Endoluminal Sigmoid Sinus Occlusion During Jugular Foramen Tumor Surgery: Novel Technique, Operative Nuances, and Clinical Experience With 33 Patients.

BACKGROUND AND IMPORTANCE: Surgery of jugular foramen tumors (JFTs) often requires vascular control by means of ligating the internal jugular vein and sigmoid sinus (SS) to allow intrabulbar access. Occlusion of the SS traditionally involves presigmoid and retrosigmoid durotomies allowing introduction of ligature devices, predisposing to cerebrospinal fluid (CSF) leakage and pseudomeningoceles. We describe a simple and novel endoluminal sigmoid sinus occlusion (ESSO) technique with Gelfoam that is entirely extradural. CLINICAL PRESENTATION: An extended anterolateral infralabyrinthine approach with ESSO was performed in 33 patients with JFTs. After ligating the internal jugular vein, the SS is opened and Gelfoam is placed endoluminally into the proximal SS. Care is taken to avoid occlusion of the venous outflow of the vein of Labbe to avoid temporal lobe venous infarction. Hemostatic gelatin matrix is injected distally to stop venous backflow from the inferior petrosal sinus. The jugular venous system is isolated, and the outer jugular wall can be opened to expose the JFT for resection. There were no complications of temporal lobe venous infarction or postoperative hematoma observed. Four patients with intradural tumor extension developed pseudomeningoceles. For patients with purely extradural JFTs, none developed postoperative incisional CSF leaks and one had pseudomeningocele. CONCLUSION: This ESSO technique is fast and effective, permitting occlusion of the SS during JFT surgery. It has the advantage of being entirely extradural, avoiding durotomy which can result in postoperative CSF leak. It is important to keep the Gelfoam distal to the transverse-sigmoid junction to avoid occlusion of the vein of Labbe inlet and temporal lobe venous infarction.

Elective Neck Dissection for cT1-4 N0M0 Head and Neck Verrucous Carcinoma.

OBJECTIVE: To investigate the survival benefit of elective neck dissection (END) over neck observation in cT1-4 N0M0 head and neck verrucous carcinoma (HNVC). STUDY DESIGN: Retrospective cohort study. SETTING: The 2006 to 2017 National Cancer Database. METHODS: Patients with surgically resected cT1-4 N0M0 HNVC were selected. Linear, binary logistic, Kaplan-Meier, and Cox proportional hazards regression models were utilized. RESULTS: Of 1015 patients satisfying inclusion criteria, 223 (22.0%) underwent END. The majority of patients were male (55.4%) and white (91.0%) with disease of the oral cavity (67.6%) classified as low grade (90.0%) and cT1-2 (81.8%). The minority of ENDs (4.0%) detected occult nodal metastases. The rate of END increased from 2006 to 2017 for both cT1-2 (16.3% vs 22.0%, p = .126, R2 = 0.405) and cT3-4 (41.7% vs 70.0%, p = .424, R2 = 0.232) disease but these trends were not statistically significant. Independent predictors of undergoing END included treatment at an academic facility (adjusted odds ratio [aOR]: 1.75, 95% confidence interval [CI]: 1.19-2.55), cT3-4 disease (aOR: 3.31, 95% CI: 2.16-5.07), and tumor diameter (aOR: 1.09, 95% CI: 1.01-1.19) (p < 0.05). The 5-year overall survival (OS) of patients treated with and without END was 71.3% and 70.6%, respectively (p = .661). END did not significantly reduce the 5-year hazard of death (adjusted hazard ratio: 1.25, 95% CI: 0.91-1.71, p = .172). END did not significantly improve 5-year OS in univariate and multivariate analyses stratified by several patient, facility, tumor, and treatment characteristics. CONCLUSION: END does not confer an appreciable survival benefit in HNVC, even after stratifying univariate and multivariate analyses by several patient, facility, tumor, and treatment characteristics. LEVEL OF EVIDENCE: Level 4.

