Risk factors for postoperative complications in total thyroidectomy: A retrospective, risk-adjusted analysis from the National Surgical Quality Improvement Program.

Thyroid cancer incidence is increasing, and with it, an increase in total thyroidectomy. There are limited studies comparing outcomes in total thyroidectomy performed in the inpatient versus outpatient setting.The objective of this study was to perform a comparative analysis of risk factors and outcomes of postoperative morbidity and mortality in total thyroidectomy performed as an inpatient versus outpatient surgery.Retrospective cohort study of data from the 2005 to 2014 multi-institutional, risk-adjusted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. A multivariate regression model with corresponding odds ratios and 95% confidence intervals was used to determine 30-day morbidity and mortality after total thyroidectomies, and also risk factors of postoperative outcomes.From 2005 to 2014, 40,025 total thyroidectomies were performed (48.5% inpatient, 51.5% outpatient). The 30-day complication rate for all total thyroidectomies was 7.74%. Multivariate logistic regression analysis was performed to control for potential confounding variables. Preoperative factors that affected complications rates for inpatient thyroidectomies included: age ≥70, non-Caucasian race, dependent functional status, history of congestive heart failure, smoking history, bleeding disorder, wound infection, and preoperative sepsis (P < 0.05). In addition, preoperative factors affecting complications in thyroidectomy performed as an outpatient surgery included malignant thyroid pathology (P  0.05).We identified a subset of preoperative conditions that affect risk of complications after total thyroidectomy. Recommendations for patient selection for outpatient total thyroidectomies should be modified to account for pre-existing conditions that increase the risk of postoperative morbidity.

Is there a group of patients at greater risk for hematoma following thyroidectomy? A systematic review and meta-analysis.

OBJECTIVE: The purpose of this study was to perform a systematic review and meta-analysis to determine whether a difference exists in hematoma rates following thyroidectomy for any of the following subgroups of patients: Graves disease, toxic nodular goiter (TNG), and malignancy. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic literature search was performed for all relevant English and French language studies (1946-2015) using Ovid MEDLINE, EMBASE, and PubMed. Three authors independently extracted data and analyzed articles for quality using the Newcastle-Ottawa Quality Assessment Scale. Our primary outcome of interest was hematoma requiring re-operation. RESULTS: A total of 301 studies were screened, with 11 studies meeting the inclusion criteria. The results of our analysis demonstrated that Graves disease is the only indication for thyroidectomy that appears to have an increased risk of postoperative hematoma formation, pooled odds ratio = 1.58 (1.09-2.31); P = 0.02. Malignancy and TNG did not demonstrate significantly higher rates of postoperative hematoma formation. CONCLUSION: This study demonstrates that of patients undergoing thyroidectomy, Graves disease is the only indication in which patients are at increased risk of postoperative hematoma formation. This information may help guide future decisions regarding the implementation of outpatient thyroidectomy. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:1483-1490, 2017.

Complication rates of open surgical versus percutaneous tracheostomy in critically ill patients.

BACKGROUND: In the setting of critical care, the most common indications for tracheostomy include: prolonged intubation, to facilitate weaning from mechanical ventilation, and for pulmonary toileting. In this setting, tracheostomy can be performed either via open surgical or percutaneous technique. Advantages for percutaneous dilatational tracheostomy (PDT) include: simplicity, smaller incision, less tissue trauma, lower incidence of wound infection, lower incidence of peristomal bleeding, decreased morbidity from patient transfer, and cost-effectiveness. Despite many studies comparing surgical tracheostomy (ST) versus PDT, there remains no consensus on which of these techniques minimizes complications in critically ill patients. PURPOSE: To provide an updated meta-analysis to answer the following question: Is there a difference in complication rates between ST and PDT in the setting of critically ill patients? Our secondary outcome of interest was to examine the difference in procedure time in the ST versus PDT groups. METHODS: We conducted a literature search using the following databases: Ovid MEDLINE, Embase, Google Scholar, and Cochrane Database of Systematic Reviews. Studies from 1985 until October 2014 published in French or English languages in peer-reviewed journals were included. RESULTS: With regard to rates of mortality, intraoperative hemorrhage, and postoperative hemorrhage, there was no statistically significant difference between the two techniques. Evaluation of infections rates and operative time, however, revealed a statistically significant difference, favoring PDT over ST. CONCLUSION: In critically ill patients, PDT appears to be a safe and efficient alternative to open ST. LEVEL OF EVIDENCE: NA Laryngoscope, 126:2459-2467, 2016.

The effectiveness of webcast compared to live lectures as a teaching tool in medical school.

