RESUMEN
BACKGROUND: Modern disease staging systems have restructured human papillomavirus (HPV)-negative (HPV-) and HPV-positive (HPV+) oropharyngeal carcinoma (OPC) into distinct pathologic nodal systems. Given that quantitative lymph node (LN) burden is the dominant prognostic factor in most head and neck cancers, we investigated whether HPV- and HPV+ OPC warrant divergent pathologic nodal classification. METHODS: Multivariable Cox regression models of OPC surgical patients identified via U.S. cancer registry data were constructed to determine associations between survival and nodal characteristics. Nonlinear associations between metastatic LN number and survival were modeled with restricted cubic splines. Recursive partitioning analysis (RPA) was used to derive unbiased nodal schema. RESULTS: Mortality risk escalated continuously with each successive positive LN in both OPC subtypes, with analogous slope. Survival hazard increased by 18.5% (hazard ratio [HR], 1.19 [95% CI, 1.16-1.21]; P < .001) and 19.1% (HR, 1.19 [95% CI, 1.17-1.21]; P < .001), with each added positive LN for HPV- and HPV+ OPC, respectively, up to identical change points of 5 positive LNs. Extranodal extension (ENE) was an independent predictor of HPV- OPC (HR, 1.55 [95% CI, 1.20-1.99]; P < .001) and HPV+ OPC (HR 1.73 [95% CI, 1.36-2.20]; P < .001) mortality. In RPA for both diseases, metastatic LN was the principal nodal covariate driving survival, with ENE as a secondary determinant. Given the similarities across analyses, we propose a concise, unifying HPV-/HPV+ OPC pathologic nodal classification schema: N1, 1-5 LN+/ENE-; N2, 1-5 LN+/ENE+; N3, >5 LN+. CONCLUSION: HPV- and HPV+ OPC exhibit parallel relationships between nodal characteristics and relative mortality. In both diseases, metastatic LN number represents the principal nodal covariate governing survival, with ENE being an influential secondary element. A consolidated OPC pathologic nodal staging system that is based on these covariates may best convey prognosis. LAY SUMMARY: The current nodal staging system for oropharyngeal carcinoma (OPC) has divided human papillomavirus (HPV)-negative (HPV-) and HPV-positive (HPV+) OPC into distinct systems that rely upon criteria that establish them as separate entities, a complexity that may undermine the core objective of staging schema to clearly communicate prognosis. Our large-scale analysis revealed that HPV- and HPV+ pathologic nodal staging systems in fact mirror each other. Multiple analyses produced conspicuously similar nodal staging systems, with metastatic lymph node number and extranodal extension delineating the highest risk groups that shape prognosis. We propose unifying HPV- and HPV+ nodal systems to best streamline prognostication and maximize staging accuracy.
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Carcinoma , Neoplasias Orofaríngeas , Infecciones por Papillomavirus , Carcinoma/patología , Carcinoma/virología , Humanos , Estadificación de Neoplasias , Neoplasias Orofaríngeas/patología , Neoplasias Orofaríngeas/virología , Infecciones por Papillomavirus/epidemiología , PronósticoRESUMEN
BACKGROUND: While numerous factors affect prognosis in papillary thyroid carcinoma (PTC), the comparative impact of histologic grade has not been well described. Moreover, indications for external beam radiation therapy (EBRT) remain imprecise. We evaluate clinicopathologic characteristics and outcomes for PTC stratified by grade. METHODS: We profiled histologic grade for PTC (well differentiated, moderately differentiated, poorly differentiated) via hospital (National Cancer Database) and population-based (Surveillance, Epidemiology, and End Results) registries. Cox regression was used to adjust for clinicopathologic covariates. Statistical interactions between subtypes and the effect of EBRT on survival were assessed. RESULTS: Collectively, worsening clinicopathologic factors (age, tumor size, extrathyroidal extension, nodal spread, M1 disease) and outcomes (disease-free survival, overall survival) correlated with less differentiated state, across all histologic grades (p < 0.001). Multivariable analysis showed escalating hazard with loss of differentiation relative to well-differentiated PTC (moderately differentiated hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.04-1.41, p = 0.02; poorly differentiated HR 2.62, 95% CI 2.23-3.08, p < 0.001). Correspondingly, greater survival benefit was associated with EBRT for poorly differentiated cases (HR 0.36, 95% CI 0.18-0.72, p = 0.004). This finding was upheld after landmark analysis to address potential immortal time bias (HR 0.37, 95% CI 0.17-0.80, p = 0.01). CONCLUSIONS: Worsening histologic grade in PTC is independently associated with parallel escalation in mortality risk, on a scale approximating or surpassing established thyroid cancer risk factors. On preliminary analysis, EBRT was associated with improved survival in the most aggressive or least differentiated subvariants. Further investigation is warranted to examine the efficacy of EBRT for select poorly differentiated thyroid carcinomas.
