Active Versus Passive Transcutaneous Bone Conduction Hearing Devices: A Systematic Review and Meta-Analysis.

OBJECTIVES: Active and passive transcutaneous devices (tBCHDs) have been introduced in an effort to address complication concerns with percutaneous devices. Direct comparison of active and passive devices through evidence synthesis practices is incomplete. This systematic review and meta-analysis sought to synthesize and compare available evidence on audiological, quality of life, and complication-related outcomes of active and passive tBCHDs. DESIGN: MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL were searched from inception to September 23, 2019. Observational and experimental studies investigating active or passive tBCHDs in adults were eligible. Studies were screened independently in duplicate. This study is reported in accordance with the PRISMA guidelines. Risk of bias and quality assessments were completed using the Newcastle-Ottawa Scale and the Quality Appraisal Tool for Case Series. Meta-analysis was performed with random-effects models. Audiological outcomes included changes in pure-tone average, functional hearing, and high-frequency hearing. Quality of life outcomes included patient-reported results. Complications included minor, major, and total complications experienced. RESULTS: One thousand five hundred forty-two nonduplicate articles were screened. Twenty-eight studies were included. Quality of included studies was low overall. The pooled complication rate for active devices was 14.8% (95% confidence interval: 0.09-0.21, I2: 0%). The pooled improvement in functional hearing for active devices among those with mixed or conductive hearing loss was 31.8 dB (95% confidence interval: 27.7-35.9, I2: 44.6). Improvement in functional hearing ranged from 25.2 to 44.3 dB for passive devices. Active devices provided improved high-frequency hearing compared to passive devices: the weighted average hearing gains at 2, 3, 4, and 6 kHz were 26.5, 25.7, 31.8, and 34.3 dB for active devices and 26.2, 21.1, 16.8, and 6.4 dB for passive devices, respectively. Both device types demonstrated improvement in ease of communication, reverberation, and understandability in background noise. CONCLUSIONS: Both active and passive tBCHDs demonstrate acceptable safety profiles and QoL improvements. Active devices may provide better hearing outcomes, especially in high frequencies, but high-quality comparative studies are lacking. Future work is needed in this regard.

Elective neck dissection versus positron emission tomography-computed tomography-guided management of the neck in clinically node-negative early oral cavity cancer: A cost-utility analysis.

BACKGROUND: In early oral cavity cancer, elective neck dissection (END) for the clinically node-negative (cN0) neck improves survival compared with observation. This paradigm has been challenged recently by the use of positron emission tomography-computed tomography (PET-CT) imaging in the cN0 neck. To inform this debate, we performed an economic evaluation comparing PET-CT-guided therapy with routine END in the cN0 neck. METHODS: Patients with T1-2N0 lateralized oral tongue cancer were analyzed. A Markov model over a 40-year time horizon simulated treatment, disease recurrence, and survival from a US health care payer perspective. Model parameters were derived from a review of the literature. RESULTS: The END strategy was dominant, with a cost savings of $1576.30 USD, an increase of 0.055 quality-adjusted life years (QALYs), a net monetary benefit of $4303 USD, and a 0.22 life-year advantage. END was sensitive to variation in cost and utilities in deterministic and probabilistic sensitivity analyses. PET-CT became the preferred strategy when decreasing occult nodal disease to 18% and increasing the negative predictive value (NPV) of PET-CT to 89% in 1-way sensitivity analyses. In probabilistic sensitivity analysis, assuming a cost effectiveness threshold of $50,000 USD/QALY, END was dominant in 64% of simulations and cost effective in 69.8%. CONCLUSION: END is a cost-effective strategy compared with PET-CT in patients who have node-negative oral cancer. Although lower PET standardized uptake value thresholds would result in fewer false negatives and improved NPV, it is still uncertain that PET-CT would be cost effective, as this would likely result in more false positive tests.

A cost-utility analysis comparing CT surveillance, PET-CT surveillance, and planned postradiation neck dissection for advanced nodal HPV-positive oropharyngeal cancer.

