve access to the larynx and allow for successful transoral resection of laryngeal cancer in patients with otherwise inaccessible tumors.

High-resolution microendoscope imaging of inverted papilloma and normal sinonasal mucosa: evaluation of interobserver concordance

BACKGROUND

High-resolution microendoscopy (HRME) enables real-time imaging of epithelial tissue. The utility of this novel imaging modality for inverted papilloma has not been previously described. This study examines the ability of otolaryngologists to differentiate between images of inverted papilloma and normal sinonasal mucosa obtained with a HRME.

METHODS

Inverted papilloma and normal sinonasal mucosa specimens were stained with a contrast agent, proflavine. HRME images were subsequently captured. Histopathological diagnosis was obtained for each sample. Quality-controlled images were used to assemble a training set. After reviewing the training images, 6 otolaryngologists without prior HRME experience reviewed and classified test images.

RESULTS

Five samples of inverted papilloma and 2 normal sinonasal mucosa samples were collected. Four representative images from each specimen were used for the 28-image test set. The mean accuracy among all reviewers was 89.9% (95% confidence interval [CI], 84.3% to 94.0%). The sensitivity to correctly identify inverted papilloma was 86.7% (95% CI, 79.2% to 92.2%), and the specificity was 92.9% (95% CI, 89.0% to 100.0%). The Fleiss kappa interrater reliability score was 0.80 (95% CI, 0.70 to 0.89).

CONCLUSION

Inverted papilloma and normal sinonasal mucosa have distinct HRME imaging characteristics. Otolaryngologists can be successfully trained to distinguish between inverted papilloma and normal sinonasal mucosa. HRME is a feasible tool for identification of inverted papilloma. By conducting future in vivo trials, HRME potentially may enable real-time surgical margin determination during surgical excision of inverted papilloma.

Sinus Disease following Total Laryngectomy: A Radiographic Review

Objectives:

(1) Compare the incidence of radiographic sinus disease before and after laryngectomy by retrospective analysis of preoperative and postoperative computed tomography (CT) scans. (2) Analyze the change in pre-existing radiographic sinus disease via a subset analysis.

Methods:

A single-institution retrospective chart review was conducted. Patients who received a total laryngectomy or total laryngopharyngectomy between 2002 and 2012 with preoperative and postoperative CT scans were included. The Lund-Mackay (LM) Scores for each sinus as well as the total LM score were recorded for both scans. The assessment of differences in these scores is based on McNemar’s statistic for each sinus and on a paired t-test for the total LM score.

Results:

Surgical removal of the larynx creates an anatomical disconnect between the sinonasal cavity and distal respiratory tract. Normal nasal airflow is disrupted, resulting in alterations to the nasal mucosa, mucociliary clearance, and nasal flora. While the incidence of sinonasal disease in patients undergoing total laryngectomy has been studied via subjective scoring methods, this study is the first to evaluate radiographic sinusitis via an objective measure by comparing Lund-Mackay scores before and after total laryngectomy. There were no significant differences in the LM scores between preoperative and postoperative scans within each sinus ( P value >.05) or in the total LM score ( t statistic >0.56).

Conclusions:

In patients undergoing total laryngectomy, disruption in nasal airflow has been correlated with altered sino-nasal physiology and decreased subjective symptoms. However, our study shows no significant change in radiographic evidence of sinonasal disease after laryngectomy.