The Impact of Medicaid Expansion on Head and Neck Malignancies Presentation and Survival.

OBJECTIVE: Under the Affordable Care Act (ACA), Medicaid expansion became effective in states that have adopted it. We aim to examine its impact on head and neck cancers. METHODS: A retrospective study that utilizes the Surveillance, Epidemiology, and End Results database, 2010-2016. Study population included patients with head and neck squamous cell carcinoma (HNSCC), differentiated thyroid carcinoma, and head and neck cutaneous melanoma. The objective is to examine disease-specific survival before and after Medicaid expansion. RESULTS: In states that adopted Medicaid expansion, the ratio of Medicaid: uninsured patients increased from 3:1 to 9:1 (p < 0.001). In states that did not adopt Medicaid expansion, the ratio increased from 1:1 to 2:1 (p < 0.001), making the increase in Medicaid coverage in states that adopted the expansion significantly higher (p < 0.001). Patients diagnosed with HNSCC before the expansion had worse survival (hazard ratio [HR]: 1.24, 95% confidence interval: 1.11, 1.39, p < 0.001) in states that adopted Medicaid expansion. CONCLUSIONS: Early data indicate that implementation of ACA improved disease-specific survival of patients with HNSCC. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1409-1414, 2023.

Presentation and Outcomes of Otolaryngologic Surgeries in Patients With Mental Illness History.

BACKGROUND: Describe the epidemiology and characteristics of patients with a history of mental illness undergoing otolaryngologic procedures. METHODS: A retrospective cross-sectional analysis utilizing the Nationwide Readmissions Database, 2010 to 2015. The study sample included adult (≥18 years) patients undergoing otolaryngologic procedures. RESULTS: A total of 146 182 patients were included, 18.3% with mental illness history. The prevalence of patients who required otolaryngologic surgeries with history of mental illness increased significantly from 14.9% in 2010 to 25.0% in 2015 (P < .001). Mental illness diagnoses included: depression (6.9%), anxiety (5.8%), alcohol dependence (4.2%), substance dependence (2.9%), bipolar disorder (1.4%), memory disorders (1.2%), delusional disorders (0.6%), self-harm (0.1%). Patients with a history of mental illness were more likely to be <65 years, female, and have multiple comorbidities (P < .05 each). Patients with history of mental illness had a higher risk of complications [OR:1.59, 95% CI:1.50,1.69, P < .001]. CONCLUSIONS: Patients with a history of mental illness are increasingly encountered in otolaryngology service. This study provides an epidemiological perspective that warrants increasing clinical investigation of this subpopulation.

Presentation and outcomes of patients with clinically T1-2, N0 oropharynx squamous cell carcinoma: The interplay of primary treatment modality and human papillomavirus status.

BACKGROUND: To examine the pattern of utilization and outcomes of definitive radiotherapy (RT) versus primary robotic-assisted surgery in patients with early-stage oropharyngeal squamous cell carcinoma (OPSCC). METHODS: A retrospective cohort analysis of patients with clinically T1-2, N0 OPSCC was performed using the National Cancer Database, 2010-2016. RESULTS: A total of 1451 patients were included. Prevalence of human papillomavirus (HPV)-positive tumors was 58.30%. Primary surgery was performed in 30.25% of the sample. Tongue base and clinically T1 tumors were each associated with a higher likelihood of undergoing surgery (p < 0.05). Histopathology of patients who underwent surgery demonstrated a prevalence of 15.95% with lymphovascular invasion, 16.67% with extranodal extension, 19.36% were T updated, and 30.00% were N upstaged. Improved survival was observed in the surgery + adjuvant RT group compared to RT alone for HPV-positive tumors (HR: 0.27; 95%CI: 0.12, 0.62; p = 0.002). CONCLUSION: This study provides epidemiological perspective regarding management pattern and outcomes of patients with early-stage OPSCC.

Endoscopic pituitary surgery: National database review.