BACKGROUND: The cost utility of image-guided surveillance using computed tomography (CT) and positron emission tomography (PET)-CT to planned postradiation neck dissection (PRND) was compared for the management of advanced nodal human papillomavirus-positive oropharyngeal cancer following chemoradiation. METHODS: A universal payer perspective was adopted. A Markov model was designed to simulate four treatment approaches with 3-month cycles over a lifetime horizon: 1) CT surveillance, 2) standard PET-CT surveillance, 3) a novel PET-CT approach with repeat PET at 6 months postchemoradiation for equivocal responders, and 4) PRND. Parameters including probabilities of CT nodal progression/resolution, PET avidity, recurrence, and survival were obtained from the literature. Costs were reported in 2019 Canadian dollars and utilities were expressed in quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty. RESULTS: PET-CT surveillance dominated CT surveillance and PRND in the base case scenario, and the novel PET-CT approach was the most cost-effective strategy across a wide range of variables tested in one-way sensitivity analysis. On probabilistic sensitivity analysis, novel PET-CT surveillance was the most cost-effective strategy in 78.1% of model iterations at a willingness-to-pay of $50,000/QALYs. Novel PET-CT surveillance resulted in a 49% lower rate of neck dissection compared with traditional PET-CT, and yielded an incremental benefit of 0.14 QALYs with average cost savings of $1309. CONCLUSIONS: Image-guided surveillance including PET-CT and CT are more cost effective than PRND. The novel PET-CT approach with repeat PET for equivocal responders was the dominant strategy and yielded both higher benefit and lower costs compared with standard PET-CT surveillance.

Psychometric testing of the Skull Base Inventory health-related quality of life questionnaire in a multi-institutional study of patients undergoing open and endoscopic surgery.

PURPOSE: The skull base inventory (SBI) was developed to better assess health-related quality of life (HR-QOL) in patients with anterior and central skull base neoplasms treated by endoscopic and open approaches. The primary objective of this study was to prospectively assess the psychometric properties of the SBI. METHODS: This study is part of a multi-center study of patients undergoing endoscopic and open procedures completed between 2012 and 2018. Participants were eligible if they were over 18 years of age; had benign or malignant anterior, antero-lateral, or central skull base tumors; and required either an open or endoscopic skull base surgical approach. In order to assess the psychometric properties of the SBI, patients completed the instrument at six time points (preoperative, 2 weeks, 3 months, 6 months, 12 months postoperative). Patients also completed the Anterior Skull Base (ASB) questionnaire and the Sinonasal Outcome Test (SNOT-22) to allow comparison to the SBI. RESULTS: One hundred and eighty-seven patients were included across five centers, with 121 having an endoscopic procedure. Internal consistency (Cronbach's alpha = 0.95) and test-retest at 12 months and 12 months plus 2 weeks (intraclass correlation > 0.90) were excellent. Concurrent validity was demonstrated by very strong correlation between total SBI scores and ASB scores (r = 0.810 to 0.869, p < 0.001) and moderate correlation between nasal domain SBI scores and SNOT-22 scores (r = - 0.616 to - 0.738, p < 0.001). Convergent validity was demonstrated by moderate correlation between change in SBI scores and global QOL change (rs = 0.4942, p < 0.001). The minimally important clinical difference (global HR-QOL change of "a little better" or "a little worse") was 6.0. CONCLUSION: The SBI questionnaire is reliable and valid for patients treated by both endoscopic and open approaches and can be used for assessment of HR-QOL in these settings.

Development and validation of a Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN) in a scarce resource setting: Response to the COVID-19 pandemic.

BACKGROUND: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes. METHODS: Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high-priority, intermediate-priority, and low-priority indications for surgery were established and subdivided. A point-based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient. RESULTS: A total of 62 indications for surgical priority were rated. Weights for each indication ranged from -4 to +4 (scale range; -17 to 20). The response rate for the validation exercise was 100%. The SPARTAN-HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha, .91 [95% CI, 0.88-0.93]; and rho, 0.81 [95% CI, 0.45-0.95]). CONCLUSIONS: The SPARTAN-HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID-19 era. Formal evaluation and implementation are required. LAY SUMMARY: Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID-19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability. Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden. The current study sought to develop what to the authors' knowledge is the first cancer-specific surgical prioritization tool for use in the COVID-19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID-19 era and provides evidence for the initial uptake of the SPARTAN-HN.

