Conventional clinical signs and symptoms are poor predictors of postoperative cerebrospinal fluid leak: A single-centre cohort perspective.

BACKGROUND: Postoperative cerebrospinal fluid (CSF) leak remains a concerning complication of the endoscopic endonasal approach (EEA) for skull base pathology. Signs and symptoms suggesting CSF leak often trigger additional workup during the postoperative course. We systematically evaluate associations between subjectively reported clinical signs/symptoms noted during the immediate postoperative period and incidence of postoperative CSF leaks. METHODS: Retrospective chart review was conducted at a tertiary academic medical centre including 137 consecutive patients with intraoperative CSF leak during EEA with primary repair between July 2018 and August 2022. Postoperative CSF leak associations with clinical signs and symptoms were evaluated using positive (PPV) and negative predictive values (NPV), sensitivity, specificity and odds ratio (OR) via univariate logistic regression. RESULTS: Seventy-nine patients (57.7%) had high-flow leaks repaired and 5 (3.6%) developed CSF leaks postoperatively. Of reported symptoms, rhinorrhea was most common (n = 52, 38.0%; PPV [95% CI] = 7.6% [4.8%, 11.9%]), followed by severe headache (n = 47, 34.3%; 6.3% [3.1%, 12.5%]), dizziness (n = 43, 31.4%; 2.3% [0.4%, 12.1%]), salty or metallic taste (n = 20, 14.6%; 9.9% [3.3%, 25.8%]), and throat drainage (n = 10, 7.3%; 9.9% [1.7%, 41.4%]). Nausea or vomiting constituted the most reported sign concerning for CSF leak (n = 73, 53.3%; PPV [95% CI] = 4.1% [2.0%, 8.1%]). On univariate regression, no sign or symptom, including rhinorrhea (OR [95% CI] = 7.00 [0.76-64.44]), throat drainage (3.42 [0.35-33.86]), salty/metallic taste (4.22 [0.66-27.04]), severe headache (3.00 [0.48-18.62]), dizziness (0.54 [0.06-4.94]), fever (3.16 [0.50-19.99]), and nausea/vomiting (1.33 [0.22-8.21]), associated with postoperative CSF leak. CONCLUSIONS: A range of subjectively reported symptoms and signs failed to predict postoperative CSF leak. Further investigation is warranted to inform appropriate attention and response.

Outcomes of Short-Term Surgical Trips in Otolaryngology-Head and Neck Surgery: A Scoping Review.

OBJECTIVE: This scoping review aims to explore the current body of literature to characterize how short-term surgical trips (STSTs) in Otolaryngology-Head and Neck Surgery (OtoHNS) contribute to surgical, educational, and sustainability-based outcomes in low- and middle-income countries (LMICs). We aim to use these data to synthesize aspects of STSTs that are successful with the hopes of shaping future global efforts. DATA SOURCES: Data sources included Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. REVIEW METHODS: A comprehensive search was conducted on several databases from inception to October 14, 2021. We included primary studies exploring any surgical or educational outcomes of global short-term surgical endeavors within LMICs. Data were then extracted to evaluate the heterogenous body of literature that exists, characterizing the surgical, educational, and sustainability-based outcomes. RESULTS: Forty-Seven studies were included in the final analysis. Most publications were focused on surgical interventions (39 of 47; 82.9%); 13 (27.7%) studies included education as the primary aim and 12 (25.5%) considered sustainability a significant aim. Of the 94 first and last authors, there were zero first authors and only one last author with an LMIC affiliation. Twenty-six studies (55%) mentioned that any patients were seen in follow-up, ranging from one day to five years. CONCLUSION: Our scoping review demonstrates that most STSTs have focused primarily on surgical procedures with a lack of appropriate long-term follow-up. However, the available outcome-based information presented helps identify factors that characterize a strong short-term global surgical program. LEVEL OF EVIDENCE: NA Laryngoscope, 134:32-39, 2024.

Induction Chemotherapy for Locoregionally Advanced Sinonasal Squamous Cell Carcinoma.

