Substance use and mental health burden in head and neck and other cancer survivors: A National Health Interview Survey analysis.

BACKGROUND: Tobacco dependence, alcohol abuse, depression, distress, and other adverse patient-level influences are common in head and neck cancer (HNC) survivors. Their interrelatedness and precise burden in comparison with survivors of other cancers are poorly understood. METHODS: National Health Interview Survey data from 1997 to 2016 were pooled. The prevalence of adverse patient-level influences among HNC survivors and matched survivors of other cancers were compared using descriptive statistics. Multivariable logistic regressions evaluating covariate associations with the primary study outcomes were performed. These included 1) current cigarette smoking and/or heavy alcohol use (>14 drinks per week) and 2) high mental health burden (severe psychological distress [Kessler Index ≥ 13] and/or frequent depressive/anxiety symptoms). RESULTS: In all, 918 HNC survivors and 3672 matched survivors of other cancers were identified. Compared with other cancer survivors, more HNC survivors were current smokers and/or heavy drinkers (24.6% [95% CI, 21.5%-27.7%] vs 18.0% [95% CI, 16.6%-19.4%]) and exhibited a high mental health burden (18.6% [95% CI, 15.7%-21.5%] vs 13.0% [95% CI, 11.7%-14.3%]). In multivariable analyses, 1) a high mental health burden predicted for smoking and/or heavy drinking (odds ratio [OR], 1.4; 95% CI, 1.0-1.9), and 2) current cigarette smoking predicted for a high mental health burden (OR, 1.7; 95% CI, 1.2-2.3). Furthermore, nonpartnered marital status and uninsured/Medicaid insurance status were significantly associated with both cigarette smoking and/or heavy alcohol use (ORs, 1.9 [95% CI, 1.4-2.5] and 1.5 [95% CI, 1.0-2.1], respectively) and a high mental health burden (ORs, 1.4 [95% CI, 1.1 -1.8] and 3.0 [95% CI, 2.2-4.2], respectively). CONCLUSIONS: Stakeholders should allocate greater supportive care resources to HNC survivors. The interdependence of substance abuse, adverse mental health symptoms, and other adverse patient-level influences requires development of novel, multimodal survivorship care interventions.

High-Risk Cutaneous Squamous Cell Carcinoma of the Head and Neck: A Clinical Review.

BACKGROUND: Given the rapidly evolving nature of the field, the current state of "high-risk" head and neck cutaneous squamous cell carcinoma (HNcSCC) is poorly characterized. METHODS: Narrative review of the epidemiology, diagnosis, workup, risk stratification, staging and treatment of high-risk HNcSCC. RESULTS: Clinical and pathologic risk factors for adverse HNcSCC outcomes are nuanced (e.g., immunosuppression and perineural invasion). Frequent changes in adverse prognosticators have outpaced population-based registries and the variables they track, restricting our understanding of the epidemiology of HNcSCC and inhibiting control of the disease. Current heterogeneous staging and risk stratification systems are largely derived from institutional data, compromising their external validity. In the absence of staging system consensus, tumor designations such as "high risk" and "advanced" are variably used and insufficiently precise to guide management. Evidence guiding treatment of high-risk HNcSCC with curative intent is also suboptimal. For patients with incurable disease, an array of trials are evaluating the impact of immunotherapy, targeted biologic therapy, and other novel agents. CONCLUSION: Population-based registries that broadly track updated, nuanced, adverse clinicopathologic risk factors, and outcomes are needed to guide development of improved staging systems. Design and development of randomized controlled trials (RCTs) in advanced-stage HNcSCC populations are needed to evaluate (1) observation, sentinel lymph node biopsy, or elective neck dissection for management of the cN0 neck, (2) indications for surgery plus adjuvant radiation versus adjuvant chemoradiation, and (3) the role of immunotherapy in treatment with curative intent. Considering these knowledge gaps, the authors explore a potential high-risk HNcSCC treatment framework.

Remission of vulvar pain among women with primary vulvodynia.

OBJECTIVE: To determine whether rates of remission differed among women with primary versus secondary vulvodynia. METHODS: Using a community-based observational study based in Minneapolis/St. Paul, 138 clinically confirmed cases of vulvodynia between 18 and 40 years old were classified as primary (vulvar pain starting at the time of sexual debut or first tampon insertion) or secondary (vulvar pain starting after a period of pain-free intercourse) and queried regarding their pain history to determine whether they had ever experienced any vulvar pain-free time (remission) or pain-free time lasting 3 months or longer. RESULTS: Remission prevalence was 26% (9/34) for women in the shortest quartile of duration of vulvar pain (<3.8 y) and 38% (13/34) for the longest quartile of duration (≥13 y). After adjusting for vulvar pain duration, generalized vestibular pain, medical treatment, body mass index, and history of pregnancy, women who had primary vulvodynia were 43% less likely to report remission (95% CI = 0.33-0.99) than women with later onset (secondary cases). The association was strengthened when restricting to only remissions lasting 3 months or longer (adjusted risk ratio = 0.43, 95% CI = 0.22-0.84). Generalized vestibulodynia and obesity also reduced the likelihood of remission. CONCLUSIONS: Our study underscores the heterogeneity of vulvodynia and provides evidence that primary vulvodynia may have a less wavering course and, as such, a potentially different underlying mechanism than that of secondary vulvodynia.