BACKGROUND: Pituitary tumors surgery is increasingly performed via endoscopic transsphenoidal approach (TSP). This study describes outcomes of TSP surgery in the United States. METHODS: A retrospective cross-sectional analysis of adult patients with pituitary adenoma was performed using the Nationwide Readmissions Database, 2010-2015. RESULTS: A total of 5891 patients were identified. The average age was 51.29 ± 0.29 years. The risk of postoperative epistaxis, diabetes insipidus, cerebrospinal fluid (CSF) leak, and other general postoperative complications was 0.71%, 10.20%, 8.35%, and 2.37%, respectively. Independent risk factors of CSF leak included: age <65-year, male, body mass index ≥25, and multiple comorbidities (p < 0.001 each). The prevalence of CSF leak was not associated with hospital TSP volume and teaching status. CONCLUSION: This study provides a national epidemiological perspective on TSP in the United States. The risk of postoperative CSF leak appears to be associated with intrinsic patient factors rather than resource and expertise availability.

National perspective on hospital readmissions following adrenalectomy.

Background: Examining risk factors of readmission in adrenalectomy patients and estimated the cost burden of unplanned readmission on the United States' healthcare system. Methods: According to the Nationwide Readmission Database, 20,494 patients underwent adrenalectomy between 2010-2014. Demographics, comorbidities, clinical data, length of stay (LOS), annual case volume, and discharge disposition of 30- and 90-day readmission cohorts were compared to the non-readmitted cohort. Results: A total of 1,463 (7.9%) and 1,959 (12.7%) adrenalectomy patients were readmitted at 30 and 90 days after discharge, respectively. Prolonged initial hospital stays [odds ratio (OR) =1.93; 95% confidence interval (CI): 1.63-2.27] and postoperative complications (OR =4.91; 95% CI: 1.98-12.16) were associated with a higher risk of readmission. Complications were significantly more frequent in patients with a primary or secondary malignancy (OR =1.42; 95% CI: 1.23-1.64) and in patients undergoing a procedure at a low adrenalectomy volume hospital [hazard ratio (HR) =0.75; 95% CI: 0.62-0.91; P=0.003]. Readmission extended overall LOS by an average of 2.06 days, costing an additional $18,529.49 per admission. Conclusions: Readmission adds significantly to the burden of disease after adrenalectomy. Understanding contributing factors may identify strategies to reduce readmissions and improve healthcare for patients.

Presentation and outcomes of patients with clinically T1-2, N0 parotid mucoepidermoid carcinoma: The roles of elective neck dissection and adjuvant radiotherapy.

OBJECTIVES: Examine the role of elective neck dissection (END) and adjuvant radiotherapy (RT) in early-stage clinically N0 parotid mucoepidermoid carcinoma (MEC). METHODS: The study is a retrospective analysis of the National Cancer Database, 2004-2016. The study population included adult patients with MEC who underwent parotidectomy. RESULTS: A total of 1233 patients were included. Histopathology demonstrated well, moderately, and poorly differentiated MEC 47.12%, 39.98%, and 12.90% of the time, respectively. END was performed in 78.67% of patients, resulting in nodal upstaging in 4.43% and identification of extracapsular extension (ECE) in 0.72%. RT was utilized in 67.33% of patients with advanced pathological features. Neither END nor RT improved overall survival separately (p < 0.05) or combined (adjusted HR: 1.19, 95%CI: 0.52, 2.70, p = 0.68). CONCLUSION: This study provides an epidemiological perspective regarding patients with clinically T1-2, N0 MEC. There was no observed survival advantage with END and RT.

Recurrent Laryngeal Nerve Invasion by Thyroid Cancer: Laryngeal Function and Survival Outcomes.