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Cáncer Papilar Tiroideo , Neoplasias de la Tiroides , Supervivencia sin Enfermedad , Humanos , PronósticoRESUMEN
PURPOSE OF REVIEW: The treatment of small, low-risk papillary thyroid carcinoma has undergone a paradigm shift, with many tumors now initially treated with active surveillance rather than upfront surgery. Further studies on patients enrolled in active surveillance have refined our knowledge of the clinical behavior of papillary thyroid microcarcinomas. RECENT FINDINGS: This article summarizes the major conclusions of landmark trials that launched active surveillance as a viable treatment option for selected patients. We discuss patient factors such as age and tumor size, the assessment of candidates for active surveillance, barriers to acceptance of active surveillance, quality of life issues, and economic considerations. SUMMARY: Active Surveillance is a viable first-line treatment option for select papillary microcarcinomas.
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Carcinoma Papilar/diagnóstico , Carcinoma Papilar/terapia , Neoplasias de la Tiroides/diagnóstico , Neoplasias de la Tiroides/terapia , Espera Vigilante/métodos , Carcinoma Papilar/patología , Ensayos Clínicos como Asunto , Humanos , Uso Excesivo de los Servicios de Salud/prevención & control , Neoplasias de la Tiroides/patología , TiroidectomíaRESUMEN
BACKGROUND: Patient Satisfaction (PS) is a commonly used metric in health care settings to assess the quality of care given by physicians. Monitoring physicians in this way may impact physician quality of life. Studies evaluating this impact are not available. This study sought to examine the physician experience of measuring PS among practicing otolaryngologists. METHODS: Using an online survey platform, a 34-item survey was given to practicing otolaryngologists through email distribution. The survey included questions about physician, practice and patient demographics, as well as inquiries regarding the way in which PS was measured and how it affected physician work and personal life. Data from these questions were reviewed and analyzed. RESULTS: 174 otolaryngologists responded to the survey. A majority of physicians' (55.3%) PS scores had been tracked with 89.9% reporting being tracked for a length of at least 1 year. PS scores for individual physicians were noted to be inconsistent and vary significantly between reports. Measuring patient satisfaction led to increased occupational stress, yet most physicians (63.8%) felt the monitoring did not lead to improvements in their practice. Some physicians (36.2%) reported that the collection of patient satisfaction scores had negatively influenced the way they practiced medicine, including the pressure to order superfluous tests or to prescribe unnecessary medications. CONCLUSION: Overall, physicians are negatively affected by the tracking of patient satisfaction scores. Occupational stress caused by the collection of patient satisfaction scores may contribute to physician burnout.