Background There is emerging evidence to suggest the role of induction chemotherapy (IC) in definitive management of locoregionally advanced sinonasal squamous cell carcinoma (SNSCC). We evaluated the influence of IC on survival and predictors of its use in SNSCC patients. Methods The 2004 to 2017 National Cancer Database was queried for patients with locoregionally advanced SNSCC (T4/M0). Treatments were stratified into seven groups: definitive chemoradiation (CRT), IC with definitive CRT (IC + CRT), IC + CRT with salvage surgery (IC + CRT + Sx), definitive surgery (Sx), IC with definitive surgery (IC + Sx), definitive surgery with adjuvant radiation or CRT (Sx + ATx), or IC + Sx + ATx. Cox proportional-hazards regression assessed overall survival (OS) and logistic regression identified predictors of IC. Results Of 3,162 patients, 1,088 (34.4%) were female with a mean age of 63.4 ± 13.4 years. The 2- and 5-year OS rates were 58.6 and 42.0%, respectively. Compared with CRT, Sx + ATx (hazard ratio [HR]: 0.663; p < 0.001), IC + Sx (HR: 0.606; p = 0.005), or IC + Sx + ATx (HR: 0.468; p = 0.001) exhibited reduced mortality. Among patients who were treated with definitive surgery, those receiving IC had additional OS benefit (all p s < 0.05). Older age (odds ratio [OR]: 0.607; p < 0.001), female sex (OR: 0.759; p = 0.028), Black race (OR: 1.650; p < 0.001, T4b stage (OR: 1.674; p < 0.001), and higher N stage (OR: 1.395; p < 0.001) were predictors of IC. Conclusion IC prior to definitive surgery with or without adjuvant therapy exhibited the highest OS for locoregionally advanced SNSCC. Age, sex, race, and T/N staging were predictors of IC. Multimodal treatment regimens involving surgery as the primary modality may, therefore, provide the greatest therapeutic response.

The impact of nasal packing on skull base reconstruction and quality-of-life outcomes following endoscopic skull base surgery.

KEY POINTS: Nasal packing type was not associated with postoperative cerebrospinal fluid leaks Nondissolvable packing conferred an increased risk for postoperative sinonasal infections Nasal packing type did not influence short- and long-term quality-of-life scores.

Severe unilateral refractory epistaxis arising from the septal branch of the anterior ethmoid artery.

KEY POINTS: The septal branch of the anterior ethmoid artery (sbAEA) is an underrecognized source of severe refractory epistaxis. Herein, we describe the presentation, predisposing factors, treatment strategies, and outcomes of a series of patients with this condition.

Predictors of length of postoperative stay following endoscopic skull base surgery with intraoperative CSF leak.

OBJECTIVE: Establishing benchmarks for length of stay (LOS) may inform strategies to improve resource efficiency, decrease costs, and advance care quality. In this study, the authors characterize postoperative LOS in endoscopic skull base surgery (ESBS) and elucidate prolonging factors. METHODS: A retrospective chart review was conducted at a tertiary academic center including consecutive adult patients who underwent intradural ESBS with intraoperative CSF leak during primary repair between July 2018 and March 2024. LOS, calculated as the time between the end of anesthesia until discharge from the hospital, comprised the primary outcome. Categorical and continuous independent study variables were assessed for univariate LOS association via the Mann-Whitney U-test and Kendall's tau-b correlation, respectively, and those with significant associations were included as multiple linear regression inputs. RESULTS: One hundred sixty-three patients were included, with a median LOS of 4.0 (interquartile range [IQR] 2.8-5.8) days. LOS was significantly prolonged in high-flow (n = 82) compared with low-flow (n = 81) CSF leak cohorts (median 4.5 [IQR 3.9-6.5] vs 2.9 [IQR 2.1-4.7] days, p = 0.002). Defects involving the anterior cranial fossa (n = 16, median 4.6 [IQR 3.3-7.5)] days), suprasellar region (n = 94, median 4.4 [IQR 3.2-6.4] days), sella (n = 138, median 3.9 [IQR 2.8-5.8] days), or posterior cranial fossa (n = 17, median 4.5 [IQR 3.9-6.5] days) had variable LOSs. On multiple linear regression, after controlling for numerous patient, surgical, and postoperative factors, lesion diameter (B = 0.16, 95% CI 0.048-0.26), bone defect area (B = 0.008, 95% CI 0.001-0.014), anesthesia time (B = 0.015, 95% CI 0.004-0.026), bed rest length (B = 2.34, 95% CI 1.12-3.56), postoperative CSF leak (B = 11.06, 95% CI 4.11-18.01), postoperative meningitis (B = 11.79, 95% CI 4.83-18.74), postoperative stroke/hemorrhage (B = 25.25, 95% CI 18.43-32.06), and postoperative pneumonia (B = 5.59, 95% CI 0.79-10.38) independently predicted overall prolonged LOS. CONCLUSIONS: With healthcare utilization receiving increased attention, mitigating factors that extend LOS are important. Extent of surgery and certain postoperative complications may constitute key factors prolonging LOS following intradural ESBS with intraoperative CSF leak.