Turn analysis and patient-centredness in paediatric otolaryngology surgical consultations.

OBJECTIVES: Physician and patient/parent communication is of utmost importance in consultations to improve the shared decision-making (SDM) processes. This study investigated SDM-related outcomes through turn analysis and an assessment of patient-centred dialogue. DESIGN: Multi-centre prospective cohort study analysing audio- and video-recorded patient/parent-physician interactions. SETTING: Two tertiary paediatric hospitals in Halifax, Nova Scotia and Salt Lake City, Utah. PARTICIPANTS: Paediatric otolaryngologists, patients and parents during consultation for adenotonsillectomy. MAIN OUTCOME MEASURES: Medical dialogue measures (turn analysis, patient-centredness scores via the Roter Interaction Analysis System) and SDM questionnaires (SDM-Q-9). RESULTS: Turn density was significantly higher for physicians than patients/parents (P < .001), as were total statements (P < .001), and total time talking (P < .001). The opening statement was completed by the physician in 91.5% of interactions and was significantly longer than family opening statements (P = .003). The mean number of informed consent elements addressed per interaction was 4.5 out of 6. The mean patient-centredness score was 0.2 (range 0-0.56). Significant negative correlations between patient-centredness score and physician turn density (r = -.390, P = .002), physician mean turn time (r = -.406, P = .001), total physician statements (r = -.426, P = .001) and total physician speaking time (r = -.313, P = .016) were noted. There were no correlations in SDM questionnaire scores with turn analysis variables, informed consent elements or patient-centredness scores. CONCLUSIONS: Surgeons dominated the consultation in terms of talking, mostly in a unidirectional manner. Neither patient-centredness nor turn analysis correlated with perceptions of SDM from the parents' perspective.

Radial Forearm Flap for Esophageal Perforation After Anterior Cervical Hardware Removal: Surgical Technique and Case Report.

CASE: A 51-year-old woman, who had previously undergone C5-C7 anterior cervical discectomy and fusion, presented with symptomatic hardware failure and subsequently underwent instrumentation removal. Her postoperative course was complicated by an esophageal perforation. Despite initial repair using a rotational flap, the leak persisted, prompting esophageal reconstruction with a radial forearm free flap (RFFF). CONCLUSION: Persistent esophageal perforation is exceedingly rare and difficult to treat. This report discusses the surgical technique for RFFF, an excellent option for revising failed sternocleidomastoid rotational flaps. The decision between rotational repair and free flap reconstruction depends on factors such as defect size, vascularization, wound condition, and donor site morbidity.

Patient-Initiated Communication After Parotidectomy.

OBJECTIVES: We sought to study the incidence of patient-initiated communication after parotidectomy, identify patient and surgical factors associated with patient-initiated communication, and evaluate trends and possible areas for improvement. METHODS: A retrospective cohort study of patients who underwent parotidectomy without combined procedures from 2018 to 2022 in a single tertiary-care institution was performed. We reviewed all patient communications documented within the electronic medical record within 30 days of discharge. We categorized patient communications as requiring an action by the surgeon, instruction by support staff, or reassurance. RESULTS: A total of 363 patients were included. Most patients were women (55.4%), Caucasian (78.8%), and had an average age of 56 years ± 16. We found 123 (33.9%) patients initiated postoperative communications. Swelling (47.2%) was the most common concern followed by wound concerns (15.4%). Switching from planned inpatient to outpatient surgery increased (OR = 2.635; 95% CI = 1.200-6.146, p = 0.026) propensity for postoperative communication. We found 31 (25.2%) postoperative communications required an action by the surgeon, 40 (32.5%) required instruction by the support staff, and the other 52 (42.3%) required reassurance or clarification. Multivariate analysis showed swelling (OR = 6.5, CI = 2.2-19, p < 0.001), male sex (OR = 3.27, CI = 1.127-9.459, p = 0.029), previous smoking (OR = 3.468, CI = 1.181-10.185, p = 0.024), and cancer (OR = 6.862, CI = 1.757-26.804, p = 0.006) were predictive of requiring an action by the surgeon. CONCLUSIONS: This is the first study to evaluate patient-initiated communication after parotidectomy and found it occurred 33.4% of the time. We found significant opportunities to improve perioperative care, enhance patient satisfaction, and reduce the overall burden on medical personnel. LEVEL OF EVIDENCE: Level IV Laryngoscope, 2024.