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Agotamiento Profesional/etiología , Estrés Laboral/etiología , Otorrinolaringólogos/psicología , Satisfacción del Paciente , Pautas de la Práctica en Medicina , Calidad de la Atención de Salud , Calidad de Vida , Proyectos de Investigación , Encuestas y Cuestionarios , Humanos , Estados UnidosRESUMEN
Nasal obstruction is a common presenting complaint, with many possible etiologies. Herein, we provide an introductory anatomic description, clinical relevance, and proposed nomenclature for an underappreciated soft tissue focus in the nasal vestibule-the nasal vestibular body (NVB)-that can contribute to nasal obstruction in a subset of patients. This is a small mound of dynamic soft tissue in the lateral aspect of the internal nasal valve, situated inferior and anterior to the head of the inferior turbinate that can be missed on routine examination for many salient reasons. In well-selected patients, whose symptoms of nasal obstruction may in part be secondary to the presence of this soft tissue focus, directed testing and tissue reduction can be performed.
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Cavidad Nasal , Descongestionantes Nasales/uso terapéutico , Obstrucción Nasal , Humanos , Cavidad Nasal/patología , Cavidad Nasal/fisiopatología , Obstrucción Nasal/etiología , Obstrucción Nasal/patología , Obstrucción Nasal/fisiopatología , Obstrucción Nasal/terapia , Tabique Nasal/patología , Tabique Nasal/fisiopatología , Cirugía Endoscópica por Orificios Naturales/métodosRESUMEN
BACKGROUND: Allergic rhinitis (AR) is a common condition that is frequently associated with atopic inferior turbinate hypertrophy (ITH) resulting in nasal obstruction. Current guidelines support the use of subcutaneous allergen immunotherapy (SCIT) when patients fail pharmacologic management. However, there is a lack of consensus regarding the role of inferior turbinate reduction (ITR), a treatment that we hypothesize is cost-effective compared with other available treatments. METHODS: We conducted a cost-effectiveness analysis comparing the following treatment combinations over a 5-year time horizon for AR patients presenting with atopic nasal obstruction who fail initial pharmacotherapy: (1) continued pharmacotherapy alone, (2) allergy testing and SCIT, (3) allergy testing and SCIT and then ITR for SCIT nonresponders, and (4) ITR and then allergy testing and SCIT for ITR nonresponders. Results were reported as incremental cost-effectiveness ratios (ICERs). RESULTS: For patients who fail initial pharmacotherapy, prioritizing ITR, either by microdebrider-assisting submucous resection or radiofrequency ablation, before SCIT was the most cost-effective strategy. Probabilistic sensitivity analysis demonstrated that prioritizing ITR before SCIT was the most cost-effective option in 95.4% of scenarios. ITR remained cost-effective even with the addition of concurrent septoplasty. CONCLUSION: For many AR patients who present with nasal obstruction secondary to atopic inferior turbinate hypertrophy that is persistent despite pharmacotherapy, ITR is a cost-effective treatment that should be considered prior to immunotherapy. LEVEL OF EVIDENCE: NA - Laryngoscope, 2023 Laryngoscope, 134:1572-1580, 2024.
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Obstrucción Nasal , Rinitis Alérgica , Humanos , Análisis de Costo-Efectividad , Cornetes Nasales/cirugía , Obstrucción Nasal/terapia , Obstrucción Nasal/complicaciones , Rinitis Alérgica/terapia , Rinitis Alérgica/complicaciones , Desensibilización Inmunológica/métodos , Inmunoterapia/métodos , Hipertrofia , Resultado del TratamientoRESUMEN
OBJECTIVE: Circulating tumor DNA assays have robust potential as molecular surveillance tools. They may also exacerbate patient distress without improving outcomes. We investigate patient acceptability of a validated ctHPVDNA assay (NavDx) during cancer surveillance for HPV(+) oropharyngeal cancer (OPC). METHODS: Consented HPV(+) OPC participants completed the NCCN Distress Thermometer, the Hospital Anxiety Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-General (FACT-G) scale both (1) before NavDx blood draw, and (2) after results were provided. Patients then completed a series of focused questions related to their perceptions of the assay. RESULTS: Overall, 55 patients completed the study, with 98.2 % showing no recurrence. For the NCCN Distress Thermometer, median patient distress decreased (2.0 (IQR 1-5) vs. 1.0 (IQR 0-3)) (p < 0.001) in association with NavDx. Using scores ≥ 4 as a cutoff point to define clinically elevated distress, scores also improved (36.4 % vs. 18.2 %, p = 0.031). For HADS, anxiety significantly improved (5.0 (IQR 2.0-7.0) vs. 3.0 (IQR 1.0-6.5)) (p = 0.037), but not depression (3.0 (IQR 1.0-7.0) vs. 3.0 (IQR 1.0-6.5)) (p = 0.870). FACT-G scores showed no substantial differences. On survey questionnaires, 95.5 % of patients believed the test to be helpful, and 100 % felt "somewhat" or "extremely" confident in the assay as a monitoring tool. While 59.1 % felt that it reduced anxiety, 88.4 % concordantly felt that it did not introduce anxiety. CONCLUSION: ctHPVDNA as a molecular surveillance tool reduced distress levels in HPV(+) OPC patients, with notably high patient confidence in the approach. Further investigation is warranted to judiciously incorporate this emerging modality in surveillance guidelines.
