Assessment of Biomarker Heterogeneity in Sinus Versus Inferior Turbinate Tissue in Patients Without Chronic Rhinosinusitis.

BACKGROUND: Currently, no consensus exists on the appropriate control specimen site to utilize in studies evaluating for biomarkers in chronic rhinosinusitis (CRS). Studies thus far have utilized tissue from various anatomic sites despite regional heterogeneity. OBJECTIVE: We set out to quantify the differences in biomarker levels present in inferior turbinate versus sphenoid sinus mucosa in paired healthy control patients. We hypothesize that statistically significant differences in cytokine/chemokine expression exist between these two distinct sites. METHODS: A 38-plex commercially available cytokine/chemokine Luminex Assay was performed on 54 specimens encompassing paired inferior turbinate and sphenoid sinus mucosa samples from 27 patients undergoing endoscopic anterior skull base surgery. Patients with a history of CRS were excluded. Paired sample t-tests and Fisher's exact tests were performed. RESULTS: Twenty-seven patients were included in the study, including 10 male and 17 female patients with an average age of 48 years. The following 8 biomarkers had statistically significant concentration differences between inferior turbinate mucosa and sphenoid mucosa sites: Flt-3L, Fractalkine, IL-12p40, IL-1Ra, IP-10, MCP-1, MIP-1ß, and VEGF, with all P-values <0.01. CONCLUSION: No consensus exists regarding the optimal choice of control specimen for CRS research. We present statistically significant quantitative differences in biomarker levels between paired inferior turbinate and sphenoid mucosa samples. This confirms the presence of heterogeneity between different subsites of sinonasal mucosa and highlights the need for standardization in future CRS research.

National Analysis of 30-Day Readmission Following Inpatient Sinus Surgery for Chronic Rhinosinusitis.

OBJECTIVES: To characterize the incidence, causes, risk factors, and costs of 30-day readmission after inpatient functional endoscopic sinus surgery (FESS) for patients with chronic rhinosinusitis. STUDY DESIGN: Retrospective cohort study. METHODS: The Nationwide Readmissions Database was used to characterize readmission after inpatient sinus surgery for chronic rhinosinusitis from 2015 to 2017. International Classification of Disease codes were used to identify the patient population, which included 5,644 patients. Incidence, causes, costs, and predictors of readmission were analyzed and determined. RESULTS: Among 6,386 patients who underwent inpatient FESS, 742 (11.6%) were readmitted within 30 days of discharge. On univariate analysis, patients who were readmitted were more commonly older than 70 years (23.3% vs. 16.2%); had a higher burden of comorbidities including chronic kidney disease (15.0% vs. 7.8%), diabetes (25.6% vs. 20.4%), and hypertension (13.5% vs. 8.5%); had a greater rate of postoperative complications (20.7% vs. 12.2%); and had a longer length of stay (12.4 vs. 6.9 days) compared to patients who were not readmitted. Readmissions cost an additional $27,141 per patient. On multivariable analysis, age greater than 70 years, Medicaid insurance, several comorbidities, prolonged length of stay, postoperative neurologic complications, and lower hospital volume were independent predictors of 30-day readmission. The most common cause for readmission was infection (36.3%). CONCLUSION: Readmission following inpatient FESS is not uncommon. Identification and management of preoperative comorbidities, optimized patient selection for inpatient surgery, and thorough postoperative discharge care may improve patient outcomes and decrease healthcare expenditures. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E1422-E1428, 2021.

Nationwide analysis of unplanned 30-day readmissions after transsphenoidal pituitary surgery.

