Intraoperative Image Guidance Improves Outcomes in Complex Orbital Reconstruction by Novice Surgeons.

PURPOSE: This study aims to describe the utility of surgical navigation in improving operative outcomes in complex orbital reconstruction by novice compared with experienced surgical trainees. MATERIALS AND METHODS: A randomized, controlled cadaveric study was conducted at the University of Pittsburgh School of Medicine with otolaryngology and ophthalmology residents and fellows. Participants were divided into novice (postgraduate year 2-4 residents) and experienced (postgraduate year 5 residents and fellows) groups. Ten cadaveric specimens with pre-dissection computed tomography images underwent endoscopic resection of the orbital floor and lamina papyracea bilaterally. Participants performed reconstruction with or without the use of surgical navigation, randomized by laterality and order of the use of navigation. Post-dissection imaging was obtained after reconstruction and compared with pre-dissection imaging. The primary outcome was orbital volume; secondary outcomes included the participant's operative time and National Aeronautics and Space Administration Task Load Index score, a subjective workload assessment measure. Matched-pair t tests and 2-way analysis of variance were used for statistical analysis. RESULTS: Novice participants (n = 6) had improved outcomes with respect to orbital volume when using surgical navigation compared with experienced participants (n = 4). There were no differences in operative times or National Aeronautics and Space Administration Task Load Index scores when using surgical navigation. CONCLUSIONS: In a cadaveric setting, use of surgical navigation by novice surgeons improves post-dissection orbital volume in complex orbital reconstruction. Surgical navigation should be considered as an adjunct to surgical training and simulation curricula.

What parents are reading about laryngomalacia: Quality and readability of internet resources on laryngomalacia.

OBJECTIVE: The goal of this study is to measure the quality and readability of websites related to laryngomalacia, and to compare the quality and readability scores for the sites accessed through the most popular search engines. INTRODUCTION: Laryngomalacia is a common diagnosis in children but is often difficult for parents to comprehend. As information available on the internet is unregulated, the quality and readability of this information may vary. METHODS: An advanced search on Google, Yahoo, and Bing was conducted using the terms "laryngomalacia" OR "soft larynx" OR "floppy voice box." The first ten websites meeting inclusion and exclusion criteria were evaluated, for each search engine. Quality and readability were assessed using the DISCERN criteria and the Flesch reading ease scoring (FRES) and Flesch-Kincaid grade level (FKGL) tests, respectively. RESULTS: The top 10 hits on each search engine yielded 15 unique web pages. The median DISCERN score (out of a possible high-score of 80) was 48.5 (SD 12.6). The median USA grade-level estimated by the FKGL was 11.3 (SD 1.4). Only one website (6.7%), had a readability score in the optimal range of 6th to 8th grade reading level. DISCERN scores did not correlate with FKGL scores (r = 0.10). CONCLUSION: Online information discussing laryngomalacia often varies in quality and may not be easily comprehensible to the public. It is important for healthcare professionals to understand the quality of health information accessible to patients as it may influence medical decision-making by patient families.

What might parents read: Sorting webs of online information on vascular anomalies.

INTRODUCTION: The internet is increasingly a source of healthcare information utilized by parents, especially in rarer pathologies such as vascular malformations. The quality, validity and thoroughness of these websites is variable and unregulated. The goal of this study was to evaluate the quality and understandability of websites related to vascular malformations. METHODS: The terms "hemangioma", "vascular malformation", and "vascular anomalies" were searched in Google. The first 30 websites meeting inclusion and exclusion criteria were evaluated. Quality and readability were assessed using the DISCERN criteria and the Flesh-Kincaid Reading Grade Level (FKGL), respectively. Date of last update, HONcode accreditation, and the website category were recorded. RESULTS: Most websites were owned by academic institutions (n = 19, 63.3%). The mean DISCERN score for all websites was 2.97, or a partially valid source of information on a 1-5 scale. The average reading level estimated by FKGL was grade 12; only one website was scored at less than a grade 9 level. Two websites were HONcode accredited. Of the 18 sites giving an explicit date of last update, 12 (67.7%) had been updated in the previous 12 months. CONCLUSIONS: Websites relating information about vascular anomalies may not be understandable to the general public, including parents. Health care providers should be cognizant of the quality and availability of such information as it may impact parent perspectives and bias toward treatment options.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty.

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty Executive Summary.