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ADN Tumoral Circulante , Neoplasias Orofaríngeas , Humanos , Masculino , Neoplasias Orofaríngeas/psicología , Neoplasias Orofaríngeas/virología , Femenino , Persona de Mediana Edad , Anciano , ADN Tumoral Circulante/sangre , Infecciones por Papillomavirus/psicología , Infecciones por Papillomavirus/virología , Carcinoma de Células Escamosas/virología , Carcinoma de Células Escamosas/psicología , Carcinoma de Células Escamosas/sangreRESUMEN
BACKGROUND: As a surrogate of malnutrition, degree of weight loss and recovery from head and neck cancer (HNC) treatment is understudied. The influence of modifiable factors that affect weight, including speech/language pathology (SLP) and nutrition counseling, is also poorly defined. We characterize weight loss trends, baseline weight recovery (BWR), and the impact of interdisciplinary care on oncologic outcomes. METHODS: Retrospective cohort study assessing 266 newly diagnosed patients with HNC who completed curative-intent radiation (definitive or adjuvant) between January 2016 to January 2022. Relevant treatment factors were analyzed using multivariable Cox regression models. RESULTS: Altogether, 266 patients completed full-course radiation therapy (RT), encompassing definitive chemoRT (53.0%), surgery with chemoRT (18.4%), surgery with RT (17.7%), and RT alone (10.9%). Patient weight reached a nadir at median 3.0 months (IQR 3.0-11.3) after radiation, with a median weight loss of 12.6% (IQR 7.9-18.7). Notably, only 47.4% exhibited BWR. For those who recovered, median time to BWR was 10.5 months (IQR 3.0-24.0). On multivariable analysis, BWR by 6 months was significantly associated with overall survival (HR 0.28 [95% CI 0.10-0.76], p = 0.013), as was SLP consultation (HR 0.40 [95% CI 0.17-0.92], p = 0.031) and nutrition consultation (HR 0.34 [95% CI 0.13-0.89], p = 0.028). CONCLUSION: A high proportion of patients with HNC fail to recover baseline weight after treatment; those that do can take longer than expected to return. Failure to recover baseline weight is associated with a notable decrease in survival. Similarly, SLP and nutrition consultation are independent, modifiable determinants correlated with outcomes, supporting the emphasis on multidisciplinary management. Measures to promote BWR may reduce mortality.
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Medullary thyroid cancer is a rare thyroid malignancy with unique management considerations. In general, small intrathyroidal tumors are cured by total thyroidectomy with central compartment dissection, while large tumors and those with disease spread to regional lymph nodes and distant organs (most commonly lung, liver, and bone) are more difficult to cure. The last decade has seen significant progress in the treatment of advanced MTC, largely due to the discovery and availability of novel targeted therapies, including new drugs specifically targeting the RET protooncogone.