Assessing the Association Between Time to Surgery and Survival in Sinonasal Squamous Cell Carcinoma.

INTRODUCTION: To assess the association between time to surgery (TTS) and survival in sinonasal squamous cell carcinoma patients (SSCC). METHODS: We queried the 2004-2016 National Cancer Database for all cases of adult SSCC undergoing primary surgical treatment. Patients with missing TTS information were excluded. We conducted a multivariate analysis of patient demographic and clinicopathological characteristics' effect on overall survival (OS) using a Cox proportional hazards model enhanced with cubic spline non-linear approximation. Bootstrapping methods were utilized to detect the aggregate risk of TTS delay on patient OS. RESULTS: A total of 2,881 patients met the inclusion criteria. The majority of patients were male (63.5%), White (86.3%), and over the age of 60 (58.4%). Parametric cubic spline approximation Cox hazard model detected a non-linear association between patient OS and TTS below 30 days with the lowest risk occurring at 18 days and steadily increasing subsequently. To analyze the aggregate risk and identify the optimal TTS cut-off after 30 days of surgical delay, the cohort sample was bootstrapped and dichotomized. The largest increase in aggregated risk was identified at 59 days (Hazards Ratio [HR] = 1.006 [0.839-1.084], p = 0.003). 60 days were used as the optimal TTS cut-off for analyzing the survival rate using the Cox proportional hazard model. Undergoing surgery within 60 days translated to a 14.6% decreased chance of death (HR: 0.854 [0.83-0.96]). CONCLUSIONS: Increasing TTS is associated with worse overall survival in patients with SSCC. Our study suggests that surgery should be done within 60 days to achieve optimal survival results. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:3389-3395, 2023.

Effect of obesity on outcomes after open laryngeal surgery including total laryngectomy: A NSQIP database analysis.

BACKGROUND: The impact of obesity on outcomes after open laryngeal surgery has not been well-described. METHODS: The NSQIP database was queried for all open laryngeal surgeries including total laryngectomies between 2005 and 2018. Outcomes of patients identified as obese or nonobese by BMI were compared. RESULTS: Of 1865 patients, 20.1% classified as obese. The most common operation performed was total laryngectomy with or without radical neck dissection (73.2%). Operation time and length of hospital stay were significantly less for obese patients. On multivariate analysis, obesity was associated with less bleeding transfusions occurrences (aOR, 0.395, p = 0.0052), surgical complications (aOR, 0.604, p < 0.001), and any complication (aOR, 0.730, p = 0.0019). CONCLUSION: Though there may be an inverse association of obesity with complications and bleeding transfusion occurrences, as well as decreased operation time and length of hospital stay, several confounders and bias may exist; therefore, it is difficult to conclude that the obesity paradox is present.

Opioid prescription trends among American Head and Neck Society fellowship graduates.

BACKGROUND: Opioids are commonly used to manage the pain of head and neck (HN) cancer patients. METHODS: Retrospective cohort of graduates from American Head and Neck Society accredited fellowships from 1997 to 2018. The Center for Medicare and Medicaid Services Part D Provider Utilization and Payment database 2014-2019 was cross-referenced with provider names to identify opioid prescription trends. RESULTS: From 2014 to 2019, there was no significant difference in the average number of opioid beneficiaries per provider (18.02 vs. 18.10, p = 0.586) or opioid claims per provider (28.06 vs. 26.73, p = 0.708). The average total opioid day supply per beneficiary declined from 11.09 to 7.05 days from 2014 to 2019 (p < 0.001). In 2019, providers in the Northeast had the lowest prescribed opioid day supply (3.67 days) compared to those from the South who had the highest (10.32 days). CONCLUSIONS: Opioid prescription length has significantly declined among HN surgeons, with variations across geographic regions.

Facility volume and survival: Human papilloma virus positive oropharyngeal squamous cell carcinoma.

