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Although outcomes account for 45% of the total ranking score in otolaryngology in the 2023-2024 U.S. News Best Hospitals rankings, little attention has been paid to the representativeness of their outcomes or volume analyses. Through retrospective review of finance data from an academic otolaryngology department, we found the overall 2023-2024 USNWR volume estimate accounted for only 10.0% (n = 2, usw 024/20,334) of all adult admissions and outpatient procedures and did not adequately represent the overall case mix or caseload.
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Otolaringologia , Humanos , Otolaringologia/estatística & dados numéricos , Estados Unidos , Estudos Retrospectivos , Avaliação de Resultados em Cuidados de SaúdeRESUMO
Objective: To evaluate for correlation between intraoperative ultrasound (IOUS)-measured tumor thickness (TT) (uTT) and histopathological TT (hTT), and to compare IOUS-assisted resection with conventional resection in patients with oral tongue cancers. Data Sources: Ovid MEDLINE (1946-2023), Embase.com (1947-2023), and Web of Science (All Databases 1900-2023). Review Methods: Inclusion criteria were the use of IOUS for the management of oral tongue cancer. Studies that did not report quantitative data were excluded. Additionally, studies that were not contributory to meta-analysis, or a narrative analysis of pooled results were excluded. Selection was carried out by 2 reviewers. A total of 2417 studies were initially identified, with 12 ultimately being included in this review, and 7 included in the meta-analysis. Data were extracted by 2 investigators and were pooled using a random-effects model. Results: Our meta-analysis reveals a pooled correlation coefficient of 0.92 (95% confidence interval: 0.80-0.96) for studies comparing uTT to hTT. Studies comparing IOUS-assisted resection to conventional resection found IOUS-assisted resection yielded wider nearest margins in all studies reporting this outcome. Conclusion: IOUS reliably measures TT, similarly to that of histopathology measurement. IOUS-assisted resection, which allows the surgeon to view the deep extent of tumor invasion, may increase closest radial margin distance compared to conventional resection. IOUS-assisted resection may represent a more reliable approach to achieving clear margins than conventional resection.
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In this narrative medicine essay, a surgical oncologist reflects on his 30-year practice and the care he receives for his leukemia, understanding how vital the relationships and discourse with the care team are for his recovery.
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Hematologia , Oncologia , Neoplasias , Assistência ao Paciente , Relações Médico-Paciente , Humanos , Oncologia Cirúrgica , Neoplasias/terapiaRESUMO
Reputation score has been shown to be the strongest predictor of ranking in the US News & World Reports (USNWR) Best Hospitals report. However, the extent to which physicians participate in the underlying USNWR reputation survey is not well-characterized. We conducted a retrospective cross-sectional study of USNWR public methodology reports from 2015 to 2023 to characterize trends in physician response rates by specialty, region, and Doximity membership. Overall response rates declined between 2015 (24.0%) and 2023 (8.9%). In 2023, rates ranged from 4.7% (psychiatry) to 13.9% (otolaryngology). Otolaryngology had the highest response rate among all specialties between 2017 and 2023. Within otolaryngology, both response rates (25.0% to 13.9%) and count (2106 to 1724 physicians) declined between 2015 and 2023. Among Doximity members, response rates were consistently higher for otolaryngologists in the Northeast and Midwest compared to other regions. Though hospital rankings often influence where patients seek care, our findings suggest USNWR reputation scores may not be reliable or representative.
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Medicina , Otolaringologia , Humanos , Estados Unidos , Estudos Transversais , Estudos Retrospectivos , HospitaisRESUMO
BACKGROUND: Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown. METHODS: Single-institution retrospective review of patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022. RESULTS: A total of 49 patients underwent stricture dilation after TL/TLP. Thirty-five (71%) underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group. CONCLUSIONS: Shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.