BACKGROUND: Recurrent laryngeal nerve (RLN) invasion by thyroid carcinoma represents an advanced disease status with potentially significant co-morbidity. METHODS: In a retrospective single-center study, we included patients with invaded RLNs operated on while using nerve monitoring techniques. We studied pre-, intra-, and postoperative parameters associated with postoperative vocal cord paralysis (VCP); 5-year recurrence-free survival (RFS); and 5-year overall survival (OS) in addition to two subgroup analyses of postoperative VCP in patients without preoperative VCP and based on source of RLN invasion. RESULTS: Of 65 patients with 66 nerves-at-risk, 39.3% reported preoperative voice complaints. Preoperative VCP was documented in 43.5%. The RLN was invaded by primary tumor in 59.3% and nodal metastasis in 30.5%. Papillary thyroid carcinoma was the most common pathologic subtype (80%). After 6 months, 81.8% had VCP. Complete tumor resection of the RLN was not associated with 5-year RFS (p = 0.24) or 5-year OS (p = 0.9). Resecting the RLN did not offer statistically significant benefit on 5-year RFS (p = 0.5) or 5-year OS (p = 0.38). Radioactive Iodine (RAI) administration was associated with improvement in 5-year RFS (p = 0.006) and 5-year OS (p = 0.004). Patients without preoperative VCP had higher IONM amplitude compared with patients with VCP. After a mean follow-up of 65.8 months, 35.9% of patients had distant metastases, whereas 36.4% had recurrence. CONCLUSION: Preoperative VCP accompanies less than half of patients with RLN invasion. Invaded RLNs may have existent electrophysiologic stimulability. Complete tumor resection and RLN resection were not associated with better 5-year RFS or OS, but postoperative RAI was. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:2285-2292, 2022.

Presentation and Outcomes of Non-Squamous Cell Carcinoma Sinonasal Malignancies: A National Perspective.

BACKGROUND: Non-squamous cell carcinoma sinonasal malignancies (NSCCSM) are relatively rare. Neoadjuvant radiotherapy and/or chemotherapy (NTx) have been proposed to improve outcomes compared to surgery alone. In this study, we aim to examine the prevalence of NTx utilization and associated outcomes. METHODS: A retrospective study utilizing the National Cancer Database, 2004 to 2015. The study population included adult patients diagnosed with primary NSCCSM. RESULTS: A total of 574 patients were included. The mean age of the study population was 61.7 ± 16.5 years. The median follow-up time was 40.4 months (interquartile range: 15.3-81.3 months). The histopathological diagnoses identified included: (i) 37.0% adenocarcinoma, (ii) 22.8% adenoid cystic carcinoma, (iii) 20.0% mucosal melanoma, (iv) 11.9% esthesioneuroblastoma, and (v) 8.2% sinonasal undifferentiated carcinoma (SNUC). NTx was utilized in 70 (12.20%) of the study population. Patients who received NTx were more likely to have SNUC or esthesioneuroblastoma (P < .01 each) and to have stage III or IV disease (P < .01 each). NTx was most likely to be administrated in a high-volume center [OR: 3.94, 95%CI: (1.47, 10.53), P = .006]. Patients who received NTx had a significantly lower prevalence of positive margin postoperatively [OR: 0.48, 95%CI: (0.26, 0.87), P = .016]. In patients with NSCCSM, negative margin was associated with improved overall survival [HR: 0.55, 95%CI: (0.36, 0.82), P = .004]. CONCLUSIONS: This study provides an epidemiological perspective regarding NSCCSM and related practice patterns and survival outcomes. Neoadjuvant radiotherapy and/or chemotherapy is likely to decrease the risk of positive margin which ultimately could improve survival in this population.

Can Red Blood Cell Distribution Width Predict Laryngectomy Complications or Survival Outcomes?