BACKGROUND: To analyze the impact of facility volume on survival for human papilloma virus positive oropharyngeal squamous cell carcinoma (HPV+ OPSCC) patients. METHODS: Patients treated for HPV+ OPSCC from 2010 to 2017 were queried from the National Cancer Database. Facilities of average annual case volume <50th percentile were categorized as low-volume (LV) and >95th percentile as high-volume (HV). RESULTS: 11,546 were included, with 10,305 patients (89.3 %) treated at LV and 1241 (10.7 %) at HV facilities. A greater proportion of cases involving resection of base of tongue and lingual tonsil were treated at HV (30.3 %) compared to LV (22.3 %) facilities (p < 0.001). Patients treated at a HV facility had greater percentage of clinical T4 (11.2 % vs. 8.6 %, p = 0.001) and N+ disease (90.5 % vs. 85.7 %, p < 0.001) patients. Survival analysis showed no statistically significant difference between five-year overall survival rates by facility volume (p = 0.388) for all patients. On multivariable analysis, facility volume was not associated with survival (HR: 0.968 [0.758-1.235], p = 0.791). These trends were found for both patients undergoing primary surgery or chemoradiotherapy. CONCLUSION: Our data indicates that patients with HPV+ OPSCC do not experience a survival benefit with treatment at HV facility, suggesting these patients may be adequately treated at LV centers.

Understanding basal cell adenocarcinoma of the head and neck: Population-based study.

BACKGROUND: Using a population-based database, this study investigates the risk factors, epidemiology, and outcomes of basal cell adenocarcinoma (BCAC) of the head and neck. METHODS: The Surveillance, Epidemiology, and End Results database was analyzed for all patients with BCAC of the head and neck from 1973 to 2015. RESULTS: Three hundred and twenty-two cases of BCAC of the head and neck were identified. Mean age of diagnosis was 64.1 years. 52.5% were male and 77.3% were white. The most common primary site was the parotid gland (71.7%). Most patients underwent surgery alone (51.9%). Five-year disease-specific survival (5Y-DSS) was 95.6%, and 10Y-DSS was 90.3%. Highest survival was seen with surgery alone followed by combined surgery and radiation (10Y-DSS: 93.9% vs. 88.9%, p = 0.001). Age, primary site, T-classification, grade, and treatment type significantly affected survival. CONCLUSIONS: BCAC of the head and neck presents most frequently in the parotid glands. Surgery alone is associated with highest survival.

Understanding giant cell sarcoma of the head and neck: A population-based study.

BACKGROUND: Giant cell sarcomas (GCS) are rare head and neck neoplasms. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was analyzed for all patients who have been diagnosed with GCS from 1973 to 2014. RESULTS: Four hundred and forty cases of GCS of the head and neck were identified. The average age at diagnosis was 74.4 years, 86.8% were white, 82.5% were male, 70.7% were insured, and 88.2% lived in an urban metropolitan region. Connective tissue was the most frequent primary site (42.5%). The 5Y-DSS rate was 91.1%, while the 5Y-OS was 54.6% for all cases. Patients treated with surgery alone had the highest 5Y-DSS rate of 94.5. T-classification odds ratio was a significant predictor of survival accounting for confounding variables on multivariate analysis. CONCLUSIONS: GCS presents most frequently in connective tissue of the head and neck with overall high probability of survival. The treatment of choice is surgery alone.

Exploratory analysis on the association of mental health disorders with in-hospital postoperative complications and mortality in head and neck cancer surgery.