Risk-adjusted analysis of perioperative outcomes after the Sistrunk procedure.

Objectives: Thyroglossal duct cyst (TGDC) is the most common pediatric congenital neck mass. The Sistrunk procedure is the standard method of excision and is associated with low rates of recurrence. This study aimed to review our institution's outcomes following the Sistrunk procedure, specifically the rates of wound complications and cyst recurrence. Methods: This was a retrospective case series of pediatric patients undergoing the Sistrunk procedure from June 2009 to April 2021. Results: A total of 273 patients were included. Of these, 139 (53%) patients were male and 181 (66%) were white. The average age at the time of surgery was 7.1 years. The overall cyst recurrence rate was 11%. The most common wound complications were seroma (14%) and surgical site infections (SSIs) (12%). Wound complications were associated with prior history of cyst infection (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.07-3.60, z-test 2.2, p = .03). Pediatric surgery was associated with fewer wound complications (OR 0.18; 95% CI 0.05-0.6, z-test -2.78, p = .005). However, pediatric surgery operated on fewer patients with a history of cyst infection (36% vs. 55%, p = .012). Drain placement and postoperative antibiotics did not affect rates of wound complications. Conclusions: Prior cyst infection is associated with increased rates of postoperative wound complications. Postoperative antibiotics and drain placement did not significantly affect complication rates. Level of Evidence: 4.

Emergency Department Visits and Hospitalizations After Pediatric Tracheostomy.

OBJECTIVE: To determine factors associated with frequent emergency department (ED) visits and hospitalizations after pediatric tracheostomy. METHODS: A prospective cohort of children (<18 years) with a tracheostomy placed at a tertiary children's hospital between 2015 and 2019 were followed for 24 months after index discharge. ED visits and hospitalizations were recorded to identify risk factors for frequent utilization (≥4 visits). RESULTS: A total of 239 children required 1285 total visits to the ED or hospital after index discharge with 112 children (47%) having ≥4 visits. Respiratory-related illness was the most common reason (N = 699, 54%) followed by gastrostomy tube issues (N = 119, 9.3%). Frequent utilization was associated with Black race (OR: 2.01, 95% CI: 1.18-3.70, p = 0.01), mechanical ventilation (OR: 2.74, 95% CI: 1.35-5.59, p = 0.006), and Spanish language (OR: 3.86, 95% CI: 1.47-10.11, p = 0.006) on regression modeling. There were no predictors of visits for tracheostomy-related complications, which accounted for 4.8% of all encounters. A sub-analysis showed that Hispanic ethnicity and gestational age predicted visits for respiratory failure. CONCLUSION: Frequent ED visits or hospitalizations are required for 47% of children in the first 2 years after tracheostomy placement. Ventilatory support, Black race, and Spanish language increase the likelihood of high utilization. Although tracheostomy-related visits are uncommon, strategies to anticipate and decrease respiratory-related admissions may have the most impact. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2018-2024, 2023.

Accidental Tracheostomy Decannulations in Children-A Prospective Cohort Study of Inpatients.

OBJECTIVES: To determine the incidence of tracheostomy accidental decannulations (AD) among pediatric inpatients and identify risks for these events. STUDY DESIGN: Prospective cohort. METHODS: All tracheostomy patients (≤18 years) admitted at a tertiary children's hospital between August 2018 and April 2021 were included. AD were recorded and patient harm was classified as no harm/minor, moderate, or severe. Monthly AD incidence was described as events per 1000 tracheostomy-days. RESULTS: One-hundred seventeen AD occurred among 67 children with 33% (22/67) experiencing multiple events (median: 2.5 events, range: 2-10). Mean age at AD was 4.7 years (SD: 4.4). AD resulted from patient movement (32%, 37/117), performing tracheostomy care (27%, 31/117), repositioning or transporting (15%, 17/117), or unclear reasons (27%, 32/117). A parent or guardian was involved in 28% (33/117) of events. Nearly all AD resulted in no more than minor harm (84%, 98/117) but moderate (12%, 14/117) and severe (4%, 5/117) events did occur. There were no deaths. Tracheostomy care or repositioning were frequently responsible in acute versus subacute events (48% vs. 26%, p = 0.04). Mean monthly AD incidence was 4.7 events per 1000 tracheostomy-days (95% CI: 3.7-5.8) and after implementation of safety initiatives, the mean rate decreased from 5.9 events (95% CI: 4.2-7.7) to 3.7 events (95% CI: 2.5-5.0) per 1000 tracheostomy-days (p = 0.04). CONCLUSIONS: AD in children occur at nearly 5 events per 1000 tracheostomy-days and often result in minimal harm. Quality initiatives targeting patient movement, provider education, and tracheostomy care might reduce the frequency of these complications. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:963-969, 2023.