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Transtornos de Deglutição , Estenose Esofágica , Humanos , Constrição Patológica/complicações , Dilatação/efeitos adversos , Laringectomia/efeitos adversos , Transtornos de Deglutição/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Estenose Esofágica/complicações , Estenose Esofágica/terapiaRESUMO
Importance: Despite the widespread use of fibula free flap (FFF) surgery for head and neck reconstruction, there are no studies assessing if early weight-bearing (EWB) affects postoperative recovery, and the timing of weight-bearing initiation following FFF surgery varies considerably across institutions. Therefore, it is important to understand the effect of EWB in these patients and whether it could improve postoperative recovery. Objective: To assess the association of EWB after FFF surgery with donor-site complications, length of stay, and discharge to home status. Design, Setting, and Participants: This retrospective cohort study took place at Massachusetts Eye and Ear, a single tertiary care institution in Boston, Massachusetts. A total of 152 patients who received head and neck reconstruction with a fibula osteocutaneous free flap between January 11, 2010, and August 11, 2022, were included. Exposure: EWB on postoperative day 1 vs non-EWB on postoperative day 2 or later. Main Outcomes and Measures: Patient characteristics, including demographic characteristics and comorbidities, surgical characteristics, donor-site complications, length of stay, and discharge disposition, were recorded. Descriptive statistics and multivariate logistic regressions were used to compute effect sizes and 95% CIs to compare postoperative outcomes in EWB and non-EWB groups. Results: A total of 152 patients (median [IQR] age, 63 [55-70] years; 89 [58.6%] male) were included. The median (IQR) time to postoperative weight-bearing was 3 (1-5) days. Among all patients, 14 (9.2%) had donor-site complications. EWB on postoperative day 1 was associated with shorter length of stay (adjusted odds ratio [AOR], 0.10; 95% CI, 0.02-0.60), increased rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80), and decreased donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94). Conversely, weight-bearing 3 or more days postoperatively was associated with an increased risk of pneumonia (AOR, 6.82; 95% CI, 1.33-34.99). Conclusions and Relevance: In this cohort study, EWB after FFF surgery was associated with shorter length of stay, increased rate of discharge to home, and decreased donor-site complications. These findings support the role of early mobilization to optimize postoperative recovery after FFF surgery.
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Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Estudos de Coortes , Estudos Retrospectivos , Fíbula , Suporte de Carga , Complicações Pós-Operatórias/epidemiologiaRESUMO
The status of resection margins is a proxy for the completeness of resection in oral tongue cancer surgery and is therefore a useful predictor for post-operative prognosis. Historically, a margin distance of 5 mm or greater has been deemed a negative margin and is believed to yield a benefit in terms of control and survival. To summarize the literature more completely on this topic, we conducted a systematic review that examines radial margin distance and its relationship to disease control and survival in oral tongue cancer. Our review includes 34 studies which reported survival and/or recurrence outcomes for oral tongue cancer patients based on margin status. Most studies reported outcomes for the 5 mm margin, while the minority utilized other margin cutoffs. For the 5 mm cutoff, outcomes were generally favorable regarding survival and recurrence outcomes. Nonetheless, studies using 4 mm, 3.3 mm, and 10 mm cutoffs also found favorable survival and recurrence outcomes; however, these are a minority of the included studies.
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Carcinoma de Células Escamosas , Neoplasias Bucais , Neoplasias da Língua , Humanos , Neoplasias da Língua/cirurgia , Carcinoma de Células Escamosas/cirurgia , Recidiva Local de Neoplasia , Neoplasias Bucais/cirurgia , Prognóstico , Margens de Excisão , Estudos RetrospectivosRESUMO
OBJECTIVE(S): To characterize the change in sensory function following partial glossectomy for oral tongue cancer (OTC) and to identify predictors of loss of tongue-tip sensation (LoTTS). MATERIALS AND METHODS: Patients with at least three months follow-up after partial glossectomy for primary OTC were included. All patients underwent a qualitative tongue sensation assessment and an objective tongue sensory exam of the native tongue tip. Additional details regarding the oncologic resection, surgical reconstruction, and pathological stage were collected. Multiple linear and logistic regressions were used for statistical analysis. RESULTS: Sixty-four patients were enrolled, including 34 (53%) men with a median age of 65 at enrollment. Ten (15%) patients reported LoTTS. Increased depth of resection (DOR) was an independent predictor of LoTTS on multivariate analysis, with an increased risk at a threshold of 1.3 cm. LoTTS was also associated with worse subjective quality of life and perceptive speech performance in our qualitative tongue assessment. CONCLUSIONS: In this pilot study, we found that DOR is a critical prognostic factor in predicting post treatment function. Patients with an increased DOR, particularly above 1.3 cm, are at greatest risk of LoTTS and associated morbidity. These findings may be used to predict post-operative sensory deficits, manage patients' expectations, and optimize the reconstructive approach. Future studies are needed to validate and replicate our results.