BACKGROUND: The objective was to assess the association of mental health disorders with in-hospital complication and mortality rates in patients undergoing head and neck cancer surgery. METHODS: In this exploratory retrospective study, the Nationwide Inpatient Sample was queried from 2003 to 2014 for all patients with a diagnosis of head and neck cancer who underwent surgery. Univariate cross-tabulation, logistic regression, and propensity score matching (PSM) were used to compare demographics, procedure-related variables, and in-hospital postoperative complications and mortality between patients with and without selected comorbid mental health disorders. RESULTS: Of 39 600 included patients, 3390 (8.6%) had a selected comorbid mental health disorder diagnosis. After PSM, patients with selected mental health disorders had increased risk of overall medical complications on multivariable analysis (OR 1.28 [CI 1.12-1.46], P < 0.001) but not overall surgical complications or mortality. CONCLUSIONS: Patients with a mental health disorder diagnosis have increased risk of in-hospital medical, certain surgical, and total complications.

The Affordable Care Act: Implications for underserved populations with head & neck cancer.

PURPOSE: This study was done to determine the direct impact implementation of the Affordable Care Act (ACA) on patients with Head and Neck Cancer (HNCA) in states that chose to expand Medicaid compared to in states that did not, as well as assess whether this impact varied among different demographic groups. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for cases of HNCA diagnosed from 2011 to 2014. Rates of uninsured status were compared before and after Medicaid expansion and contrasted between states that did and did not expand coverage, stratified by patient and tumor characteristics, and assessed via multivariate regression. RESULTS: Overall rates of uninsured status (UR) were decreased by 63.08% in states that expanded coverage (ES) but only by 2.6% in states that did not (NS). In NS, there was an increase in proportion of black patients who were uninsured over the study period (13.7%, p = 0.077) whereas in ES, this proportion decreased by 73.3%. When stratified by primary site, patients with laryngeal cancer had the highest UR with an increase by 16.7% in NS and a decrease by 70.5% in ES. Multivariate analysis yielded predictors of uninsured status including residence in a NS, Hispanic ethnicity, and black race. CONCLUSIONS: Implementation of the ACA resulted in expanded insurance coverage for patients diagnosed with HNCA concentrated mainly in states that expanded Medicaid coverage and for patients derived from vulnerable populations, including black and Hispanic patients. In states that did not expand Medicaid, vulnerable populations were disproportionately affected.

The "July effect": Outcomes in microvascular reconstruction during resident transitions.

OBJECTIVES/HYPOTHESIS: To evaluate the "July effect," as a possible risk factor for perioperative complications in otolaryngology microvascular reconstruction during the transitional period in the academic calendar. STUDY DESIGN: Retrospective database review. METHODS: Microvascular reconstruction outcomes in the National Surgical Quality Improvement Program (2005-2016) database were compared between the first academic quarter (July-September) to the last academic quarter (April-June). The primary outcome was 30-day morbidity, and secondary outcomes included 30-day mortality, operative complications, or postoperative adverse events. RESULTS: There were 612 and 580 patients who underwent microvascular reconstruction during the first and last academic quarters, respectively. There was no significant difference between the 30-day mortality between the first academic quarter (1.5%) and the last academic quarter (0.7%) (P = .194). There was no difference in 30-day morbidity (47.9% vs. 49.5%, P = .586), operative complications (wound disruption, P = .151; bleeding, P = .526; operative time, P = .162), or postoperative adverse events (deep vein thrombosis, P = .460; pneumonia, P = .737; reintubation, P = .201; pulmonary embolism, P = .452; ventilation for >48 hours, P = .769; acute renal failure, P = .500; urinary tract infection, P = .693; unplanned readmission, P = .202; and mean length of stay, P = .497). CONCLUSIONS: There appears to be no July effect in microvascular reconstruction. Further studies should identify the mechanisms that preserve the safety of this operation year-round for application to other areas of medicine who have observed the July effect. LEVEL OF EVIDENCE: NA Laryngoscope, 130:893-898, 2020.

Risk assessment of hypertension in carotid body surgeries: A NSQIP analysis.