Surgical Care Through a Community Free Clinic-Ambulatory Surgical Center Partnership.

BACKGROUND: Disparities secondary to underinsurance present throughout the surgical care continuum. Community free clinics are uniquely capable to provide health care services to the medically underserved, but surgery often falls outside their scope of care. METHODS: Retrospective chart review was conducted on consecutive community free clinic patients receiving free surgical services via referral to a partnering ambulatory surgery center between March 2016 and September 2021. Those with documented contact information were recruited 1-3 years post-procedure for long-term quality-of-life (LTQOL) outcomes assessment via modified Veterans RAND 12-item health survey. RESULTS: Of 142 included patients, 95.7% identified as Hispanic/Latino and 75.6% were uninsured. Twelve patients had cancerous or precancerous lesions detected and/or removed through diagnostic or definitive procedures. 3.5% experienced postoperative complication including bacterial (n = 2) or fungal (n = 1) surgical site infection and wound dehiscence (n = 2). With a 48.9% response rate, no significant differences in sociodemographic or clinical characteristics were found between surveyed vs non-surveyed patients. Of surveyed patients, 59.7% and 52.2% reported pre-/post-operative improvement in physical health and emotional health, respectively. DISCUSSION: Free diagnostic screening procedures provided timely diagnoses while free definitive surgeries safely and positively impacted long-term patient-reported physical health. Longitudinal, multidisciplinary follow-up and social support may be warranted to concurrently improve emotional and mental health in similarly underinsured populations.

Tissue Sealant Impact on Skull Base Reconstruction Outcomes: A Systematic Review and Meta-Analysis.

OBJECTIVE: Despite significant advances in understanding of skull base reconstruction principles, the role of tissue sealants in modifying postoperative cerebrospinal fluid (CSF) leak outcomes remains controversial. We evaluate postoperative CSF leak incidence associated with tissue sealant use in skull base defect repair during endoscopic skull base surgery (ESBS). DATA SOURCES: Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library. REVIEW METHODS: Systematic review and meta-analysis of risk differences (RD). A search strategy identified original studies reporting CSF leakage following ESBS with disaggregation by tissue sealant use and/or type. RESULTS: 27 non-randomized studies (n = 2,403) were included for qualitative and meta-analysis. Reconstruction with a tissue sealant did not significantly reduce postoperative CSF leak risk compared with reconstruction without sealant (RD[95% CI] = 0.02[-0.01, 0.05]). Sub-analyses of dural sealant (-0.02[-0.11, 0.07]) and fibrin glue (0.00[-0.07, 0.07]) compared with no sealant were similarly unremarkable. Postoperative CSF leakage was not significantly modulated in further sub-analyses of DuraSeal (0.02[-0.02, 0.05]), Adherus (-0.03[-0.08, 0.03]), or Bioglue (-0.06[-0.23, 0.12]) versus no dural sealant use, or Tisseel/Tissucol versus fibrin glue nonuse (0.00[-0.05, 0.05]). No significant association was seen comparing dural sealant use versus fibrin glue use on pairwise (0.01[-0.03, 0.05]) or network meta-analysis (-0.01[-0.05, 0.04]). Limitations in source literature prevented sub-analyses stratified by leak characteristics, defect size and location, and accompanying reconstruction materials. CONCLUSION: Tissue sealant use did not appear to impact postoperative CSF leak incidence when compared with nonuse. Higher quality studies are warranted to thoroughly elucidate the clinical value of adjunct sealant use in endoscopic skull base reconstruction. LEVEL OF EVIDENCE: N/A Laryngoscope, 134:3425-3436, 2024.

Short-Term Bedrest is not a Risk Factor for Venous Thromboembolism after Endoscopic Skull Base Surgery.