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Carcinoma Neuroendocrino , Neoplasias de la Tiroides , Carcinoma Neuroendocrino/cirugía , Humanos , Proteínas Proto-Oncogénicas c-ret/genética , Neoplasias de la Tiroides/tratamiento farmacológico , Neoplasias de la Tiroides/patología , TiroidectomíaRESUMEN
BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.
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Carcinoma de Células Escamosas , Neoplasias de Cabeza y Cuello , Cirugía Endoscópica por Orificios Naturales , Neoplasias Orofaríngeas , Procedimientos Quirúrgicos Robotizados , Carcinoma de Células Escamosas/patología , Estudios de Cohortes , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Márgenes de Escisión , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Resultado del TratamientoRESUMEN
The incidence of cerebrospinal fluid leak after ventral skull base reconstruction is a primary outcome of interest to skull base surgeons. Exposure to pre-operative radiation may put patients at an increased risk of skull base reconstructive failure. A systematic search identified studies which included patients receiving ventral skull base reconstruction in the setting of pre-operative radiation. A meta-analysis using a random effects model was conducted to estimate an odds ratio of cerebrospinal fluid (CSF) leak in patients exposed to pre-operative radiation. A meta-analysis of 13 studies demonstrated that the odds ratio of CSF leak was 1.73 (95% CI 0.98-3.05). The majority of studies (77%) used vascularized tissue grafts for reconstruction. We identified an increased incidence of CSF leak among patients undergoing ventral skull base reconstruction after prior radiation therapy, although not of statistical significance. Skull base surgeons should exercise caution when planning reconstruction in this population.
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Procedimientos de Cirugía Plástica , Colgajos Quirúrgicos , Pérdida de Líquido Cefalorraquídeo/epidemiología , Pérdida de Líquido Cefalorraquídeo/etiología , Endoscopía , Humanos , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Base del Cráneo/cirugíaRESUMEN
BACKGROUND: Chronic rhinosinusitis with nasal polyposis (CRSwNP) in the setting of aspirin-exacerbated respiratory disease (AERD) is a disease that is difficult to treat and prone to recurrence. Dupilumab is a promising treatment for these patients, but its cost-effectiveness has not yet been compared with aspirin (acetylsalicyclic acid, or ASA) desensitization, a known and effective treatment. We aimed to compare the cost-effectiveness of ASA desensitization with dupilumab therapy for the treatment of CRSwNP in AERD. METHODS: Analyses of cost-effectiveness, as measured in quality-adjusted life years (QALYs), and cost-utility, as measured in number of required revision endoscopic sinus surgeries (ESSs), were conducted. RESULTS: ASA desensitization after ESS was cost-effective and dominated appropriate medical management. Adding salvage dupilumab was also cost-effective (incremental cost-effectiveness ratio [ICER] $135,517.33), and upfront dupilumab therapy was not cost-effective in any scenario (ICER $273,181.32). The cost-utility analysis demonstrated that, over a 10-year period per patient, appropriate medical management after ESS cost $54,125.31 and resulted in 2.25 revision ESSs, ASA desensitization after ESS cost $53,775.15 and resulted in 2.02 revision ESSs, ASA desensitization with salvage dupilumab cost $121,176.25 and resulted in 1.68 revision ESSs, and upfront dupilumab cost $185,950.34 and resulted in 1.51 revision ESSs. CONCLUSION: Dupilumab for the treatment of severe CRSwNP was found to be cost-effective as salvage therapy under the willingness-to-pay threshold of $150,000. Further analysis highlighted that the cost-effectiveness of dupilumab was most sensitive to drug price and expected gains in quality of life. This suggests that additional investigation into improving patient population selection and tailoring treatment algorithms may improve the cost-effectiveness of dupilumab in specific scenarios.