OBJECTIVE: The purpose of this study is to investigate whether webcast lectures are comparable to live lectures as a teaching tool in medical school. METHODS: Three Otolaryngology-Head&Neck Surgery (OTO-HNS) lectures were given to third year medical students through their regular academic curriculum with one group receiving lectures in a live lecture format and the other group in a webcast format. All lectures (live or webcast) were given by the same lecturer and contained identical material. Three outcome measures were used: a student satisfaction survey, performance on the OTO-HNS component of their written examination, and performance on an OTO-HNS OSCE station in the general end of year OSCE examination session. RESULTS: Students performance on the written examination was equal between the two groups. The webcast group outperformed the live lecture group in the OSCE station. The majority of students in the webcast group felt it was an effective learning tool for them. Most viewed the lectures more than once, and felt that this was beneficial to their learning. CONCLUSION: Webcasts appear equally effective to live lectures as a teaching tool.

Comparison of the rotation-advancement and philtral ridge techniques for unilateral cleft lip repair.

BACKGROUND: The Millard rotation-advancement flap has become the most widely used technique for unilateral cleft lip repair. The philtral ridge repair is a modified straight-line technique that was developed to further optimize the scar associated with the rotation-advancement flap. The purpose of this article is to introduce the philtral ridge repair and objectively compare the outcomes of these two techniques. METHODS: Two senior board-certified surgeons, who are active members of their respective craniofacial teams, use different surgical techniques for the unilateral cleft lip: the philtral ridge and rotation-advancement repairs. The authors retrospectively analyzed preoperative and postoperative photographs of consecutive patients who underwent repair performed by each surgeon between 2003 and 2009. Using Adobe Photoshop imaging software, facial points on the cleft and noncleft sides were measured, including height and symmetry of Cupid's bow, width and height of the nasal vestibule, height of the vermilion, and alar base position. Ratios of cleft side to noncleft side measurements were calculated to standardize comparisons between patients. In addition, the symmetry of each lip repair was graded subjectively by health care professionals and the general public. RESULTS: There were no differences in preoperative ratios between the two techniques with the exception of a wider cleft nasal vestibule in the rotation-advancement group (p = 0.04). There were no statistically significant differences in postoperative measures or subjective analysis of symmetry between the groups. CONCLUSION: Both the rotation-advancement and philtral ridge techniques produced outcomes with a high degree of facial symmetry and are excellent options for unilateral cleft lip repair.

Connexin gene mutations among Ugandan patients with nonsyndromic sensorineural hearing loss.

OBJECTIVES/HYPOTHESIS: Congenital deafness occurs in approximately 1 in 1,000 live births, and 50% of these cases are hereditary. Connexin mutations have been identified as the most common cause of hereditary hearing loss in many populations. The prevalence of this mutation in African patients has not been adequately studied. The objective of this study was to determine the prevalence of connexin 26 and 30 mutations in a population of hearing-impaired patients from Uganda. STUDY DESIGN: This is an observational study. METHODS: Coding regions of both GJB2 and GJB6, noncoding exon 1 of GJB2, and 30 nucleotides of intronic sequence bordering the exons were analyzed in 126 subjects from Uganda with confirmed bilateral, severe-to-profound sensorineural hearing loss. All variants were analyzed for possible clinical significance using a combination of database searches and in silico tools. RESULTS: Complete sequence data were obtained on 115/126 individuals; 11 had only partial or no results. Only one reported pathogenic variant was found in GJB2 (c.208C>G; p.Pro70Ala) and none in GJB6. Three reported variants and two novel variants within intron 1 of GJB2 and two variants within exon 3 of GJB6 were also found. CONCLUSIONS: None of the most common types of deletions in the GJB2 gene (c.35delG, c.167delT or c.235delC) were found in this large cohort of deaf children from Uganda. This prompts a search for genetic causes of deafness among this and other previously studied African populations.

Complications of septal extension grafts in Asian patients.

IMPORTANCE Nasal tip-plasty is one of the most important and difficult parts of rhinoplasty. Three-dimensional positioning of the nasal tip is a vital component in the overall appearance of the tip. The use of a septal extension graft (SEG) is a versatile technique that can supply nasal tip support and aid in positioning of the tip, as well as provide projection and lengthening. However, complications with this method can occur, and the incidence of these issues has risen with the increased use of this technique. OBJECTIVE To investigate the problems resulting from nasal tip surgical procedures using an SEG. DESIGN, SETTING, AND PARTICIPANTS This study involved a retrospective review of 44 consecutive patients who underwent nasal tip-plasty using an SEG. Patient results were analyzed with medical record review, patient questionnaires, and preoperative and postoperative photographs. Anthropometric measurements and analysis were performed for the pre- and postoperative tip projection and nasolabial angle. MAIN OUTCOMES AND MEASURES Prevalence of different complications of SEGs in Asian patients. RESULTS Eighty-six percent of the patients who had SEGs were satisfied with the cosmetic appearance of their nasal tip. Septal cartilage was the most frequently used material for SEGs. Complications in patients who had SEGs included nasal tip stiffness (45.5%), a decrease of projection (45.5%), nasal tip deviation (11.4%), and infection (4.5%). The revision rate was 9.0%. CONCLUSIONS AND RELEVANCE Asian nasal tip-plasty using an SEG can result in successful outcomes, providing nasal tip support, projection, and length. However, care needs to be taken to prevent complications such as hardness, loss of projection, nasal tip deviation, and infection.