INTRODUCTION: Deep venous thromboembolisms (DVT) increase morbidity in postoperative patients, and no current guidelines identify which patients undergoing endoscopic endonasal approach (EEA) to the skull base may be at increased risk. Postoperative care for these patients often includes a period of inactivity to prevent transient ICP shifts which may impact skull base reconstruction. We seek to characterize if postoperative bedrest puts EEA patients at increased risk of developing thromboembolic complications. METHODS: Retrospective chart review of patients undergoing intradural surgery with primary skull base reconstruction for intraoperative CSF leak via EEA for any skull base pathology between July 2018 and May 2024 was performed yielding 221 patients who met inclusion criteria. Univariate and multivariable regression were performed with patient demographics, extent of approach, intraoperative leak flow rate, bedrest duration, presence and length of postoperative lumbar drainage (LD), and use of postoperative mechanical VT prophylaxis. RESULTS: The mean age of included patients was 52.6 ± 16.8 years, 48% were male, and 3.6% of patients had DVTs. Age (OR 1.01, 95% CI 0.96-1.06, p=0.83), sex (OR 0.40, 95% CI 0.05-2.19, p=0.31), BMI (OR 0.98, 95% CI 0.87-1.07, p=0.74), extended approach (OR 0.80, 95% CI 0.13-4.36, p=0.80), CSF leak flow rate (OR 5.71, 95% CI 0.77-118.90, p=0.14), bedrest duration (OR 1.06, 95% CI 0.77-1.27, p=0.60), and presence of LD (OR 1.10, 95% CI 0.55-2.02, p=0.76) were not significant predictors of postoperative VTE incidence on multivariable analysis. CONCLUSION: Short-term bedrest after EEA is not a risk factor for development of VTE in the immediate postoperative period.

Intranasal Anticholinergics for Treatment of Chronic Rhinitis: Systematic Review and Meta-Analysis.

OBJECTIVE: Topical intranasal anticholinergics are commonly prescribed for the relief of chronic rhinitis and associated symptoms, warranting thorough assessment of the supporting evidence. The present study aimed to evaluate the safety and efficacy of anticholinergic nasal sprays in the management of allergic and non-allergic rhinitis symptom severity and duration. METHODS: A search encompassing the Cochrane Library, PubMed/MEDLINE, and Scopus databases was conducted. Primary studies describing rhinorrhea, nasal congestion, and/or postnasal drip outcomes in rhinitis patients treated with an anticholinergic spray were included for review. RESULTS: The search yielded 1,029 unique abstracts, of which 12 studies (n = 2,024) met inclusion criteria for qualitative synthesis and 9 (n = 1,920) for meta-analysis. Median follow-up was 4 weeks and ipratropium bromide was the most extensively trialed anticholinergic. Compared to placebo, anticholinergic treatment was demonstrated to significantly reduce rhinorrhea severity scores (standardized mean difference [95% CI] = -0.77 [-1.20, -0.35]; -0.43 [-0.72, -0.13]) and duration (-0.62 [-0.95, -0.30]; -0.29 [-0.47, -0.10]) in allergic and non-allergic rhinitis patients respectively. Benefit was less consistent for nasal congestion, postnasal drip, and sneezing symptoms. Reported adverse effects included nasal mucosa dryness or irritation, epistaxis, headaches, and pharyngitis, though comparison to placebo found significantly greater risk for epistaxis only (risk ratio [95% CI] = 2.19 [1.22, 3.93]). CONCLUSION: Albeit treating other symptoms with less benefit, anticholinergic nasal sprays appear to be safe and efficacious in reducing rhinorrhea severity and duration in both rhinitis etiologies. This evidence supports their continued use in the treatment of rhinitis-associated rhinorrhea. LEVEL OF EVIDENCE: 1 Laryngoscope, 133:722-731, 2023.

Facility Volume as a Prognosticator of Survival in Locally Advanced Papillary Thyroid Cancer.