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Pólipos Nasales , Rinitis , Anticuerpos Monoclonales Humanizados , Aspirina/efectos adversos , Enfermedad Crónica , Análisis Costo-Beneficio , Desensibilización Inmunológica , Humanos , Pólipos Nasales/tratamiento farmacológico , Calidad de Vida , Rinitis/tratamiento farmacológicoRESUMEN
OBJECTIVE: Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP. STUDY DESIGN: Cohort-style Markov decision-tree economic model with a 36-year time horizon. METHODS: A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed. RESULTS: The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855. CONCLUSIONS: The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner. LEVEL OF EVIDENCE: 2C Laryngoscope, 131:E26-E33, 2021.
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Anticuerpos Monoclonales Humanizados/economía , Anticuerpos Monoclonales Humanizados/uso terapéutico , Análisis Costo-Beneficio , Endoscopía/economía , Pólipos Nasales/tratamiento farmacológico , Pólipos Nasales/cirugía , Rinitis/tratamiento farmacológico , Rinitis/cirugía , Sinusitis/tratamiento farmacológico , Sinusitis/cirugía , Adulto , Enfermedad Crónica , Estudios de Cohortes , Árboles de Decisión , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pólipos Nasales/complicaciones , Años de Vida Ajustados por Calidad de Vida , Rinitis/complicaciones , Sinusitis/complicacionesRESUMEN
OBJECTIVE: Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed. STUDY DESIGN: A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given. SETTING: Patients with nonabsorbable nasal packing placed. METHODS: Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model. RESULTS: The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective. CONCLUSIONS: Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence. LEVEL OF EVIDENCE: 3a.
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Profilaxis Antibiótica/economía , Infecciones por Clostridium/prevención & control , Técnicas de Apoyo para la Decisión , Epistaxis/terapia , Choque Séptico/microbiología , Choque Séptico/prevención & control , Tampones Quirúrgicos , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Modelos Económicos , Calidad de VidaRESUMEN
BACKGROUND: This is a report of the histopathological evaluation of the acute damage profile in human skin following treatment with two novel short-pulsed fractional carbon dioxide resurfacing devices used independently and in combination in vivo. METHODS: The panni of eight abdominoplasty patients were treated with either the Active FX, the Deep FX (Lumenis Ltd., Yokneum, Israel), or a combination of the two (Total FX) prior to the start of the excisional surgical procedure. Multiple combinations of energies, pulse widths, and densities were evaluated for each device. After surgical removal (two to five hours), each pannus was immediately biopsied and samples were processed for histopathological evaluation. RESULTS: The Active FX system resulted in extensive epidermal injury with wide shallow ablation craters that, at higher fluences, extended through the basement membrane of the epidermis into the papillary dermis. The Deep FX fractional treatment caused deep microcolumns of ablation penetrating up to 3 to 4 mm from the epidermal surface into the deep reticular dermis with a variable rim of coagulated collagen surrounding each ablation column. CONCLUSIONS: The in vivo histopathological evaluation of these devices furthers our understanding of the fundamental laser/tissue interaction following treatment with each device independently and in combination.
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Terapia por Láser/efectos adversos , Láseres de Gas/efectos adversos , Piel/lesiones , Abdomen/cirugía , Biopsia , Humanos , Etiquetado Corte-Fin in Situ/métodos , Terapia por Láser/métodos , Piel/metabolismoRESUMEN
Objective To identify perioperative factors that may predict postoperative cerebrospinal fluid (CSF) leak and meningitis following expanded endoscopic transsphenoidal surgery (EETS). Study Design This is a retrospective study. This study was set at the Cedars-Sinai Medical Center, Los Angeles. A total of 78 patients who underwent EETS between January 2007 and November 2018 were participated. The main outcome measures were CSF leak and meningitis. Results A total of 78 patients underwent a total of 100 EETS procedures; 17.9 and 10.3% of patients developed postoperative CSF leaks and meningitis, respectively. Out of eight, three patients with meningitis did not develop an observable CSF leak. The risk of developing meningitis in patients with a CSF leak was significantly higher than those without a leak, with an odds ratio (OR) of 11.48 (95% confidence interval, 2.33-56.47; p = 0.004). Pituicytomas were significantly associated with meningitis compared with other pathologies. No other patient-specific factors were identified as risks for leak or meningitis, including method of skull base repair, sex, tumor volume, or body mass index, although there was a strong trend toward reduced CSF leak rates in patient with nasoseptal flaps used for skull base repair, compared with those without (9.5 vs. 25%). CSF protein was consistently elevated on the first CSF values obtained when meningitis was suspected. Conclusion CSF leak and meningitis are common complications of expanded endonasal surgery No statistically significant risk factors for developing a postoperative leak other than the pathology of pituicytoma were identified, including method of skull base repair, although the use of a vascularized nasoseptal flap did trend toward a reduced CSF leak rate. CSF protein is the most sensitive marker for the presumptive diagnosis and timely treatment of meningitis.