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline executive summary is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patient satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The guideline development group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

The Pursuit of Otolaryngology Subspecialty Fellowships.

OBJECTIVES: To examine otolaryngology resident interest in subspecialty fellowship training and factors affecting interest over time and over the course of residency training STUDY DESIGN: Cross-sectional study of anonymous online survey data. SETTING: Residents and fellows registered as members-in-training through the American Academy of Otolaryngology-Head and Neck Surgery. SUBJECTS AND METHODS: Data regarding fellowship interest and influencing factors, including demographics, were extracted from the Section for Residents and Fellows Annual Survey response database from 2008 to 2014. RESULTS: Over 6 years, there were 2422 resident and fellow responses to the survey. Senior residents showed a statistically significant decrease in fellowship interest compared with junior residents, with 79% of those in postgraduate year (PGY) 1, 73% in PGY-2 and PGY-3, and 64% in PGY-4 and PGY-5 planning to pursue subspecialty training (P < .0001). Educational debt, age, and intended practice setting significantly predicted interest in fellowship training. Sex was not predictive. The most important factors cited by residents in choosing a subspecialty were consistently type of surgical cases and nature of clinical problems. CONCLUSIONS: In this study, interest in pursuing fellowship training decreased with increased residency training. This decision is multifactorial in nature and also influenced by age, educational debt, and intended practice setting.

Tumor volume as a predictor of survival in human papillomavirus-positive oropharyngeal cancer.

BACKGROUND: Increasing evidence exists that tumor volume may be a superior prognostic model than traditional TNM staging. It has been observed that oropharyngeal squamous cell carcinoma (oropharyngeal SCC) in the setting of human papillomavirus (HPV) positivity have a greater propensity for cystic nodal metastases, and, thus, presumably larger volume with relatively smaller primary tumors. The influence of HPV status on the predictive value of tumor volume is unknown. METHODS: Fifty-three patients with HPV-positive oropharyngeal SCC were treated with definitive chemotherapy and intensity-modulated radiotherapy (IMRT). RESULTS: The estimated 2-year overall survival (OS) and disease-free survival (DFS) was 92.2% and 83.6%, respectively. Nodal classification did not predict OS (p = .096) or DFS (p = .170). Similarly, T classification did not predict OS (p = .057) or DFS (p = .309). Lower nodal volume was associated with greater DFS (p = .001). CONCLUSION: Nodal tumor volume was found to be predictive of DFS. DFS was best predicted by nodal gross tumor volume (GTV) at 24 months. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1613-E1617, 2016.

Association of pretreatment body mass index and survival in human papillomavirus positive oropharyngeal squamous cell carcinoma.

BACKGROUND: Pretreatment body mass index (BMI) >25kg/m(2) is a positive prognostic factor in patients with head and neck cancer. Previous studies have not been adequately stratified by human papilloma virus (HPV) status or subsite. Our objective is to determine prognostic significance of pretreatment BMI on overall survival in HPV+ oropharyngeal squamous cell carcinoma (OPSCC). METHODS: This is a retrospective review of patients with HPV+ OPSCC treated between 8/1/2006 and 8/31/2014. Patients were stratified by BMI status (>/<25kg/m(2)). Univariate and multivariate analyses of survival were performed. RESULTS: 300 patients met our inclusion/exclusion criteria. Patients with a BMI >25kg/m(2) had a longer overall survival (HR=0.49, P=0.01) as well as a longer disease-specific survival (HR=0.43, P=0.02). Overall survival remained significantly associated with high BMI on multivariate analysis (HR=0.54, P=0.04). CONCLUSIONS: Pre-treatment normal or underweight BMI status is associated with worse overall survival in HPV+ OPSCC.

A prospective phase 2 trial of reirradiation with stereotactic body radiation therapy plus cetuximab in patients with previously irradiated recurrent squamous cell carcinoma of the head and neck.