OBJECTIVES: To evaluate the influence of facility case-volume on survival in patients with locally advanced papillary thyroid cancer (PTC), and to identify prognostic case-volume thresholds for facilities managing this patient population. STUDY DESIGN: Retrospective database study. METHODS: The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for locally advanced PTC. Using K-means clustering and multivariable Cox proportional-hazards (CPH) regression, two groups with distinct spectrums of facility case-volumes were generated. Multivariable CPH regression and Kaplan-Meier analysis assessed for the influence of facility case-volume and the prognostic value of its stratification on overall survival (OS). RESULTS: Of 48,899 patients treated at 1304 facilities, there were 34,312 (70.2%) females and the mean age was 48.0 ± 16.0 years. Increased facility volume was significantly associated with reduced all-cause mortality (HR 0.996; 95% CI, 0.992-0.999; p = 0.008). Five facility clusters were generated, from which two distinct cohorts were identified: low (LVF; <27 cases/year) and high (HVF; ≥27 cases/year) facility case-volume. Patients at HVFs were associated with reduced mortality compared to those at LVFs (HR 0.791; 95% CI, 0.678-0.923, p = 0.003). Kaplan-Meier analysis of propensity score-matched N0 and N1 patients demonstrated higher OS in HVF cohorts (all p < 0.001). CONCLUSIONS: Facility case-volume was an independent predictor of improved OS in locally advanced PTC, indicating a possible survival benefit at high-volume medical centers. Specifically, independent of a number of sociodemographic and clinical factors, facilities that treated ≥27 cases per year were associated with increased OS. Patients with locally advanced PTC may, therefore, benefit from referrals to higher-volume facilities. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:443-450, 2023.

Racial and ethnic disparities in the presentation size and timing of pituitary adenomas resected via endoscopic endonasal approach.

KEY POINTS: In a single-center cohort of pituitary adenoma patients, non-White race independently predicted larger tumor size at initial presentation. Uninsured patients suffered a significantly higher rate of pituitary apoplexy at initial presentation. Geographically distant care appeared to present a greater barrier for non-White and Hispanic patients relative to their White and non-Hispanic counterparts.

Outcomes of perioperative vasopressor use for hemodynamic management of patients undergoing free flap surgery: A systematic review and meta-analysis.

This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n = 3881, OR = 0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

Characteristics and Outcomes in Pediatric Versus Adult Craniopharyngiomas: A Systematic Review and Meta-Analysis.

BACKGROUND: Craniopharyngiomas account for 1.2% to 4.6% of all intracranial tumors. Although age at presentation is distributed bimodally, with a pediatric peak occurring between 5 and 15 years and an adult peak between 50 and 70 years, presentation, treatment, and outcome differences between these two craniopharyngioma populations have not been thoroughly characterized. OBJECTIVE: To compare treatments and outcomes between adult and pediatric craniopharyngiomas. METHODS: This is a systematic review and meta-analysis. Web of Science, MEDLINE, and Scopus databases were searched for primary studies reporting postoperative complications, functional outcomes, recurrence, and overall survival in patients with craniopharyngioma undergoing surgery. RESULTS: The search yielded 1,202 unique articles, of which 106 (n=4,202 patients) met criteria for qualitative synthesis and 23 (n=735 patients) met criteria for meta-analysis. Compared with adult, pediatric craniopharyngiomas were less likely to present with visual defects (odds ratio [OR] 0.54, 95% CI 0.36-0.80) or cognitive impairment (OR 0.29, 95% CI 0.12-0.71) and more likely with headaches (OR 2.08, 95% CI 1.16-3.73). Children presented with significantly larger tumors compared with adults (standardized mean difference 0.68, 95% CI 0.38-0.97). Comparing functional outcomes, pediatric patients sustained higher rates of permanent diabetes insipidus (OR 1.70, 95% CI 1.13-2.56), obesity (OR 3.15, 95% CI 1.19-8.31), and cranial nerve and/or neurological defects (OR 4.87, 95% CI 1.78-13.31) than adults. No significant differences were found in rates of postoperative cerebrospinal fluid leak, overall or progression-free survival, or recurrence. CONCLUSION: Adult and pediatric craniopharyngiomas seem to have fundamental differences in clinical presentation and functional outcomes. These patients frequently require multimodality treatment and are best managed with a multidisciplinary team and an individualized approach.

The Global Otolaryngology-Head and Neck Surgery Workforce.