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OBJECTIVES/HYPOTHESIS: Ear fullness and pressure is a common complaint seen in otolaryngology clinics and frequently is attributed to eustachian tube dysfunction (ETD). In addition to traditional tympanometry and physical examination, the seven-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) has recently been used to aid in the diagnosis of ETD and to assess its severity. Temporomandibular joint disorder (TMJD) is a common condition that causes similar symptoms to ETD and has been recognized as a potential confounding condition in patients presenting with ETD symptoms. We sought to determine the cross-sectional prevalence of ETD symptoms in patients with TMJD using the ETDQ-7. STUDY DESIGN: Prospective cross-sectional analysis. METHODS: An analysis was performed of ETDQ-7 scores in patients diagnosed with TMJD. RESULTS: A total of 21 patients with confirmed TMJD completed the ETDQ-7 at routine consult or follow-up for their TMJD. The mean ± standard deviation ETDQ-7 score for the cohort was 24.5 ± 12.5. Two-thirds of patients had an ETDQ-7 score of >14.5, which has been used in the literature to denote clinically significant ETD. No single question was scored significantly higher than the others. CONCLUSIONS: Symptoms of ETD are highly prevalent among patients with TMJD determined by patient-reported outcome measures. It is not clear if these symptoms reflect true derangement of eustachian tube function in these patients or whether there is only clinical similarity between ETD and TMJD. However, future research efforts may resolve this dilemma. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E233-E236, 2020.
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Enfermedades del Oído/etiología , Enfermedades del Oído/fisiopatología , Trompa Auditiva/fisiopatología , Trastornos de la Articulación Temporomandibular/complicaciones , Trastornos de la Articulación Temporomandibular/fisiopatología , Pruebas de Impedancia Acústica , Estudios Transversales , Femenino , Humanos , Masculino , Prevalencia , Estudios Prospectivos , Encuestas y CuestionariosRESUMEN
BACKGROUND: Flexible fiberoptic laryngoscopy is performed prior to thyroid surgery to evaluate the function of the recurrent laryngeal nerve. We assess the cost-effectiveness of preoperative laryngoscopy prior to total thyroidectomy for a low-risk thyroid cancer patient without dysphonia. METHODS: A decision tree analysis was performed from a third-party payer perspective. We assessed the cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for T2N0M0 papillary thyroid carcinoma, such that an ipsilateral vocal fold paralysis alters the surgical plan to hemi-thyroidectomy, when permissible, to avoid the risk of bilateral vocal fold paralysis. RESULTS: Performing preoperative laryngoscopy to assess vocal fold function has an incremental cost-effectiveness ratio (ICER) of 45 193 USD/QALY compared to no laryngoscopy. At a willingness-to-pay of 100 K/QALY, the intervention is cost-effective if the incidence of vocal fold paralysis is at least 0.57%, or when the permissible rate of hemithyroidectomy in cases of incidental paralysis is at least 41%. Probabilistic sensitivity analysis shows that laryngoscopy is cost-effective in 90.9% of cases. CONCLUSIONS: Fiberoptic laryngoscopy is a cost-effective prior to total thyroidectomy in asymptomatic, low-risk thyroid cancer patients.
