Unilateral Tonsillar Enlargement as Initial Presentation of Bilateral Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma.

Unilateral tonsillar enlargement is a common indication for tonsillectomy, but there are varying rates of malignancy among tonsils removed for asymmetry and a lack of clear guidelines for management within the literature. Lymphoma of the palatine tonsils is among the concerns leading to tonsillectomy, but chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) of the tonsil is rare. We report a case of primary CLL/SLL of the palatine tonsil in a 51-year-old gentleman who presented with tonsillar asymmetry and obstructive sleep apnea (OSA) but lacked signs and symptoms suspicious for malignancy, including lymphadenopathy and "B-symptoms." To our knowledge, only 7 cases of CLL/SLL of the palatine tonsil have been reported in the English literature, with the tonsil being the primary site of involvement in only 4 of those cases. Our unique case highlights the importance of thorough physical exam, family history, and tissue biopsy in patients presenting to the otolaryngologist with OSA and asymmetric tonsils.

Emergency abdominal surgery in patients presenting from skilled nursing facilities: Opportunities for palliative care.

BACKGROUND: Residents of skilled nursing facilities (SNF) with acute abdomen present with more comorbidities and frailty than community-dwelling (CD) counterparts. Outcomes in this population are poorly described. METHODS: We hypothesized that SNF patients have higher mortality and morbidity than CD patients. This retrospective review of the NSQIP database from 2011 to 2015 compared outcomes of SNF and CD patients presenting with bowel obstruction, ischemia and perforation. Primary outcomes were in-hospital and 30-day mortality and failure-to-rescue (FTR). RESULTS: 18,326 patients met inclusion criteria. 904 (5%) presented from SNF. In-hospital (26% vs 10%) and 30-day mortality (33% vs 26%) was higher in SNF patients (p < 0.001). The FTR rate was 34% for SNF patients and 20% for CD patients (p < 0.001). CONCLUSIONS: Presentation from SNF is an independent predictor of mortality and FTR. Presentation from SNF is a potential trigger for early, concurrent palliative care to assist surgeons, patients, and families in decision making and goal-concordant treatment.

Morbidity and mortality associated with ventral skull base surgery: analysis of the National Surgical Quality Improvement Program.

BACKGROUND: Ventral skull base (VSB) surgery has associated morbidity and mortality that is poorly defined. In this study we aim to identify factors associated with adverse events in VSB surgery. METHODS: We queried the database of the American College of Surgeons National Surgical Quality Improvement Program for cases of VSB surgery during the period 2005-2014. Patients with complications, readmissions, reoperations, or mortality were compared to those without adverse events. RESULTS: Nine hundred patients were included; 253 (28.1%) had complications, underwent reoperation, were readmitted, or died. These patients were older (42.6% vs 32.8, p = 0.032) and had higher rates of congestive heart failure (CHF) (3.2% vs 0.2%, p < 0.0001), disseminated cancer (8.3% vs 4.6%, p = 0.032), and preoperative sepsis (8.7% vs 2.2%, p < 0.0001). Other comorbidities included long-term steroid use (13.4% vs 9.0%, p = 0.046) and higher rates of preoperative transfusion (2.4% vs 0%, p < 0.0001). The most common complication was bleeding (13.7%). Preoperative systemic sepsis (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.0-6.6) and lower hematocrit (OR, 2.1; 95% CI, 1.4-3.4) were more likely to be associated with a complication. Those with disseminated cancer (OR, 12.0; 95% CI, 2.9-50.5) were more likely to experience 30-day mortality. Black patients had lower rates of reoperation (OR, 0.3; 95% CI, 0.1-0.8), whereas patients with CHF (OR, 12.6; 95% CI, 1.7-94.4) and hypertension (OR, 2.1; 95% CI, 1.1-4.0) had higher rates of reoperation. Predictors of extended length of stay were Hispanic ethnicity (OR, 2.2; 95% CI, 1.2-4.1) and lower hematocrit (OR, 2.3; 95% CI, 1.5-3.6). CONCLUSION: VSB surgery can involve significant morbidity and mortality, and thus identifying risk factors allows for better prognostication and delivery of care in these patients.

Patients with End-Stage Renal Disease and Acute Surgical Abdomen: Opportunities for Palliative Care.