OBJECTIVES: Carotid body tumors (CBT) are rare paragangliomas of the carotid body at the carotid bifurcation. The purpose of this study was to determine the effect of hypertension on outcomes in carotid body tumor surgery. STUDY DESIGN: A retrospective database review. METHODS: Data on carotid body resections performed from 2005 to 2014 were drawn from the American College of Surgeons' National Surgical Quality Improvement database. Two groups were created based on the presence of preoperative hypertension. These groups were analyzed for demographics, comorbidities, and postoperative complications using bivariate and multivariate methods. RESULTS: Of the 452 patients included in the analysis, 49.3% had hypertension. Those with hypertension were significantly more likely to have additional comorbidities, which were controlled for by multivariate analysis to focus on hypertension. These hypertensive patients also had significantly longer hospital stays. Multivariate analysis showed that patients with hypertension undergoing carotid body resections had increased risk for overall medical complications but did not have increased risk for postoperative surgical complications or specific medical complications CONCLUSION: This statistically robust study revealed that hypertension does not independently increase a patient's risk for specific postoperative surgical complications following a carotid body tumor resection. However, hypertension increases the risk for postoperative medical complications and longer hospital stays. It is notable that almost half of all CBT patients have hypertension, and these hypertensives patients are significantly more likely to carry additional comorbid conditions that may have an adverse effect on outcomes including overall medical complications. LEVEL OF EVIDENCE: NA Laryngoscope, 130: 2008-2012, 2020.

Refusal of Cancer-Directed Surgery in Head and Neck Squamous Cell Carcinoma Patients.

OBJECTIVES/HYPOTHESIS: To investigate the risk factors for refusal of recommended surgery in head and neck squamous cell carcinoma (HNSCC) treatment STUDY DESIGN: Retrospective review of a national database. METHODS: The Surveillance, Epidemiology, and End Results database was queried for all cases of HNSCC from 1989 to 2014. Patients who underwent recommended surgery (N = 98,270) were identified and compared to patients who refused recommended surgery (N = 3,582). Groups were compared for patient demographics, socioeconomic variables, and tumor characteristics including stage, grade, and primary site. Binary logistic regression was performed to determine independent predictors of surgery refusal. RESULTS: Of the total population, 1.8% of patients refused cancer directed surgery. Following regression, the strongest predictors of surgery refusal were found to be age greater than 75years (odds ratio [OR]: 4.23 [95% confidence interval {CI}: 3.00-5.96]), and stage III (OR: 4.19 [95% CI: 3.15-5.57]) or stage IV at diagnosis (OR: 4.49 [95% CI: 3.46-5.80]). Black race was significantly predictive (OR: 1.71 [95% CI: 1.37-2.13]) as well as marital status other than married (OR: 1.76 [95% CI: 1.49-2.07]) and Medicaid insurance status (OR:1.46 [95% CI: 1.20-1.77]). Primary site of larynx (OR: 2.01 [95% CI: 1.71-2.37]) or base of tongue (OR: 2.34 [95% CI: 1.87-2.92]) additionally predicted surgery refusal. CONCLUSIONS: A number of demographic, socioeconomic, and tumor-related variables are associated with refusal of cancer-directed surgery in head and neck squamous cell carcinoma. Recognition of these factors may help identify situations where more active education and support are needed to help patients accept optimal care. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1368-1373, 2019.

Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery.

IMPORTANCE: Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck. OBJECTIVE: To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using χ2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018. MAIN OUTCOMES AND MEASURES: Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked. RESULTS: Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications. CONCLUSIONS AND RELEVANCE: Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit. LEVEL OF EVIDENCE: NA.

Outpatient versus inpatient parotidectomy: Comparison of postoperative complication rates.