OBJECTIVE: Red blood cell distribution width (RDW), a reported biomarker for morbidity and mortality in chronic disease and following certain surgeries, has not been well-studied in head and neck cancer patients. The aim of the study was to examine the association of RDW with postoperative complications and survival among patients who underwent primary or salvage laryngectomy. METHODS: We analyzed a retrospective case series study of patients diagnosed with squamous cell carcinoma of the larynx treated with total laryngectomy. Survival outcomes were examined using Kaplan-Meier analysis. RESULTS: One hundred seventy-seven patients were included in the final analysis. The most common tumor subsite was the supraglottis (60%). On bivariate analysis, patients with RDW ≥14.5 had higher prevalence of non-surgical, systemic complications, including deep venous thrombosis, pneumonia, cardiovascular events, and difficulty weaning from mechanical ventilation. However, there was no significant difference in laryngectomy-specific post-operative complications, including pharyngocutaneous fistula, wound infection, stoma complications, and chyle leak. RDW was not found to be associated with survival outcomes following laryngectomy. CONCLUSIONS: Among laryngectomy patients, RDW ≥14.5 is associated with higher prevalence of systemic morbidity, but not with specific local surgical complications or decreased survival.

Human Papillomavirus-Negative Oropharyngeal Cancer Survival Outcomes Based on Primary Treatment: National Cancer Database Analysis.

OBJECTIVE: To compare survival outcomes between primary surgery and primary radiation therapy (RT) in patients with human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN: A retrospective observational cohort study. SETTING: National Cancer Database. METHODS: A National Cancer Database review was conducted of 2635 patients with HPV-negative OPSCC who underwent surgery or RT ± chemotherapy between 2010 and 2014. Univariate analysis was performed on all variables and entered into a multivariate model. The main outcome was overall survival (OS). RESULTS: A total of 2635 patients with HPV-negative OPSCC were organized into 4 groups based on cancer staging. In group 1 (T1-2 N0-1; n = 774), up-front surgery had significantly better 5-year OS (76.2%) than RT (56.8%; adjusted hazard ratio [aHR], 1.76; P = .009; 95% CI, 1.15-2.69) and chemoradiation therapy (CRT; 69.5%; aHR, 1.56; P = .019; 95% CI, 1.08-2.26). In group 2 (T3-4 N0-1; n = 327), no significant difference existed between surgery and CRT (5-year OS, 51.3% vs 52.4%; aHR, 0.96; P = .88; 95% CI, 0.54-1.69). In group 3a (T1-2 N2-3; n = 807), surgery with adjuvant treatment showed significantly better 5-year OS than CRT (78.6% vs 68.8%; aHR, 1.51; P = .027; 95% CI, 1.05-2.18). In group 3b (T3-4 N2-3; n = 737), surgery with adjuvant treatment was not statistically associated with better 5-year OS as compared with CRT (61.0% vs 43.7%; aHR, 1.53; P = .06; 95% CI, 0.98-2.39). CONCLUSION: Primary surgery may provide improved survival outcomes in many cases of HPV-negative OPSCCs. These data should be used in weighing treatment options and may serve as a basis to better delineate treatment algorithms for HPV-negative disease.

Characterizing head and neck cancer survivors' discontinuation of survivorship care.

BACKGROUND: Little is known about cancer survivors who discontinue survivorship care. The objective of this study was to characterize patients with head and neck cancer who discontinue survivorship care with their treating institution and identify factors associated with discontinuation. METHODS: This was a retrospective cohort study of patients diagnosed with head and neck cancer between January 1, 2014, and December 31, 2016, who received cancer-directed therapy at the University of Iowa Hospitals and Clinics (UIHC). Eligible patients achieved a cancer-free status after curative-intent treatment and made at least 1 visit 90+ days after treatment completion. The primary outcome was discontinuation of survivorship care, which was defined as a still living survivor who had not returned to a UIHC cancer clinic for twice the expected interval. Demographic and oncologic factors were examined to identify associations with discontinuation. RESULTS: Ninety-seven of the 426 eligible patients (22.8%) discontinued survivorship care at UIHC during the study period. The mean time in follow-up for those who discontinued treatment was 15.4 months. Factors associated with discontinuation of care included an unmarried status (P = .036), a longer driving distance to the facility (P = .0031), and a single-modality cancer treatment (P < .0001). Rurality was not associated with discontinuation (24.3% vs 21.6% for urban residence; P = .52), nor was age, gender, or payor status. CONCLUSIONS: The study results indicate that a sizeable percentage of head and neck cancer survivors discontinue care with their treating institution. Both demographic and oncologic factors were associated with discontinuation at the treating institution, and this points to potential clinical and care delivery interventions.