BACKGROUND: Transsphenoidal pituitary surgery has evolved into a safe procedure with shorter hospitalizations, yet unplanned readmissions remain a quality measure for which there is a paucity of data. We sought to examine rates, timing, etiologic factors, and costs surrounding readmission after transsphenoidal pituitary surgery. METHODS: The Nationwide Readmissions Database (NRD) was queried for patients who underwent transsphenoidal pituitary between January 2013 and November 2013. Patient, procedure, admission, and hospital-level characteristics were compared for patients with and without unplanned 30-day readmission. Multivariate logistic regression was used to identify readmission predictors. A total of 8546 patients were included in this retrospective study. RESULTS: A total of 8546 patients with a median age of 54 years and female predominance were identified, with 742 patients experiencing at least 1 unplanned readmission within 30 days of index admission. Hypertension, hypothyroidism, diabetes, and obesity were common comorbidities among readmitted patients. Readmission was most frequently because of nervous system complications, followed by neurohypophyseal or electrolyte disorders, cerebrospinal fluid leak, hemorrhage, and meningitis. Median length and cost of stay of index admission was greater in the readmission group (p < 0.001). Fluid and electrolyte disorders as well as neurologic disease (most commonly epilepsy or convulsions) present on initial admission were predictive of length of initial stay and readmission (p < 0.001). Median readmission cost was $7723 and was expected to occur within 7 days. CONCLUSION: Approximately 8.7% of patients undergoing transsphenoidal pituitary surgery experience an unplanned readmission within 30 days of discharge. Risk factors identified should be considered to reduce preventable readmissions and identify medically complex patients.

Predictors, costs, and causes of readmission after surgery for sinonasal cancer: a national perspective.

BACKGROUND: Hospital readmissions are an increasingly scrutinized marker of surgical care delivery and quality. There is a paucity of information in the literature regarding the rate, risk factors, and common causes of readmission after surgery for sinonasal cancer. METHODS: We analyzed the Nationwide Readmissions Database for patients who underwent surgery for a diagnosis of sinonasal cancer between 2010 and 2014. Rates, causes, and patient-, procedure-, and hospital-level risk factors for 30-day readmission were determined. Multivariate logistic regression was used to identify predictors of 30-day readmission. RESULTS: Among the 4173 cases, the 30-day readmission rate was 11.6%, with an average cost per readmission of $18,403. The most common readmission diagnoses were wound complications (15.3%) and infections (13.4%). On multivariate regression, significant risk factors for readmission were chronic renal failure (odds ratio [OR], 2.95; 95% confidence interval [CI], 1.41-6.17), involvement of the skull base or orbit (OR, 1.67; 95% CI, 1.11-2.51), nonelective initial surgical admission (OR, 2.35; 95% CI, 1.42-3.89), and length of stay ≥7 days (OR, 1.87; 95% CI, 1.14-3.05). CONCLUSION: Through the use of a large national database, we found that approximately 1 in 9 patients undergoing surgery for sinonasal cancer was readmitted within 30 days. Readmissions were most commonly associated with wound complications and infections. Factors related to procedural complexity were more important predictors of readmission than patients' demographics or comorbidities.

Assessing the cost of contemporary pituitary care.

OBJECT: Knowledge of the costs incurred through the delivery of neurosurgical care has been lagging, making it challenging to design impactful cost-containment initiatives. In this report, the authors describe a detailed cost analysis for pituitary surgery episodes of care and demonstrate the importance of such analyses in helping to identify high-impact cost activities and drive value-based care. METHODS: This was a retrospective study of consecutively treated patients undergoing an endoscopic endonasal procedure for the resection of a pituitary adenoma after implementation and maturation of quality-improvement initiatives and the implementation of cost-containment initiatives. RESULTS: The cost data pertaining to 27 patients were reviewed. The 2 most expensive cost activities during the index hospitalization were the total operating room (OR) and total bed-assignment costs. Together, these activities represented more than 60% of the cost of hospitalization. Although value-improvement initiatives contributed to the reduction of variation in the total cost of hospitalization, specific cost activities remained relatively variable, namely the following: 1) OR charged supplies, 2) postoperative imaging, and 3) use of intraoperative neuromonitoring. These activities, however, each contributed to less than 10% of the cost of hospitalization. Bed assignment was the fourth most variable cost activity. Cost related to readmission/reoperation represented less than 5% of the total cost of the surgical episode of care. CONCLUSIONS: After completing a detailed assessment of costs incurred throughout the management of patients undergoing pituitary surgery, high-yield opportunities for cost containment should be identified among the most expensive activities and/or those with the highest variation. Strategies for safely reducing the use of the targeted resources, and related costs incurred, should be developed by the multidisciplinary team providing care for this patient population.