Vascular progenitor clusters from peripheral blood in cancer patients following oncologic surgery.

INTRODUCTION: Vascular progenitor cells (VPCs) are recruited into the peripheral blood (PB) following ischemia and inflammation and correlate with vascular health. The impact of recruiting VPCs on surgical recovery and cancer progression following tumor resection remain unknown. METHODS: We measured VPC clusters and enumerated circulating CD34+ VEGFR2+ angiogenic cells in 18 patients with oral cancer (OC) undergoing resection and free flap reconstruction (high vascular injury) and in 18 patients undergoing colorectal cancer resection (CRC) (low vascular injury) at baseline and multiple timepoints after surgery. RESULTS: VPC clusters increased following OC resection, peaking on Day +3 and returning to baseline by Day 28. In contrast, VPC clusters decreased sharply on Day +3 in patients with CRC before returning to baseline. CD34+ VEGFR2+ cells did not increase significantly after surgery. More rapid clinical recovery following OC resection was observed in patients with greater VPC cluster levels on Day +3. Tumor size and subsequent progression of cancer did not correlate with recruitment of VPC cluster-forming cells. CONCLUSION: VPC recruitment following cancer resection may depend on cancer subtype and may relate to the degree of surgical stress and vascular injury. Recovery after surgery for OC may be accelerated in patients with greater VPC recruitment.

Effect of various facial angles and measurements on the ideal position of the nasal tip in the Asian patient population.

IMPORTANCE: Successful surgical correction of nasal tip position requires preoperative analysis. Perceived adequate nasal tip position depends on its relationship with other facial features. Nasal tip position can be affected by the subnasal contour, proportion of facial height, and relative facial size and shape. The relation of these factors to the nasolabial angle may not be as important as previously believed. OBJECTIVE: To investigate and compare the factors affecting the ideal location of the tip of the nose in Asian patients using standard photographic measurements. DESIGN: We analyzed measurements of profile photographs and compared different factors that affect nasal tip location, including the nasofrontal, nasolabial, nasomental, and Legan angles and the ratios of the dorsal height to tip projection, the radix height to tip projection, the glabella to subnasale, and the subnasale to mentum. SETTING AND PARTICIPANTS: One hundred men, 100 women, 20 to 40 years old, seen for rhinoplasty at the Department of Otorhinolaryngology, Chosun University College of Medicine. MAIN OUTCOME AND MEASURES: Contribution of different facial measurements to the ideal nasal tip position. RESULTS: Nasolabial and nasomental angles exerted a statistically significant effect on ideal nasal tip position, whereas the Legane angle, the ratio of midface to lower face, and the ratio of nasal length to lower face did not show significant effects on nasal tip position. CONCLUSIONS AND RELEVANCE: The nasolabial and nasomental angles have important effects on ideal nasal tip position and should be considered together during preoperative evaluation of the location of the nasal tip. Concurrent genioplasty should optimize rhinoplasty outcomes in appropriately selected patients. LEVEL OF EVIDENCE: NA.

Endoscopic brow lifts: have they replaced coronal lifts?

This article describes the use of the endoscopic brow-lifting technique in addressing periorbital aging. This article discusses the advantages and disadvantage of the endoscopic versus traditional techniques of brow lifting and gives our treatment algorithm depending on patient needs.

The new age of play audiometry: prospective validation testing of an iPad-based play audiometer.

OBJECTIVE: The timely diagnosis of hearing loss in the pediatric population has significant implications for a child's development. However, audiological evaluation in this population poses unique challenges due to difficulties with patient cooperation. Though specialized adaptations exist (such as conditioned play audiometry), these methods can be time consuming and costly. The objective of this study was to validate an iPad-based play audiometer that addresses the shortcomings of existing audiometry. METHODS: We designed a novel, interactive game for the Apple® iPad® that tests pure tone thresholds. In a prospective, randomized study, the efficacy of this tool was compared to standard play audiometry. 85 consecutive patients presenting to the Audiology Clinic at the Children's Hospital of Eastern Ontario (ages 3 and older) were recruited into this study. Their hearing was evaluated using both tablet and traditional play audiometry. OUTCOME MEASURE: Warble-tone thresholds obtained by both tablet and traditional audiometry. RESULTS: The majority of children in this age group were capable of completing an audiologic assessment using the tablet computer. The data demonstrate no statistically significant difference between warble-tone thresholds obtained by tablet and traditional audiometry (p=0.29). Moreover, the tablet audiometer demonstrates strong sensitivity (93.3%), specificity (94.5%) and negative predictive value (98.1%). CONCLUSION: The tablet audiometer is a valid and sensitive instrument for screening and assessment of warble-tone thresholds in children.