Importance: A core component of delivering care of head and neck diseases is an adequate workforce. The World Health Organization report, Multi-Country Assessment of National Capacity to Provide Hearing Care, captured primary workforce estimates from 68 member states in 2012, noting that response rates were a limitation and that updated more comprehensive data are needed. Objective: To establish comprehensive workforce metrics for global otolaryngology-head and neck surgery (OHNS) with updated data from more countries/territories. Design, Setting, and Participants: A cross-sectional electronic survey characterizing the OHNS workforce was disseminated from February 10 to June 22, 2022, to professional society leaders, medical licensing boards, public health officials, and practicing OHNS clinicians. Main Outcome: The OHNS workforce per capita, stratified by income and region. Results: Responses were collected from 121 of 195 countries/territories (62%). Survey responses specifically reported on OHNS workforce from 114 countries/territories representing 84% of the world's population. The global OHNS clinician density was 2.19 (range, 0-61.7) OHNS clinicians per 100 000 population. The OHNS clinician density varied by World Bank income group with higher-income countries associated with a higher density of clinicians. Regionally, Europe had the highest clinician density (5.70 clinicians per 100 000 population) whereas Africa (0.18 clinicians per 100 000 population) and Southeast Asia (1.12 clinicians per 100 000 population) had the lowest. The OHNS clinicians deliver most of the surgical management of ear diseases and hearing care, rhinologic and sinus diseases, laryngeal disorders, and upper aerodigestive mucosal cancer globally. Conclusion and Relevance: This cross-sectional survey study provides a comprehensive assessment of the global OHNS workforce. These results can guide focused investment in training and policy development to address disparities in the availability of OHNS clinicians.

Otolaryngology residency programs' perspectives on virtual interviews during the COVID-19 pandemic.

Objective: To evaluate perceptions of otolaryngology residency program directors (PDs) and department chairs (DCs) on virtual interviews (VIs) at the conclusion of the 2021 residency match. Study design: Cross-sectional survey study. Methods: An anonymous and voluntary survey was administered to PDs and DCs of U.S. otolaryngology residency programs from March 1, 2021 to April 11, 2021. Utilizing Likert scale ratings, the survey measured overall satisfaction with the VI format, perceived ability to assess key candidate attributes, relative importance of traditional candidate metrics, and likelihood to implement VIs in future cycles. Results: Ninety-four surveys were completed by PDs (48.9%) and DCs (51.1%). Sixty (63.8%) respondents found the VI experience to be satisfactory or strongly satisfactory. Sixty-six (70.2%) respondents felt confident in their ability to assess a candidate's professionalism and communication skills through VIs; however, confidence in gauging an applicant's clinical skills/knowledge (41.2%) and overall program fit (47.3%) was lower. Regarding candidate metrics, 64 (68.1%) respondents believed that personal prior knowledge of the applicant gained increased importance with VIs. Forty-four (46.8%) and 45 (47.9%) participants believed that letters of recommendation in the specialty and perceived commitment to their program similarly attained increased significance in evaluating applicants, respectively. Conclusion: Most PDs and DCs were satisfied with their VI experiences and expect the quality of interns to be unaffected by virtual assessment modalities. Majority opinion on the relative importance of traditional applicant metrics remained largely unchanged, the exception being an increase in importance of prior knowledge of the applicant.Level of Evidence: N/A.

The Influence of Facility Volume and Type on Skull Base Chordoma Treatment and Outcomes.

OBJECTIVE: To evaluate the influence of facility case volume and type on skull base chordoma treatment and overall survival (OS). METHODS: The 2004-2016 National Cancer Database was queried for skull base chordoma patients receiving definitive treatment. Facilities were categorized into 2 cohorts by calculating the mean number of patients treated per facility and using cutoff numbers that were 0.5 SD above and below the computed mean to separate the groups. As, by definition of the inclusion criteria, all included facilities treated at least 1 patient, low-volume facilities were defined as treating 1 patient, and high-volume facilities were defined as treating ≥7 patients; mid-volume facilities (facilities treating ≥2 but ≤6 patients) were excluded. Differences in treatment course, outcomes, and OS by facility type were assessed. RESULTS: The study included 658 patients (44.8% female, 79.5% White). The 187 unique facilities were categorized into 95 low-volume facilities (treating 1 patient during timeline) and 26 high-volume facilities (treating ≥7 patients during timeline). Kaplan-Meier log-rank analysis demonstrated a significant positive association between facility volume and OS (P < 0.001) and an improvement in OS in patients at academic facilities (P = 0.018). On Cox proportional hazards multivariate regression after adjusting for sex, age, Charlson-Deyo comorbidity index, and insurance type, high-volume facilities and academic facilities were associated with a lower mortality risk than low-volume facilities and nonacademic facilities (P < 0.001 and P = 0.03, respectively). CONCLUSIONS: Higher facility case volume and academic facility type appear to be associated with improved survival outcomes in treatment of skull base chordomas.

Prognostic Factors and Outcomes of De Novo Sinonasal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis.