OBJECTIVES: Parotidectomies have become a common outpatient procedure, but their impact on postoperative complications as compared to inpatient procedures has not been evaluated in a multi-institutional study. STUDY DESIGN: The aim of this retrospective analysis was to evaluate the differences in outcomes using a standardized cohort of patients undergoing outpatient or inpatient parotidectomies. METHODS: The National Surgical Quality Improvement Program database was queried for parotidectomies between 2005 and 2014. Univariate analyses were conducted to compare the outpatient and inpatient cohorts. A propensity-matching algorithm was used to ensure equal distribution of demographics and preoperative comorbidities. RESULTS: Among the 4,368 parotidectomies examined, 2,915 (66.7%) were outpatient and 1,453 (33.3%) were inpatient. In the unmatched analysis, the inpatient group had higher rates of smokers (P = < 0.001), hypertension (P = 0.003), and disseminated cancer (P = 0.014). The outpatient group had higher rates of patients under age 40 years (P = 0.015), females (P = 0.016), and American Society of Anesthesiology class 1 and 2 (P = < 0.001). The total work relative value units (RVUs) were 17.01 ± 3.44 for the inpatient cohort and 16.19 ± 3.70 for the outpatient cohort (P = < 0.001). Following propensity matching, 1,352 cases were selected for each cohort, with no significant differences in comorbidities. Total work RVU after matching was 16.90 ± 3.47 for the inpatient group and 16.75 ± 3.44 for the outpatient group (P = .235). The matched inpatient cohort had increased rates of surgical complications (3.1% vs. 1.8%, P = 0.033), pneumonia (0.5% vs. 0.0%, P = 0.016), and overall complications (4.5% vs. 2.6%, P = 0.009). CONCLUSION: Outpatient parotidectomies are associated with similar as well as decreased complication rates as compared to inpatient parotidectomies. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:655-661, 2019.

Supraglottic Squamous Cell Carcinoma: A Population-Based Study of 22,675 Cases.

OBJECTIVES/HYPOTHESIS: The authors used the Surveillance, Epidemiology, and End Results (SEER) database to analyze epidemiological features of patients presenting with supraglottic squamous cell carcinoma (SCCa) and to evaluate treatment trends and outcomes. METHODS: The SEER database was queried for patients with supraglottic SCCa from 1973 to 2013. Information on demographics; tumor size; histologic grade; American Joint Committee on Cancer (AJCC) stage; SEER local, regional, distant stage; and treatment modality were analyzed. RESULTS: There were 22,675 cases of primary supraglottic SCCa identified. The mean age at diagnosis was 62.3 years, with males accounting for 70.3% of all cases. A high percentage of patients presented with stage IV disease (44.9%). The most common treatment modality was radiotherapy (46.6%), followed by combination of surgery and radiotherapy (29.2%) and surgery alone (15.0%). Overall 5-year disease-specific survival (DSS) for all cases was 54.0%. When stratified by treatment modality, 5-year DSS was best for patients receiving surgery alone (64.2%). However, for patients with AJCC stage IV disease, survival was significantly better with combined surgery and radiotherapy (52.5%). CONCLUSION: In general, supraglottic SCCa is treated most commonly with radiotherapy, followed by surgery and radiotherapy. Patients managed surgically had better 5-year DSS when compared to patients treated by other modalities. However, when stratified by stage, patients with AJCC stage IV disease had significantly better survival with combined surgery and radiotherapy. Of patients receiving surgery, supraglottic laryngectomy was found to have a significantly better 5-year DSS when compared to both total laryngectomy and laryngectomy, not otherwise specified. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1822-1827, 2019.