A contemporary review of the management of the difficult patient.

The goal of plastic surgery is to improve the function and/or appearance of a body part(s). On the surface, providing improvement in appearance and function should result in a satisfied patient. However, the goals and expectations of patients seeking plastic surgery are complex. Understanding these expectations and psychological needs are important aspects of patient care and achieving patient satisfaction.

Distinct profile of vascular progenitor attachment to extracellular matrix proteins in cancer patients.

BACKGROUND: Vascular progenitor cells (VPCs) facilitate angiogenesis and initiate vascular repair by homing in on sites of damage and adhering to extracellular matrix (ECM) proteins. VPCs also contribute to tumor angiogenesis and induce angiogenic switching in sites of metastatic cancer. In this study, the binding of attaching cells in VPC clusters that form in vitro on specific ECM proteins was investigated. METHODS: VPC cluster assays were performed in vitro on ECM proteins enriched in cancer cells and in remodelling tissue. Profiles of VPC clusters from patients with cancer were compared to healthy controls. The role of VEGF and integrin-specific binding of angiogenic attaching cells was addressed. RESULTS: VPC clusters from cancer patients were markedly increased on fibronectin relative to other ECM proteins tested, in contrast to VPC clusters from control subjects, which formed preferentially on laminin. Specific integrin-mediated binding of attaching cells in VPC clusters was matrix protein-dependent. Furthermore, cancer patients had elevated plasma VEGF levels compared to healthy controls and VEGF facilitated preferential VPC cluster formation on fibronectin. Incubating cells from healthy controls with VEGF induced a switch from the 'healthy' VPC binding profile to the profile observed in cancer patients with a marked increase in VPC cluster formation on fibronectin. CONCLUSION: The ECM proteins laminin and fibronectin support VPC cluster formation via specific integrins on attaching cells and can facilitate patterns of VPC cluster formation that are distinct in cancer patients. Larger studies, however, are needed to gain insight on how tumor angiogenesis may differ from normal repair processes.

Global health initiatives and electives: a survey of interest among Canadian otolaryngology residents.

OBJECTIVE: To determine the level of interest among Canadian otolaryngology residents in global health initiatives (GHIs) and international health electives (IHEs) and the barriers to participation in such initiatives. METHODS: A Web-based survey was developed and sent to all Canadian otolaryngology residents. Questions were posed on demographics, the level of interest in GHIs and IHEs, past experiences in this field, real and perceived barriers in pursuing GHIs and IHEs, previous global health experience, and, finally, the current infrastructure that exists in Canadian postsecondary institutions and otolaryngology programs to encourage participation. RESULTS: The level of interest among Canadian otolaryngology residents in GHIs and IHEs is at least 32%. The greatest barriers to pursuing this interest are cost, lack of infrastructure, lack of mentors, and lack of elective time. To contribute to an important cause was the top reason (79%) cited by respondents for their interest in global health. This was followed by personal growth and to learn about medicine in low- and middle-income countries, respectively. CONCLUSION: At least 32% of Canadian otolaryngology residents showed interest in participating in a GHI or IHE. We must devise means of overcoming barriers to participation in GHIs and IHEs and facilitate the clear and substantial resident interest in GHIs and IHEs. By supporting these endeavours, we will expose a cross section of physicians to global issues and give them an important and meaningful context in our increasingly interconnected world.

Number needed to treat analysis for planned neck dissection after chemoradiotherapy for advanced neck disease.

OBJECTIVE: to analyze how many planned neck dissections (PNDs) must be performed to prevent one fatal neck recurrence after chemoradiotherapy for head and neck cancer with regional metastasis. METHODS: a systematic literature review of studies using chemoradiotherapy as primary treatment for head and neck cancer was performed. Data were extracted where possible to determine estimates for the following variables: (1) percentage of N2-3 necks still harbouring cancer after chemoradiotherapy as proven by pathology from neck dissection (C); (2) percentage of regional recurrence after PND (P); (3) percentage of regional recurrence after salvage neck dissection for patients without initial PND in whom neck disease recurred after chemoradiotherapy (S); and (4) mortality rate of PND (M). The number needed to treat was calculated using the following equation: NNT = 1/[C*(S+M) - (P+M)]. RESULTS: the number needed to treat is 7.5. CONCLUSION: to prevent one fatal neck recurrence after chemoradiotherapy for head and neck cancer with N2-3 disease, one would need to perform 7.5 PNDs. The results of this study will aid surgeons and patients in making more informed decisions regarding neck dissections.