OBJECTIVE: To review overall survival (OS), recurrence patterns, and prognostic factors of de novo sinonasal squamous cell carcinoma (DN-SCC). DATA SOURCES: PubMed, Scopus, OVID Medline, and Cochrane databases from 2006 to December 23, 2020. REVIEW METHODS: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Articles were required to report either recurrence patterns or survival outcomes of adults with DN-SCC. Case reports, books, reviews, meta-analyses, and database studies were all excluded. RESULTS: Forty-one studies reported on survival or recurrence outcomes. The aggregate 5-year OS was 54.5% (range, 18%-75%) from 35 studies (n = 1903). Patients undergoing open surgery were more likely to receive radiation therapy and present at an advanced stage compared to those receiving endoscopic surgery (all P < .001). Advanced T stage, presence of cervical nodal metastases, maxillary sinus primary site, and negative human papillomavirus (HPV) status were all correlated with significantly worse 5-year OS. Direct meta-analysis of 8 studies demonstrated patients with surgery were more likely to be alive at 5 years compared to those who did not receive surgery (odds ratio, 2.26; 95% CI, 1.48-3.47; P < .001). Recurrence was reported in 628 of 1471 patients from 26 studies (42.7%) with an aggregate 5-year locoregional control rate of 67.1% (range, 50.4%-93.3%). CONCLUSION: This systematic review and meta-analysis suggests that the 5-year OS rate for DN-SCC may approach 54.5% and recurrence rate approaches 42.7%. In addition, various tumor characteristics including advanced T stage, positive nodal status, maxillary sinus origin, and negative HPV status are all associated with decreased survival.

Long-term outcomes in sinonasal squamous cell carcinoma arising from inverted papilloma: Systematic review.

Long-term survival and recurrence patterns of squamous cell carcinoma arising from inverted papilloma (IP-SCC) have not been thoroughly investigated. Four electronic databases were searched and primary studies describing overall survival (OS), recurrence, and mean time to recurrence of patients with IP-SCC were included for review. Our search yielded 662 studies. The 28 studies selected for inclusion identified 663 patients with IP-SCC. In 596 patients with reported T classification, 439 (73.7%) were T3/T4 on presentation. Of the 650 participants with recurrence data (local, regional, and distant), 155 (23.8%) experienced a recurrence, with an aggregate mean time-to-recurrence of 24.3 months. In 565 patients with 5-year OS rates, the aggregate 5-year OS was 62%. Based on the literature to date, IP-SCC is associated with a 5-year OS rate of 62%. 23.8% of patients experienced recurrence at a mean time of 24.3 months, suggesting the need for long-term surveillance.

A Web-Based Deep Learning Model for Automated Diagnosis of Otoscopic Images.

OBJECTIVES: To develop a multiclass-classifier deep learning model and website for distinguishing tympanic membrane (TM) pathologies based on otoscopic images. METHODS: An otoscopic image database developed by utilizing publicly available online images and open databases was assessed by convolutional neural network (CNN) models including ResNet-50, Inception-V3, Inception-Resnet-V2, and MobileNetV2. Training and testing were conducted with a 75:25 breakdown. Area under the curve of receiver operating characteristics (AUC-ROC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to compare different CNN models' performances in classifying TM images. RESULTS: Our database included 400 images, organized into normal (n = 196) and abnormal classes (n = 204), including acute otitis media (n = 116), otitis externa (n = 44), chronic suppurative otitis media (n = 23), and cerumen impaction (n = 21). For binary classification between normal versus abnormal TM, the best performing model had average AUC-ROC of 0.902 (MobileNetV2), followed by 0.745 (Inception-Resnet-V2), 0.731 (ResNet-50), and 0.636 (Inception-V3). Accuracy ranged between 0.73-0.77, sensitivity 0.72-0.88, specificity 0.58-0.84, PPV 0.68-0.81, and NPV 0.73-0.83. Macro-AUC-ROC for MobileNetV2 based multiclass-classifier was 0.91, with accuracy of 66%. Binary and multiclass-classifier models based on MobileNetV2 were loaded onto a publicly accessible and user-friendly website (https://headneckml.com/tympanic). This allows the readership to upload TM images for real-time predictions using the developed algorithms. CONCLUSIONS: Novel CNN algorithms were developed with high AUC-ROCs for differentiating between various TM pathologies. This was further deployed as a proof-of-concept publicly accessible website for real-time predictions.