Background: End-stage renal disease (ESRD) is a life-limiting condition that is often complicated by acute abdominal emergency. Palliative care (PC) has been shown to improve the quality of life in patients with serious illness and yet is underutilized. We hypothesize that ESRD patients with abdominal emergency have high unmet PC needs. Objective: To characterize the outcomes of ESRD patients with acute surgical abdomen, define PC utilization patterns, and identify areas of unmet PC needs. Design: Retrospective study querying the National Inpatient Sample database (2009-2013). Setting and Subjects: Subjects were identified using ICD-9 codes for those aged ≥50 with preexisting diagnosis of ESRD with an acute abdominal emergency diagnosis of gastrointestinal perforation, obstruction, or ischemia. Measurements: Outcomes included PC rate, in-hospital mortality, discharge disposition, and intensity of care. Multivariable logistic regression analysis was used to identify predictors of PC. Results: A total of 9363 patients met the inclusion criteria; 24% underwent surgery, 16% died in hospital, and 43% were discharged to dependent living. Among in-hospital deaths, 23% received PC. Only 4% of survivors with dependent discharge received PC. Surgical mortality was 26%. PC was less utilized in surgical patients than nonsurgical patients. PC was associated with shorter hospital stay. Predictors of PC included increasing age, severity of underlying illness, white race, teaching hospitals, and the Western region. Conclusions: Patients with ESRD admitted for acute abdominal emergency have high risk for mortality and functional dependence. Despite this, few receive PC and have a high utilization of nonbeneficial life support at the end of life.

Outpatient versus inpatient parotidectomy: Comparison of postoperative complication rates.

OBJECTIVES: Parotidectomies have become a common outpatient procedure, but their impact on postoperative complications as compared to inpatient procedures has not been evaluated in a multi-institutional study. STUDY DESIGN: The aim of this retrospective analysis was to evaluate the differences in outcomes using a standardized cohort of patients undergoing outpatient or inpatient parotidectomies. METHODS: The National Surgical Quality Improvement Program database was queried for parotidectomies between 2005 and 2014. Univariate analyses were conducted to compare the outpatient and inpatient cohorts. A propensity-matching algorithm was used to ensure equal distribution of demographics and preoperative comorbidities. RESULTS: Among the 4,368 parotidectomies examined, 2,915 (66.7%) were outpatient and 1,453 (33.3%) were inpatient. In the unmatched analysis, the inpatient group had higher rates of smokers (P = < 0.001), hypertension (P = 0.003), and disseminated cancer (P = 0.014). The outpatient group had higher rates of patients under age 40 years (P = 0.015), females (P = 0.016), and American Society of Anesthesiology class 1 and 2 (P = < 0.001). The total work relative value units (RVUs) were 17.01 ± 3.44 for the inpatient cohort and 16.19 ± 3.70 for the outpatient cohort (P = < 0.001). Following propensity matching, 1,352 cases were selected for each cohort, with no significant differences in comorbidities. Total work RVU after matching was 16.90 ± 3.47 for the inpatient group and 16.75 ± 3.44 for the outpatient group (P = .235). The matched inpatient cohort had increased rates of surgical complications (3.1% vs. 1.8%, P = 0.033), pneumonia (0.5% vs. 0.0%, P = 0.016), and overall complications (4.5% vs. 2.6%, P = 0.009). CONCLUSION: Outpatient parotidectomies are associated with similar as well as decreased complication rates as compared to inpatient parotidectomies. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:655-661, 2019.

Outcomes and palliative care utilization in patients with dementia and acute abdominal emergency: opportunities for surgical quality improvement.

BACKGROUND: When patients with dementia develop acute surgical abdomen, patients, surrogates, and surgeons need accurate prognostic information to facilitate goal-concordant decision making. Palliative care can assist with communication, symptom management, and family and caregiver support in this population. We aimed to characterize outcomes and patterns of palliative care utilization among patients with dementia, presenting with abdominal surgical emergency. METHOD: We retrospectively queried the National Inpatient Sample for patients aged >50 years with dementia and acute abdominal emergency who were admitted nonelectively 2009-2013, utilizing ICD-9-CM codes for dementia and surgical indication. We characterized outcomes and identified predictors of palliative care utilization. RESULTS: Among 15,209 patients, in-hospital mortality was 10.2%, the nonroutine discharge rate was 67.2%, and 7.5% received palliative care. Patients treated operatively were less likely to receive palliative care than those who did not undergo operation (adjusted OR = 0.50; 95% CI 0.41-0.62). Only 6.4% of patients discharged nonroutinely received palliative care. CONCLUSION: Patients with dementia and acute abdominal emergency have considerable in-hospital mortality, a high frequency of nonroutine discharge, and low palliative care utilization. In this group, we discovered a large gap in palliative care utilization, particularly among those treated operatively and those who are discharged nonroutinely.