Revision orbital decompression for thyroid eye disease.

OBJECTIVE: To compare the indications, surgical techniques and outcomes for revision orbital decompression surgery for thyroid eye disease in open, endoscopic, and combined open and endoscopic approaches. METHODS: A retrospective review of all revision orbital decompression procedures for thyroid eye disease from a single large academic institution over a 17-year period (01/01/2004-01/01/2021) was performed. Patient demographics, as well as indications and types of surgery were reviewed. Outcome measures included changes in proptosis, intraocular pressure, visual acuity and diplopia. RESULTS: Thirty procedures were performed on 21 patients. There was a median of 9.4 months between primary orbital decompression and revision decompression surgery. There were 6 bilateral procedures, and 2 of these patients underwent additional revision surgeries due to decreased visual acuity with concern for persistent orbital apex compression or sight-threatening ocular surface exposure in the setting of proptosis. Twenty-five procedures were performed as open surgeries with 5 endoscopic/combined cases. Combined Ophthalmology/Otolaryngology surgery via combined open/endoscopic approaches was favoured for persistent orbital apex disease. Visual acuity remained preserved in all patients. The overall median reduction in proptosis was 2 mm and intraocular pressure change was 1 mmHg regardless of surgical approach. The overall rate of new onset diplopia after surgery was 15%. These patients had open approaches. All endoscopic/combined approach patients had pre-existing diplopia. There were no statistically significant differences between the open and endoscopic/combined groups in regard to change in visual acuity, reduction in proptosis or intraocular pressure. CONCLUSION: Revision orbital decompression is an uncommon procedure indicated for those patients with progressive symptoms despite previous surgery and intensive medical management. Both endoscopic and non-endoscopic techniques offer favourable outcomes with respect to visual acuity, decrease in intraocular pressure, and improvement in proptosis and overall lead to a low incidence of new onset diplopia. LEVEL OF EVIDENCE: Level IV.

Presentation and outcomes of patients with clinically T1-2, N0 supraglottic squamous cell carcinoma: The role of definitive radiotherapy compared to primary partial laryngectomy.

BACKGROUND: Early-stage supraglottic squamous cell carcinoma (SCC) is usually treated with a single modality. The aim of this study is to examine the role of radiotherapy (RT) versus partial laryngectomy (open, robotic-assisted, or endoscopic) with elective neck dissection (PL + END). METHODS: A retrospective analysis of the National Cancer Database, 2010-2016. The study population included adult patients with clinically T1-2, N0 supraglottic SCC. RESULTS: 3301 patients were included. RT was performed in 93.52%, open PL + END in 2.64%, robotic-assisted PL + END in 1.33%, and endoscopic surgical resection in 2.51%. In the surgery group, T was upstaged in 23.36% and N was upstage in 16.36%. Five-year survival in the primary surgery group compared to RT group was 61.89% versus 77.46% (HR: 0.56, 95%CI: 0.43, 0.72). CONCLUSIONS: T was upstaged in 23% of surgical patients. This accurate staging is likely missed in patients who undergo RT and possibly contributes to lower overall survival of this treatment group.

Thyroidectomy practice in pediatric population: a national perspective.