PURPOSE: Salvage options for unresectable locally recurrent, previously irradiated squamous cell carcinoma of the head and neck (rSCCHN) are limited. Although the addition of reirradiation may improve outcomes compared to chemotherapy alone, significant toxicities limit salvage reirradiation strategies, leading to suboptimal outcomes. We therefore designed a phase 2 protocol to evaluate the efficacy of stereotactic body radiation therapy (SBRT) plus cetuximab for rSCCHN. METHODS AND MATERIALS: From July 2007 to March 2013, 50 patients >18 years of age with inoperable locoregionally confined rSCCHN within a previously irradiated field receiving ≥60 Gy, with a Zubrod performance status of 0 to 2, and normal hepatic and renal function were enrolled. Patients received concurrent cetuximab (400 mg/m(2) on day -7 and then 250 mg/m(2) on days 0 and +8) plus SBRT (40-44 Gy in 5 fractions on alternating days over 1-2 weeks). Primary endpoints were 1-year locoregional progression-free survival and National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 graded toxicity. RESULTS: Median follow-up for surviving patients was 18 months (range: 10-70). The 1-year local PFS rate was 60% (95% confidence interval [CI]: 44%-75%), locoregional PFS was 37% (95% CI: 23%-53%), distant PFS was 71% (95% CI: 54%-85%), and PFS was 33% (95% CI: 20%-49%). The median overall survival was 10 months (95% CI: 7-16), with a 1-year overall survival of 40% (95% CI: 26%-54%). At last follow-up, 69% died of disease, 4% died with disease, 15% died without progression, 10% were alive without progression, and 2% were alive with progression. Acute and late grade 3 toxicity was observed in 6% of patients respectively. CONCLUSIONS: SBRT with concurrent cetuximab appears to be a safe salvage treatment for rSCCHN of short overall treatment time.

Stereotactic body radiotherapy for recurrent oropharyngeal cancer - influence of HPV status and smoking history.

PURPOSE: HPV status and smoking history stratifies patients into 3 distinct risk groups for survival following definitive chemoradiotherapy. Local-regional recurrences are common patterns of failure across all 3 risk-groups. SBRT±cetuximab has emerged as a promising salvage strategy for unresectable locally-recurrent, previously-irradiated head-and-neck cancer (rHNC) relative to conventional re-irradiation±chemotherapy. However the influence of HPV and smoking remains unknown in the setting of re-irradiation. METHODS/MATERIALS: Patients (n=30) with rHNC of the oropharynx salvaged with SBRT±cetuximab from August 2002 through August 2013 were retrospectively reviewed; HPV status was determined based on p16 staining of primary pathology. RESULTS: At a median follow-up of 10months for surviving patients, the mean overall survival for all patients was 12.6 months. HPV positivity was a significant predictor of overall survival (13.6 vs. 6.88 months, p=0.024), while smoking status did not significantly impact overall survival (p=0.707). CONCLUSION: HPV status remains a significant predictor of overall survival in the re-irradiation setting with HPV positive rHNC demonstrating superior overall survival following salvage SBRT±cetuximab.

Occult Primary Head and Neck Squamous Cell Carcinoma: Utility of Discovering Primary Lesions.

OBJECTIVE: Cancer of an unknown primary (CUP) squamous cell carcinoma metastatic to cervical lymph nodes is a challenging problem for the treating physician. Our aim is to determine if identification of the primary tumor is associated with improved oncologic outcomes and/or tumor characteristics including human papilloma virus (HPV) status. STUDY DESIGN: Retrospective, matched-pairs analysis contrasting 2 cohorts based upon discovery of primary lesion. SETTING: Tertiary teaching hospital. SUBJECTS AND METHODS: Records of 136 patients initially diagnosed as carcinoma of unknown primary were retrospectively reviewed (1980-2010) and divided into 2 cohorts based on discovery of the primary lesion. Primary outcome measures were overall survival and time to recurrence according to Kaplan-Meier analysis. A nested subset of 22 patients in which the primary was discovered were matched to 22 patients remaining undiscovered according to nodal stage and age. RESULTS: Discovered lesions were more likely to exhibit HPV positivity (P < .001). Matched-pairs analyses demonstrated that discovery of the primary was associated with better overall survival (HR = 0.125; 95% confidence interval [CI], 0.019-0.822; P = .030). Discovery of the primary was associated with improved cause-specific survival (HR = 0.142; 95% CI, 0.021-0.93; P = .0418) and disease-free survival (HR = 0.25; 95% CI, 0.069-0.91; P = .03). CONCLUSION: HPV positivity is associated with discovery of the primary tumor. Discovery of the primary lesion is associated with improved overall survival, cause-specific survival, and disease-free survival in patients initially presenting as CUP in matched-pair and cohort comparison analyses.

Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate the cost-effectiveness of transoral robotic surgery (TORS) for the diagnosis and treatment of cervical unknown primary squamous cell carcinoma (CUP). STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic hospital. SUBJECTS AND METHODS: A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with nondiagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Direct costs were obtained from the hospital's billing system, and national data were used for inpatient hospital costs and physician fees. The proportion of tumors found in 3 strategies was used as effectiveness to calculate the incremental cost-effectiveness ratio. RESULTS: In total, 206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. The primary tumor was located in 19 of 22 patients (86.4%). The incremental cost-effectiveness ratio for sequential and simultaneous examination under anesthesia with tonsillectomy (EUA) and TORS base of tongue resection was $8619 and $5774 per additional primary identified, respectively. CONCLUSION: Sequential EUA followed by TORS is associated with an incremental cost-effectiveness ratio of $8619 compared with traditional EUA alone. Bilateral base of tongue resection should be considered in the workup of these patients, particularly if the palatine tonsils have already been removed.

External validity reporting in behavioral treatment of childhood obesity: a systematic review.

CONTEXT: To aid translation of childhood obesity interventions evidence into practice, research studies must report results in a way that better supports pragmatic decision making. The current review evaluated the extent to which information on key external validity dimensions, participants, settings, interventions, outcomes, and maintenance of effects, was included in research studies on behavioral treatments for childhood obesity. EVIDENCE ACQUISITION: Peer-reviewed studies of behavioral childhood obesity treatments published between 1980 and 2008 were identified from (1) electronic searches of social science and medical databases; (2) research reviews of childhood obesity interventions; and (3) reference lists cited in these reviews. Included studies reported on a controlled obesity intervention trial, targeted overweight or obese children aged 2-18 years, included a primary or secondary anthropometric outcome, and targeted change in dietary intake or physical activity behaviors. EVIDENCE SYNTHESIS: 1071 publications were identified and 77 met selection criteria. Studies were coded on established review criteria for external validity elements. All studies lacked full reporting of generalizability elements. Across criteria, the average reporting was 23.9% (range=0%-100%). Infrequently reported were setting-level selection criteria and representativeness, characteristics regarding intervention staff, implementation of the intervention content, costs, and program sustainability. CONCLUSIONS: Enhanced reporting of relevant and pragmatic information in behavioral investigations of childhood obesity interventions is needed to improve the ability to evaluate the applicability of results to practice implementation. Such evidence would improve translation of research to practice, provide additional explanation for variability in intervention outcomes, and provide insights into successful adaptations of interventions to local conditions.

Murine complement deficiency ameliorates acute cigarette smoke-induced nasal damage.

OBJECTIVE: Exposure to cigarette smoke is a risk factor for chronic rhinosinusitis. Current literature confirms complement fragments are activated in human nasal mucosa. The mechanism(s) responsible for this activation is unclear. We investigated the effects of cigarette smoke on nasal mucosa in vitro and via a model of cigarette smoke exposure by using animals deficient in complement components. STUDY DESIGN: Prospective, controlled animal and in vitro human cell line study. SETTING: University laboratory. SUBJECTS AND METHODS: Human respiratory epithelial cells were exposed to five, 10, and 20 percent cigarette smoke extract (CSE) in vitro in the presence or absence of human serum. Complement activation was assessed by enzyme-linked immunosorbent assay and immunofluorescent techniques. Complement-deficient (C3(-/-), n = 6; factor B(-/-), n = 50) and sufficient mice (wild type, n = 10) were exposed to the smoke of four cigarettes per exposure for two exposures per day for three days. Mice were sacrificed 12 hours after the last exposure, and the nasal cavity was surgically removed. Histological characteristics were analyzed by the use of a subjective scale and quantitative image analysis scoring systems. RESULTS: In vitro analysis of respiratory cell cultures demonstrated that exposure of serum to CSE resulted in complement activation. Furthermore, immunofluorescent staining for C3d could only be demonstrated in CSE-exposed cultures. In vivo analysis demonstrated that complement deficiency, either C3 or factor B deficiency, resulted in a significant reduction in histological evidence of damage as compared with wild-type control mice (wild type vs C3(-/-), P = 0.02; wild type vs factor B(-/-), P = 0.07; no significant difference between C3(-/-) vs factor B(-/-)). CONCLUSION: These data demonstrate that cigarette smoke activates the complement system. Furthermore, complement deficiency protected against smoke-induced mucosal damage in this small series.