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Neoplasias da Língua , Masculino , Humanos , Feminino , Neoplasias da Língua/etiologia , Glossectomia/métodos , Projetos Piloto , Qualidade de Vida , Língua/cirurgia , SensaçãoRESUMO
The surgical resection of solid tumours can be enhanced by fluorescence-guided imaging. However, variable tumour uptake and incomplete clearance of fluorescent dyes reduces the accuracy of distinguishing tumour from normal tissue via conventional fluorescence intensity-based imaging. Here we show that, after systemic injection of the near-infrared dye indocyanine green in patients with various types of solid tumour, the fluorescence lifetime (FLT) of tumour tissue is longer than the FLT of non-cancerous tissue. This tumour-specific shift in FLT can be used to distinguish tumours from normal tissue with an accuracy of over 97% across tumour types, and can be visualized at the cellular level using microscopy and in larger specimens through wide-field imaging. Unlike fluorescence intensity, which depends on imaging-system parameters, tissue depth and the amount of dye taken up by tumours, FLT is a photophysical property that is largely independent of these factors. FLT imaging with indocyanine green may improve the accuracy of cancer surgeries.
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Verde de Indocianina , Neoplasias , Humanos , Fluorescência , Neoplasias/diagnóstico por imagem , Corantes FluorescentesRESUMO
This systematic review aims to provide insight into the ideal reconstructive approach of the oral tongue in oral tongue cancer (OTC) by investigating the relationship between functional outcomes and the extent of tongue resection. A structured search was performed in Ovid MEDLINE, EMBASE, and Web of Science. Studies comparing patient-reported and objective measurements of the oral tongue function between flap vs. non-flap reconstruction were included. Functional outcomes of interest were speech production, deglutition efficiency, tongue mobility, overall quality of life, and postoperative complications. A total of nine studies were retrieved and critically appraised. Patients with 20 % or less of oral tongue resected had superior swallowing efficiency and speech intelligibility with a non-flap reconstruction while patients with a tongue defect of 40-50 % self-reported or demonstrated better swallowing function with a flap repair. The data in intermediate tongue defects (20-40 % tongue resected) was inconclusive, with several studies reporting comparable functional outcomes between approaches. A longitudinal multi-institutional prospective study that rigidly controls the extent of tongue resected and subsites involved is needed to determine the percentage of tongue resected at which a flap reconstruction yields a superior functional result in OTC.
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Procedimentos de Cirurgia Plástica , Neoplasias da Língua , Humanos , Neoplasias da Língua/cirurgia , Estudos Prospectivos , Qualidade de Vida , Deglutição , Língua/cirurgia , Glossectomia , Inteligibilidade da FalaRESUMO
Importance: The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality. Observations: This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design. Conclusions and Relevance: Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.
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Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Bucais , Humanos , Estados Unidos , Carcinoma de Células Escamosas de Cabeça e Pescoço , Margens de Excisão , Neoplasias Bucais/patologia , Carcinoma de Células Escamosas/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Estudos RetrospectivosRESUMO
OBJECTIVES: Understand the prognostic impact of perineural invasion (PNI) in early-stage oral cavity squamous cell carcinoma (OCSCC). Assess the influence of adjuvant radiotherapy on outcomes of patients with PNI-positive early-stage OCSCC. MATERIALS AND METHODS: Retrospective seven-institution cohort study including patients with pathologic T1-2 N0-1 OCSCC who underwent primary surgery with negative margins. Outcomes included disease-free survival (DFS) and locoregional control (LRC). Cox proportional hazards models were used to evaluate oncologic outcomes. Interaction terms were introduced to assess relationships between PNI and adjuvant radiotherapy. RESULTS: Among 557 patients (mean (SD) age 61.0 (13.9), 47.2% female, 66.6% pathologic T1, 93.5% pathologic N0), 93 had PNI-positive tumors, among which 87.1% underwent neck dissection and 39.6% received radiotherapy. On multivariable analysis, PNI was associated with lower DFS and LRC. Adjuvant radiotherapy was not associated with improved outcomes on multivariable analysis of the entire cohort. However, among patients with PNI-positive tumors, adjuvant radiotherapy significantly decreased hazard for DFS. CONCLUSION: Among patients with low-risk, early-stage OCSCC, PNI was associated with worse DFS and LRC. In patients with PNI-positive tumors, adjuvant radiotherapy lowered hazard for DFS on multivariable analysis. These data support using adjuvant radiotherapy for patients with early-stage OCSCC with PNI.