PURPOSE: To examine presentations and outcomes of pediatric patients underoing thyroidectomy. MATERIALS AND METHODS: A retrospective cross-sectional analysis of the Nationwide Readmissions Database, 2010-2014, was performed. Study population included pediatric (<18 years) inpatients undergoing thyroidectomy. RESULTS: A total of 361 patients were included. Mean age was 13.5 ± 0.2 years, and 79.8% were female. Thyroid diseases included: (i) 19.0% thyroid cancer, (ii) 5.4% Multiple Endocrine Neoplasia type II, (iii) 33.6% toxic nodular disease, and (iv) 42.0% non-toxic benign disease. Total thyroidectomy was performed in 67.7% of the patients, and 3.2% of the patients who had initial lobectomy were readmitted within 3 months for completion thyroidectomy. Postoperative complications were reported in 14.2% of the sample, and hypocalcemia was the most common complication (98.2%). Risk of hypocalcemia was significantly higher in patients who had thyroid cancer (risk = 20.9%, p = 0.011) or toxic thyroid diseases (risk = 19.8%, p = 0.033). Of the study population, 25.6% were managed exclusively in children's hospitals. Management in children's hospitals was not associated with improved outcomes or shorter hospital stay; however, it was associated with a significantly higher cost of health services [US $19,4575.0 ± 195.49 vs. US $13,788.00 ± 238.51, p < 0.001]. CONCLUSIONS: This study reports a national perspective on thyroidectomy in the pediatric population. Most thyroid surgeries performed in the pediatric population are performed for benign conditions. Most pediatric thyroidectomies are performed at low-volume centers. Surgeries performed in children's hospitals are significantly higher in cost without any associated improvement in outcomes or length of hospital stay.

Tissue Engineering the Pinna: Comparison and Characterization of Human Decellularized Auricular Biological Scaffolds.

Decellularization is one of the promising techniques in tissue engineering used to create a biological scaffold for subsequent repopulation with the patient's own cells. This study aims to compare two different decellularization protocols to optimize the process of auricle decellularization by assessing and characterizing the decellularization effects on human auricular cartilage. Herein, 12 pairs (8 females, 4 males) of freshly frozen adult human cadaveric auricles were de-epithelialized and defatted leaving only the cartilaginous framework. An auricle from each pair was randomly assigned to either protocol A (latrunculin B-based decellularization) or protocol B (trypsin-based decellularization). Gross examination of the generated scaffolds demonstrated preservation of the auricles' contours and a change in color from pinkish-white to yellowish-white. Hematoxylin and eosin staining demonstrated empty cartilaginous lacunae in both study groups, which confirms the depletion of cells. However, there was greater preservation of the extracellular matrix in auricles decellularized with protocol A as compared to protocol B. Comparing protocol A to protocol B, Masson's trichrome and Safranin-O stains also demonstrated noticeable preservation of collagen and proteoglycans, respectively. Additionally, scanning electron micrographs demonstrated preservation of the cartilaginous microtopography in both study groups. Biomechanical testing demonstrated a substantial decrease in Young's modulus after decellularization using protocol B (1.3 MPa), albeit not significant (P-value > 0.05) when compared to Young's modulus prior to decellularization (2.6 MPa) or after decellularization with protocol A (2.7 MPa). A DNA quantification assay demonstrated a significant drop (P-value < 0.05) in the DNA content after decellularization with protocol A (111.0 ng/mg) and protocol B (127.6 ng/mg) in comparison to before decellularization (865.3 ng/mg). Overall, this study demonstrated effective decellularization of human auricular cartilage, and it is concluded that protocol A provided greater preservation of the extracellular matrix and biomechanical characteristics. These findings warrant proceeding with the assessment of inflammation and cell migration in a decellularized scaffold using an animal model.

The effect of race, socioeconomic status, and comorbidity on patients afflicted with COVID 19: A Local Perspective.

PURPOSE: The aim of this study is to further examine the associations of race, socioeconomic factors, and comorbidity with COVID-19 health outcomes. METHODS: This is a retrospective cohort study of 309 PCR confirmed COVID-19 positive adults who presented to Tulane Medical Center in New Orleans, LA, from March 9 to May 29, 2020. The primary outcomes investigated were need for invasive mechanical ventilation (IMV) and in-hospital mortality. A multivariate analysis was performed to determine socioeconomic and medical risk factors for IMV and in-hospital mortality. RESULTS: Compared to white patients, Black patients were more likely to present younger, female, obese, unemployed, and underinsured. However, when controlled for common risk factors, Black and white patients had similar risk for IMV and mortality. Increased age (≥65 years), obesity, and increased comorbidity were associated with increased risk for IMV and mortality. CONCLUSIONS: Race and socioeconomic factors may increase risk for COVID-19 infection but did not affect health outcomes within the hospital setting. Therefore, the higher rates of COVID-19 infection and mortality in vulnerable populations may be better explained by lower socioeconomic status, with subsequent higher comorbidity, in these populations. Community health initiatives should be prioritized in response to the COVID-19 pandemic.