Second primary lung malignancy following head and neck squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Analyze the characteristics of second primary lung malignancies (SPLMs) following an index head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN: Retrospective cohort study. METHODS: The Surveillance, Epidemiology and End Results database was queried for all cases of HNSCC between 1973 and 2014 (N = 101,856). This population was compared to a standard population to assess relative risk for lung cancer, calculated as the standardized incidence ratio (SIR). Patients who developed SPLMs were extracted (N = 8,116) and compared to all other cases of lung cancer (N = 1,160,853) to assess histopathological differences. SPLM subpopulations divided by head and neck primary site were compared for lung cancer histology and time interval between cancer diagnoses. RESULTS: Overall, 8.0% of HNSCC patients developed SPLMs (SIR = 4.22, P < .001), diagnosed an average of 6.7 years later. Patients with HNSCC of the supraglottis and hypopharynx were at the highest risk relative to a standard population, with SIRs of 8.10 and 6.34, respectively. When comparing SPLMs to all other lung cancers, there was no difference in the distribution of lung lobe affected, but SPLMs were significantly more likely to be of squamous cell carcinoma histology (42.0% vs. 21.0%, P < .001). Among head and neck subsites, lung cancers following larynx tumors had a significantly higher proportion of small cell histology, and those following oropharyngeal or hypopharyngeal tumors had significantly higher proportions of squamous cell histology. CONCLUSIONS: Patients who undergo curative treatment of HNSCC are at high risk for developing SPLMs. Subsite-specific differences may help elucidate the degree of risk attributable to smoking, genetic susceptibility, human papillomavirus infection, or metastasis masquerading as an SPLM. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:903-909, 2019.

The Impact of Duty-Hour Restrictions on Complication Rates Following Major Head and Neck Procedures.

OBJECTIVES/HYPOTHESIS: To assess the impact of resident duty-hour restrictions (DHR) in otolaryngology via comparison of postoperative outcomes between otolaryngology teaching hospitals (Oto-TH) and nonteaching hospitals (NTH) before and after complete implementation. STUDY DESIGN: Retrospective database review. METHODS: The Nationwide Inpatient Sample was queried for all major head and neck cases between 2000 and 2002 (n = 34,064) and 2008 and 2010 (n = 33,094). Cases were stratified into Oto-TH (n = 28,771) and NTH (n = 38,387) and assessed for procedure type, patient comorbidities, and complications. A subpopulation matched by procedure type was generated for direct comparison of complication rates using χ2 and binary logistic regression analyses. RESULTS: In the years following DHR, total case volume and average case complexity increased at Oto-TH only. Using a case-matched subpopulation, regression analysis found Oto-TH status to be protective for medical complications both before (odds ratio [OR]: 0.60, P < .001) and after (OR: 0.76, P = .001) DHR. In contrast, Oto-TH cases had lower risk for surgical complications in 2000 to 2002 (OR: 0.77, P < .001) but not 2008 to 2010 (OR: 1.07, P = .275). When comparing time periods, the years following DHR were associated with a significant decrease in medical complications and mortality across hospital cohorts. For surgical complications, rates significantly improved at NTH only (OR: 0.82, P = .002), with no difference at Oto-TH (OR: 0.95, P = .450). CONCLUSIONS: In the years following DHR, rates of medical complications, surgical complications, and mortality have significantly improved at NTH. At Oto-TH, there has been a lack of similar improvement in surgical complications, even after accounting for increasing case volume and complexity in more recent years. While the cause is likely multifactorial, DHR in otolaryngology residency may play a role. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2804-2810, 2018.

Outcomes in microvascular head and neck reconstruction in the setting of restricted residency hours.

BACKGROUND: Resident duty hour restrictions can limit the frequency of resident flap checks at smaller institutions with "home" call. Institutions are compensating with adjuvant nursing flap checks as well as incorporating technology; however, this management remains controversial. METHODS: A prospective cohort of 122 free flaps for reconstruction of the head and neck by a single surgeon. Demographic information, operative details, postoperative care, and flap outcomes were recorded. RESULTS: Over 42 months, 122 free flaps were performed on 115 patients. The overall flap success rate was 96%. The flap success rate at 72 h was 98% and 96% at the time of discharge with reexploration rates of 11.6%. The intraoperative and postoperative salvage rates were 71% and 64.3% respectively. CONCLUSION: Limited resident flap checks combined hourly nurse flap checks and an implantable Doppler is an effective monitoring protocol for academic programs in the setting of residency duty hour restrictions.