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Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Bucais , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Carcinoma de Células Escamosas de Cabeça e Pescoço/patologia , Estudos de Coortes , Estudos Retrospectivos , Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirurgia , Prognóstico , Radioterapia Adjuvante , Neoplasias Bucais/radioterapia , Neoplasias Bucais/cirurgia , Neoplasias de Cabeça e Pescoço/patologia , Invasividade Neoplásica/patologia , Estadiamento de NeoplasiasRESUMO
BACKGROUND: Comparisons of patient-reported donor site morbidity based on the Disabilities in Arm, Shoulder, and Hand (DASH) instrument across upper trunk free flaps in head and neck surgery, including radial forearm (RFFF), osteocutaneous radial forearm (OCRFF), scapular tip (STFF), and serratus anterior (SAFF) free flaps, may help inform donor tissue selection. METHODS: In this meta-analysis, 12 studies were included and the primary outcome was average DASH score. RESULTS: The pooled DASH scores were 12.14 (95% CI: 7.40-16.88) for RFFF (5 studies), 17.99 (11.87-24.12) for OCRFF (2 studies), 12.19 (8.74-15.64) for STFF (3 studies), and 16.49 (5.92-27.05) for SAFF (2 studies) and were not significantly different. CONCLUSIONS: Results suggest that patients generally function well, with minimal to mild donor site morbidity, when assessed at an average of 20 months after flap harvest. These results are based on few effects from primarily retrospective studies of fair quality, and further research is needed.
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Retalhos de Tecido Biológico , Humanos , Estudos Retrospectivos , Antebraço/cirurgia , Rádio (Anatomia)/cirurgia , Medidas de Resultados Relatados pelo PacienteRESUMO
OBJECTIVES: To develop a patient-reported outcomes measure (PROM) for total laryngectomy. STUDY DESIGN: Qualitative interviews with a purposive sample of patients with total laryngectomy, followed by cognitive debriefing interviews with patients and expert feedback. METHODS: Concept elicitation was performed using in-depth qualitative interviews with a purposive sample of patients who had undergone total laryngectomy. Patients were recruited from head and neck surgery and speech-language pathology clinics as well as via laryngectomy support groups. Interviews were conducted, recorded, transcribed, and coded, resulting in a conceptual framework and item pool. Using the item pool, preliminary scales were drafted. The scales were revised iteratively over 5 rounds using feedback from cognitive interviews with patients and multi-institutional and multi-disciplinary expert feedback. RESULTS: A total of 15 patients with total laryngectomy (mean age 68 years, range 57-79) were interviewed resulting in 1555 codes. The codes were used to form a conceptual framework grouped into top-level domains of stoma, function, health-related quality of life, devices, and experience of care. Items were used to form 15 preliminary scales that were revised over five rounds of cognitive debriefing interviews (n = 9 patients) and expert feedback (n = 17 experts). The field-test version of the LARY-Q has 18 scales and 277 items in total. CONCLUSIONS: The LARY-Q is a novel PROM designed to assess outcomes associated with total laryngectomy. The next step involves a field test study with a heterogenous sample of patients to assess the psychometric properties of the LARY-Q and perform item reduction.
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OBJECTIVE: In head and neck ablative surgery, traditional teaching is that the key facial nerve branch to preserve along the plane of the lower border of the mandible is the marginal mandibular branch (MMb), which is considered to control all lower lip musculature. The depressor labii inferioris (DLI) is the muscle responsible for pleasing lower lip displacement and lower dental display during natural emotive smiling. STUDY DESIGN: To understand the structure/function relationships of the distal lower facial nerve branches and lower lip musculature. SETTING: In vivo extensive facial nerve dissections under general anesthesia. METHODS: Intraoperative mapping was performed in 60 cases, using branch stimulation and simultaneous movement videography. RESULTS: In nearly all cases, the MMb innervated the depressor anguli oris, lower orbicularis oris, and mentalis muscles. The nerve branches controlling DLI function were identified 2 ± 0.5 cm below the angle of the mandible, originating from a cervical branch, separately and inferior to MMb. In half of the cases, we identified at least 2 independent branches activating the DLI, both within the cervical region. CONCLUSION: An appreciation of this anatomical finding may help prevent lower lip weakness following neck surgery. Avoiding the functional and cosmetic consequences that accompany loss of DLI function would have a significant impact on the burden of potentially preventable sequelae that the head and neck surgical patient frequently carries.
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Nervo Facial , Lábio , Humanos , Lábio/cirurgia , Lábio/inervação , Sorriso/fisiologia , Depressão , Músculos Faciais/inervaçãoRESUMO
BACKGROUND: Understanding the impact of surgical treatment on regionally metastatic cutaneous squamous cell carcinoma (cSCC). METHODS: Retrospective series of 145 patients undergoing parotidectomy and neck dissection for regionally metastatic cSCC to the parotid. Overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) analyzed over 3 years. Multivariate analysis was completed using Cox proportional hazard models. RESULTS: OS was 74.5%, DSS was 85.5% and DFS was 64.8%. On multivariate analysis, immune status (HR = 3.225[OS], 5.119[DSS], 2.071[DFS]) and lymphovascular invasion (HR = 2.380[OS], 5.237[DSS], 2.595[DFS]) were predictive for OS, DSS, and DFS. Margin status (HR = 2.296[OS], 2.499[DSS]) and ≥18 resected nodes (HR = 0.242[OS], 0.255[DSS]) were predictive of OS and DSS, while adjuvant therapy was predictive of DSS (p = 0.018). CONCLUSIONS: Immunosuppression and lymphovascular invasion portended worse outcomes in patients with metastatic cSCC to the parotid. Microscopically positive margins and <18 nodes resected are associated with worse OS and DSS, while patients receiving adjuvant therapy had improved DSS.