Presentation and outcomes of patients with undifferentiated thyroid carcinoma: a national perspective.

BACKGROUND: Undifferentiated thyroid cancer (UTC) accounts for only 1-2% of all thyroid cancers. UTC is one of the most aggressive solid tumors with high metastatic rates and mortality. The objectives of this study are to examine the characteristics of patients with UTC and their overall survival. METHODS: Retrospective analysis utilizing the National Cancer Database, 2004-2014 is performed. The study population included adults (≥18 years) patients with UTC or differentiated thyroid carcinoma (DTC), which served as a reference group. RESULTS: A total of 1,870 UTC and 209,707 DTC patients were identified. The median follow-up time of UTC patients was 3.9 months (interquartile range: 1.6-9.0 months). When compared to DTC patients, patients with UTC were more likely to be ≥45-year-old [OR: 48.62, 95% CI: (35.75, 66.14), P<0.001], male [OR: 2.02, 95% CI: (1.84, 2.22), P<0.001], and/or black [OR: 1.27, 95% CI: (1.08, 1.49), P=0.004]. UTC patients were more likely to have Medicaid/Medicare or no insurance and treated in low-volume hospitals (P<0.001). Overall survival in patients with UTC was lower in patients older than 65 years [OR: 1.63, 95% CI: (1.12, 2.38), P=0.011], with multiple comorbidities [OR: 1.65, 95% CI: (1.02, 2.67), P=0.040] and/or presented with metastatic disease [OR: 1.93, 95% CI: (1.71, 2.17), P<0.001]. Compared to thyroidectomy alone, patients without metastasis who received adjuvant radiotherapy and/or chemotherapy had a better overall survival (P<0.001 each). In patients with metastatic disease, any intervention or combination of interventions other than thyroidectomy alone improved survival (P<0.05). CONCLUSIONS: Older age, male, and/or black are associated with a higher prevalence of UTC compared to DTC. Although overall survival is poor in UTC, utilization of multi-modal treatment may improve survival.

Cost-effectiveness of computed tomography nodal scan in patients with papillary thyroid carcinoma.

OBJECTIVES: This study evaluates the cost-effectiveness of ultrasound (US) only; computed tomography (CT) only; and combined US-CT in a base-case that underwent total thyroidectomy for a newly diagnosed papillary thyroid carcinoma (PTC) (scenario I) or surgery for recurrent disease (scenario II). MATERIALS AND METHODS: Markov chain model was developed comparing the above modalities. Follow-up time was set as 10 years. Costs and probabilities values are obtained from literature and the National Cancer Database. RESULTS: Nodal mapping of the central compartment in both primary and recurrent PTC scenarios demonstrated combined utilization of preoperative US and CT is preferred over the use of US or CT separately; the final incurred management cost was [scenario I: U.S.$10,548.25 - scenario II: U.S.$11.197.88] and effectiveness was [scenario I: 6.875 Quality-adjusted-life-year (QALY) - scenario II: 6.871 QALY]. Nodal mapping of the lateral compartments favored US alone as the cost-effective modality in both scenarios; the final incurred management cost was [scenario I: U.S.$10,716.60 - scenario II: U.S.$11,247.92] and effectiveness was [scenario I: 6.879 QALY - scenario II: 6.883 QALY]. Sensitivity analysis demonstrated that for combined utilization of US and CT scans to remain cost-effective, the cost of a CT scan should be less than U.S.$1,127.54. CONCLUSIONS: Based on the model, combined utilization of US and CT is cost-effective in nodal mapping patients with PTC.