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Neoplasias de la Tiroides , Parálisis de los Pliegues Vocales , Análisis Costo-Beneficio , Humanos , Laringoscopía , Neoplasias de la Tiroides/cirugía , Tiroidectomía , Parálisis de los Pliegues Vocales/etiología , Parálisis de los Pliegues Vocales/prevención & controlRESUMEN
BACKGROUND: The taboo of avoiding nonsteroidal anti-inflammatory drugs (NSAIDs) after functional endoscopic sinus surgery (FESS) has been waning. The impetus to reduce opioid prescriptions in view of the opioid epidemic led the authors to change their practices to include NSAIDs after sinus surgery. This study's aim was to analyze the differences between patients before and after we began recommending NSAIDs after FESS. METHODS: A prospective cohort study was performed on patients undergoing FESS or other endoscopic nasal surgeries at 3 institutions, by 5 rhinologists and 1 facial plastic surgeon. Before introducing NSAIDs, all patients were given a prescription for hydrocodone-acetaminophen 5/325 mg and also recommended preferentially to use acetaminophen 325 mg. After the addition of NSAIDs, ibuprofen 200 mg and acetaminophen 325 mg were recommended preferentially, using the narcotic as a rescue medication. Patients kept a pain diary and medication log, and gave a visual analog scale (VAS) score for overall pain. Demographics, surgical variables, and comorbidities were also analyzed. RESULTS: One hundred sixty-six total patients were recruited and had data that could be analyzed (65 without NSAIDs, 101 with NSAIDs). Overall, mean pain VAS score was 3.12 ± 1.95 for the non-NSAID group and 2.33 ± 2.30 for the NSAID group (p value = 0.006). The day with the highest mean pain was the first postoperative day. The mean number of total opioid pills taken was 6.94 ± 6.85 without NSAIDs vs 3.77 ± 4.56 with NSAIDs (p = 0.018). Age and gender were found to be the only consistently significant patient variables to affect pain. There were no bleeding complications. CONCLUSION: NSAID use was introduced into the practices of 5 practicing rhinologists and 1 facial plastic surgeon. No bleeding complications were seen. Both pain and overall opioid usage were reduced significantly.
Asunto(s)
Analgésicos no Narcóticos , Procedimientos Quírurgicos Nasales , Preparaciones Farmacéuticas , Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Humanos , Procedimientos Quírurgicos Nasales/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Estudios ProspectivosRESUMEN
BACKGROUND: Chronic rhinosinusitis (CRS) has long been a suspected risk factor for Eustachian tube dysfunction (ETD). However, there have been few studies quantifying the presence of ETD in CRS patients. We sought to determine the prevalence of ETD symptoms in patients undergoing functional endoscopic sinus surgery (FESS) for CRS using the validated 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and to correlate the ETDQ-7 scores with scores of CRS symptom severity based on the 22-item Sino-Nasal Outcome Test (SNOT-22). METHODS: Patients for FESS were preoperatively administered both the ETDQ-7 and the SNOT-22 validated quality of life instruments. Pearson and Spearman correlation coefficients were calculated. Changes in ETDQ-7 were measured at 3 months and differences were compared via paired t test. RESULTS: A total of 82 patients completed the surveys. Thirty-nine (47.6%) patients had ETDQ-7 score ≥14.5, signifying clinically significant ETD symptoms. The mean ETDQ-7 score of the study population was 15.8 ± 8.8, and the mean SNOT-22 score was 37.5 ± 19.7. The Pearson and Spearman correlation coefficients between ETDQ-7 and the total SNOT-22 score were 0.52 (P > .0001) and 0.51 (P < .0001), respectively. There was significant improvement in ETDQ-7 scores postoperatively. CONCLUSION: While the association between ETD and CRS has long been known, this is one of the few prospective patient studies evaluating otologic symptoms in a CRS population. We found that a significant percentage of CRS patients suffer from ETD symptoms based on patient-reported subjective outcome measures. This study demonstrates that otologic symptoms increase with CRS severity and improve after FESS.