Caregiver quality of life after pediatric tracheostomy.

OBJECTIVE: To determine the impact of a child with a tracheostomy on caregiver quality of life. METHODS: A repeated cross-sectional analysis included families with tracheostomy-dependent children between 2019 and 2021. Caregivers were surveyed using the PedsQL™ Family Impact Module with assessments at tracheostomy placement and during ambulatory office visits. RESULTS: Two-hundred and fifty-five surveys were performed with 66 at tracheostomy placement (26%) and 189 at follow-up visits (74%). Compared to families with healthy children, total scores at placement (77.2 vs. 87.6, P < .001) and follow-up visits (78.9 vs. 87.6, P < .001) were significantly lower among pediatric tracheostomy families. Caregivers were likely to report significant improvement in emotional functioning (6.2 points; 95% CI: 0.5-12, P = .03) and worry (9 points, 95% CI: 2.1-15.9, P = .01) over time. Demographic variables demonstrated no confounding or interactive effects. CONCLUSIONS: The presence of a tracheostomy is associated with lower caregiver quality of life scores in the short- and long-term compared to caregivers of healthy children. Providers should be sensitive to these challenges and provide appropriate support for families of tracheostomy-dependent children.

Mechanical ventilation and middle ear effusions among tracheostomy-dependent children.

OBJECTIVE: To determine the cumulative 24-month incidence of middle ear effusion (MEE) among tracheostomy-dependent children requiring ventilatory support. METHODS: A prospective longitudinal cohort study included all children under 2 years of age with a tracheostomy placed at a tertiary care children's hospital between 2015 and 2020 that obtained at least one tympanometry exam. The development of MEE, defined as a flat tympanogram with normal external canal volume, and mechanical ventilation requirement at examination were recorded. RESULTS: Ninety-four children with a mean age at tracheostomy of 5.4 months (SD: 3.7) were included. During a mean follow-up of 18.3 months (SD: 14.6) (median: 14.1 months, interquartile range: 6.6-27.8), 192 tympanometry examinations were obtained with 59% (114/192) while requiring mechanical ventilation. Within 24 months after tracheostomy, 56.5% (95% CI: 48.9-64.4%) of children developed at least one MEE. Among those on mechanical ventilation, 74.0% (95% CI: 65.6-82.5%) developed MEE compared to 31.2% (95% CI: 21.4-44.0%) not on mechanical ventilation (HR: 2.97, 95% CI: 1.46-6.05, P = .003). A persistent MEE on two consecutive exams was not statistically more common for children on a ventilator (OR: 0.64, 95% CI: 0.01-6.95, P = .70). When controlling for age at exam, craniofacial syndrome, and newborn hearing test results on logistic regression, ventilator-dependence significantly predicted the presence of MEE (OR: 2.34, 95% CI: 1.18-4.68, P = .02). CONCLUSION: Children with a tracheostomy were more likely to develop MEE when requiring mechanical ventilation. Clinicians should recognize this risk factor and appropriately assess for development of MEE to mitigate adverse speech and language development outcomes in this vulnerable population.

Surgical site infections after pediatric open airway reconstruction-A National Surgical Quality Improvement Program-Pediatric analysis.

Objectives: To determine the rate of surgical site infections (SSI) after pediatric open airway reconstruction using a nationwide database. Study Design: Cross-sectional study of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) Database. Methods: The ACS NSQIP-P was queried for open airway surgeries between 2013 and 2019 determining postoperative SSI and wound dehiscence with a random sample of non-airway cases serving as a control group. Results: A total of 637 laryngotracheoplasties (LTP), 411 tracheal resections (TR) and 2100 control procedures were included. LTP and TR were both performed on younger children with more comorbidities than control surgeries (p < .05). Postoperative wound complications occurred more often after airway reconstructions than non-airway cases (6.4% vs. 2.9%, p < .001). Compared to non-airway procedures, LTP (OR: 2.42, 95% CI: 1.62-3.61) and TR (OR: 2.07, 95% CI: 1.28-3.66) developed increased SSI. Multiple logistic regression identified dirty or infected wounds (OR: 4.61, p < .001, 95% CI: 2.35-9.03) and American Society of Anesthesiologists (ASA) Class IV (OR: 3.19, p = .02, 95% CI: 1.12-8.39) as the strongest predictors of SSI after airway reconstruction. Conclusions: SSI after pediatric airway reconstruction occur in 6% of cases and are increased in infected wounds and ASA Class IV surgeries. Recognizing common factors for these complications provide reliable benchmarking to design surgical quality improvement initiatives. Level of Evidence: 4.