Tissue-engineering the larynx: Effect of decellularization on human laryngeal framework and the cricoarytenoid joint.

Decellularization approaches have been commonly used as alternative techniques to reconstruct tissues. However, due to the complex tissue compartmentation of the larynx, the decellularization process may not retain the characteristics necessary for the successful recreation of the larynx. The aim of this study was to assess the effect of the decellularization process on the framework of the human cadaveric larynx generally and the cricoarytenoid joint specifically. In this work, five freshly frozen human cadaveric larynges were decellularized utilizing a protocol that was previously demonstrated to be effective in decellularizing a porcine larynx. The decellularization protocol included: biological, chemical, and physical decellularization methods. Each specimen served as its own control to assess changes after decellularization. Studies and measurements included: histological, using Hematoxylin and Eosin (H&E) and Live/Dead™ stains; DNA quantification; micro-computed tomography (µ-CT) imaging; and biomechanical testing of the cricoarytenoid joints. The decellularization protocol took 12 days for each specimen. Microscopy of H&E stained samples demonstrated substantial removal of cells with preservation of the extracellular matrix that was more evident in cartilage than muscle specimens. Confocal microscope images of Live/Dead™ stained specimens also demonstrated almost complete removal of cells. Pre-decellularization cartilage-DNA quantity range was 27.0 to 336.8 ng/mg while post-decellularization DNA quantity range was 0 to 30.4 ng/mg (p = 0.031). For muscles, pre-decellularization DNA quantity range was 150.0 to 3,384.6 ng/mg, while post-decellularization DNA quantity range was 0 to 45.5 ng/mg (p = 0.031). µ-CT demonstrated preservation of the cartilaginous framework with a slight reduction of cricoarytenoid joint space. Furthermore, µ-CT demonstrated no significant reduction in the Housefield unit (p = 0.25) and mineral density (p = 0.25) after decellularization. Biomechanical testing demonstrated a non-significant reduction of forces required for anterior displacement of the arytenoid (mean reduction of forces, 0.1 ± 0.2 N, p = 0.16) and forces required for posterior displacement of the arytenoid (mean reduction of forces, 0.2 ± 0.3 N, p = 0.05). This study demonstrates effective decellularization of human larynges as evidenced by significant DNA depletion and preservation of extracellular matrix, which are outcomes that are required for a biological scaffold to regenerate a non-immunogenic larynx. The decellularization process caused minimal weakness in the cricoarytenoid joints due to treatment with multiple detergents and enzymes in the decellularization protocol.

Factors Associated With the Choice of Radiation Therapy Treatment Facility in Head and Neck Cancer.

OBJECTIVE: To analyze the clinicodemographic characteristics and treatment outcomes of patients receiving postoperative radiation therapy (PORT) at a different treatment facility rather than the initial surgical facility for head and neck cancer. STUDY DESIGN: Retrospective cohort analysis. METHODS: Utilizing the National Cancer Data Base, 2004 to 2015, patients with a diagnosis of oral cavity/oropharyngeal, hypopharyngeal, and laryngeal squamous cell carcinoma were studied. Multivariate analysis was completed with multivariate regression and Cox proportional hazard model, and survival outcomes were examined using Kaplan-Meier analysis. RESULTS: A total of 15,181 patients who had surgery for a head and neck cancer at an academic/research center were included in the study population. Of the study population, 4,890 (32.2%) patients completed PORT at a different treatment facility. Treatment at a different facility was more common among patients who were ≥65 years old, white, Medicare recipients, those with a greater distance between residence and surgical treatment facility, and with lower income within area of residence (each P < .05). Overall survival was worse in patients completing PORT at a different treatment facility versus at the institution where surgery was completed (61.9% vs. 66.4%; P = .002). CONCLUSIONS: PORT at a different facility was more common in older individuals, Medicare recipients, those with greater distance to travel, and lower-income individuals. Completing PORT outside the hospital where surgery was performed was associated with inferior survival outcomes among head and neck cancer patients. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1019-1025, 2021.