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Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Cutâneas , Humanos , Carcinoma de Células Escamosas/patologia , Neoplasias Cutâneas/patologia , Glândula Parótida/patologia , Estudos Retrospectivos , Neoplasias de Cabeça e Pescoço/patologia , Estadiamento de NeoplasiasRESUMO
OBJECTIVE: To understand the accuracy of pre- and intraoperative estimation of tumor depth of invasion (DOI). STUDY DESIGN: A retrospective case-control study. SETTING: Patients who presented at 1 institution with oral tongue squamous cell carcinoma that underwent oncologic resection between 2017 and 2019 were identified. METHODS: Patients that met the inclusion criteria were included. Patients with nodal, distant, or recurrent disease, prior history of head and neck cancer, or preoperative tumor assessment and/or final histopathology that did not include DOI were excluded. Preoperative DOI estimation and technique and pathology reports were obtained. Our primary outcome was the sensitivity and specificity of DOI estimation modalities including full-thickness biopsy (FTB), manual palpation (MP), punch biopsy (PB), and intraoperative ultrasound (IOUS). RESULTS: Tumor DOI was assessed quantitatively preoperatively in 40 patients by FTB (n = 19, 48%), MP (n = 17, 42%), or PB (n = 4, 10%). Additionally, 19 patients underwent IOUS to assess DOI. The sensitivities of FTB, MP, and IOUS for DOI ≥ 4 mm were 83% (confidence interval [CI]: 44%-97%), 83% (CI: 55%-95%), and 90% (CI: 60%-98%), respectively, and the specificities were 85% (CI: 58%-96%), 60% (CI: 23%-88%), and 78% (CI: 45%-94%). CONCLUSION: Our study demonstrated that DOI assessment tools measured had similar sensitivity and specificity in stratifying patients with DOI ≥4 mm, with no statistically superior diagnostic test. Our results support the need for additional research into nodal disease prediction and continued refinement of ND decisions with respect to DOI.
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Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Bucais , Neoplasias da Língua , Humanos , Neoplasias da Língua/cirurgia , Neoplasias da Língua/patologia , Carcinoma de Células Escamosas/cirurgia , Carcinoma de Células Escamosas/patologia , Estudos Retrospectivos , Estudos de Casos e Controles , Estadiamento de Neoplasias , Invasividade Neoplásica/patologia , Neoplasias Bucais/patologia , Neoplasias de Cabeça e Pescoço/patologia , Língua/patologiaRESUMO
Intraoperative ultrasound (IOUS) is a potentially useful adjunct to the resection of oral tongue cancers (OTC). IOUS images of the tumor-normal tissue interface show different patterns of invasion. In this retrospective series of 29 patients treated for OTC, we evaluated if there was a correlation between IOUS findings of patterns of invasion and final histology and assessed if there was any associated risk of increased incidence of positive or close margins with different patterns of invasion as seen on ultrasound. Although we found no significant correlation between ultrasound patterns of invasion and histological evaluation, we did find that an infiltrative pattern of invasion on IOUS did result in a significant risk of a close margin. Further exploration of these findings in a larger prospective study could provide definitive information on the efficacy of this modality in OTC resections.
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Neoplasias da Língua , Língua , Humanos , Estudos Retrospectivos , Estudos Prospectivos , Ultrassonografia , Língua/patologia , Neoplasias da Língua/patologiaRESUMO
When thin and pliable free tissue is needed, the medial sural artery perforator (MSAP) flap provides an excellent option with minimal donor site morbidity. However, among its pitfalls include difficult patient positioning and surgeon ergonomics throughout the harvest. We describe a novel positioning technique that may significantly improve surgeon ergonomics and ease of MSAP flap harvest. A cross-legged modification may eliminate many of the issues associated with the classic frog-leg position. While the patient is cross-legged, the surgeon is afforded a normal field of view that is closer to their body, while simultaneously providing support to the lateral side of the gastrocnemius muscle. This pictorial essay describes this positioning technique and subsequent harvest. By incorporating a more ergonomic cross-legged position during flap elevation, many of thedrawbacks of the MSAP flap could be eliminated.