Radiologic assessment of the paranasal sinuses after endoscopic skull base surgery.

Objectives To identify sinuses demonstrating postoperative radiographic mucosal thickening after endoscopic exposure of the cranial base through the transsphenoidal corridor. Design Retrospective review. Setting University-based medical center. Participants Patients undergoing endoscopic transnasal transsphenoidal approaches to the skull base who had both preoperative and postoperative imaging. Main Outcome Measures Change in preoperative and postoperative imaging scores for each sinus and side at 3 and 6 months. The left-sided undissected sinuses served as internal controls for comparison. Results Fifty-one patients were identified with the aforementioned inclusion and exclusion criteria. The mean difference in preoperative and postoperative imaging scores for the right anterior ethmoid sinus was significantly different from the left-sided equivalents (p = 0.0020). The difference in the frontal sinuses approached significance (p = 0.0625). Conclusions Resection of the lower half of the middle turbinate and maxillary antrostomy and harvest of a nasoseptal flap are associated with an increased radiographic incidence of mucosal thickening of the ipsilateral anterior ethmoids compared with the undissected contralateral side. When accessing the transnasal transsphenoidal corridor for skull base surgery, preservation of native anatomy is associated with a lower incidence of mucosal thickening on postoperative imaging.

Incidence and management of epistaxis after endoscopic skull base surgery.

BACKGROUND/AIMS: Endonasal endoscopic surgery continues to gain acceptance as a minimally invasive, effective approach for benign and malignant pathology of the paranasal sinuses and skull base. Postoperative epistaxis could potentially result in rapid and devastating consequences due to hemorrhage. Our objective was to assess the incidence and causes of epistaxis after endoscopic skull base surgery. METHODS: Retrospective review of patients undergoing endoscopic skull base surgeries from 2007 to 2012. The main outcome measure was epistaxis requiring a visit to a hospital or clinic occurring within 30 days of surgery. RESULTS: In our cohort of 330 consecutive patients, 10 (3%) experienced postoperative epistaxis, including 3 who had multiple episodes (14 events). A majority of the patients were controlled with packing in the emergency room (8/14 events). One patient required chemical cautery and 5 required control in the operating room. The only patient characteristic that reached significance was abstinence from alcohol (p value = 0.04). However, patients with epistaxis were more likely to be male, older and have hypertension. CONCLUSION: This study confirms that the risk of epistaxis after endoscopic skull base surgery is low and similar to sinonasal surgery for inflammatory conditions.

Standard chemoradiation versus intensity-modulated chemoradiation: a quality of life assessment in oropharyngeal cancer patients.

This study is based on the context that many patients with advanced oropharyngeal carcinoma are being treated with primary chemoradiation. The aims of this study are to identify differences in quality of life (QOL) between patients with advanced oropharyngeal cancer following traditional chemoradiation versus chemotherapy with intensity-modulated radiation therapy (CIMRT). This research is designed on a cohort study from an academic tertiary referral center. Fifty patients were identified from an institutional database of patients who had undergone primary chemotherapy and radiation (traditional or IMRT) for advanced oropharyngeal carcinoma. Patients responded via mail using the University of Washington quality of life instrument version 4. Statistical analysis of data was performed using Chi-square and Wilcoxon tests. The results comprise the responses of 17 CRT (57%) and 14 CIMRT (70%) patients. The patients completed the survey between 9 and 44 months following end of treatment. When adjusted for tumor stage and time since treatment, CIMRT patients reported improved appearance (p = 0.05), chewing (p = 0.02), and mood (p = 0.01). There was a trend toward significance for improved activity (p = 0.07), recreation (p = 0.07), and anxiety (p = 0.08). There were no differences between the two groups for saliva, taste, shoulder function, speech, and swallowing. But there was a trend for significance for improved overall QOL in patients who had undergone CIMRT (p = 0.06). In conclusion, CIMRT results in improved QOL for some domains but surprisingly not for swallowing or saliva. Patients undergoing CIMRT also report slightly better QOL overall when compared to patients receiving more traditional forms of radiation therapy.