Need for Tympanostomy Tubes in Children With Recurrent Acute Otitis Media Without Middle Ear Effusion.

OBJECTIVE: Children with recurrent acute otitis media (RAOM) presenting without middle ear effusion (MEE) do not meet indications for surgical intervention as outlined by Clinical Practice Guidelines (CPGs). The objective of this study was to determine which patients presenting with RAOM without MEE ultimately received tympanostomy tubes. STUDY DESIGN: Case series. SETTING: Single academic pediatric otolaryngology clinic. METHODS: Children (0-12 years) presenting with RAOM and no MEE were identified from October 2017 to December 2019. As per CPGs, no surgery was offered initially. Patients were given a semiurgent return appointment should they experience another suspected otitis media episode. If MEE was observed, tympanostomy tube insertion was offered. Patients were followed for 1-year following enrollment. RESULTS: One-hundred and twenty-four patients were included. The median age was 3.15 years old (interquartile range: 4.10). Seventy-five (60%) patients did not require additional follow-up and thus did not require tympanostomy tubes. Forty-nine (40%) patients were seen again; of these, 11 patients received tympanostomy tubes. Therefore, of patients presenting with no MEE, 91% did not require tympanostomy tubes. Patients who had surgery were younger on initial assessment than those who did not (mean difference 2.68 years, 95% confidence interval: 2.14-3.23). CONCLUSION: This study demonstrates the practical effect of adhering to CPGs for RAOM and suggests that many children may not require tympanostomy tube placement within the 1st year after the consultation if they did not initially present with MEE.

Gaps in Depression Symptom Management for Patients With Head and Neck Cancer.

OBJECTIVE: To understand practice patterns and identify care gaps within a large-scale depression screening program for patients with head and neck cancer (HNC). STUDY DESIGN: Retrospective cohort study. METHODS: This was a population-based study of adults diagnosed with a HNC between January 2007 and October 2020. Each patient was observed from time of first symptom assessment until end of study date, or death. The exposure of interest was a positive depressive symptom screen on the Edmonton Symptom Assessment System (ESAS). Outcomes of interest included psychiatry/psychology assessment, social work referral, or palliative care assessment. Cause specific hazard models with a time-varying exposure were used to investigate the exposure-outcome relationships. RESULTS: Of 14,054 patients with HNC, 9016 (64.2%) reported depressive symptoms on at least one ESAS assessment. Within 60 days of first reporting depressive symptoms, 223 (2.7%) received a psychiatry assessment, 646 (7.9%) a social work referral, and 1131 (13.9%) a palliative care assessment. Rates of psychiatry/psychology assessment (HR 3.15 [95% CI 2.67-3.72]), social work referral (HR 1.83 [95% CI 1.64-2.02]), and palliative care assessment (HR 2.34 [95% CI 2.19-2.50]) were higher for those screening positive for depression. Certain patient populations were less likely to receive an assessment including the elderly, rural residents, and those without a prior psychiatric history. CONCLUSION: A high proportion of head and neck patients report depressive symptoms, though this triggers a referral in a small number of cases. These data highlight areas for improvement in depression screening care pathways. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2638-2646, 2023.

Association of Household Income at Diagnosis With Financial Toxicity, Health Utility, and Survival in Patients With Head and Neck Cancer.

Importance: While several studies have documented a link between socioeconomic status and survival in head and neck cancer, nearly all have used ecologic, community-based measures. Studies using more granular patient-level data are lacking. Objective: To determine the association of baseline annual household income with financial toxicity, health utility, and survival. Design, Setting, and Participants: This was a prospective cohort of adult patients with head and neck cancer treated at a tertiary cancer center in Toronto, Ontario, between September 17, 2015, and December 19, 2019. Data analysis was performed from April to December 2021. Exposures: Annual household income at time of diagnosis. Main Outcome and Measures: The primary outcome of interest was disease-free survival. Secondary outcomes included subjective financial toxicity, measured using the Financial Index of Toxicity (FIT) tool, and health utility, measured using the Health Utilities Index Mark 3. Cox proportional hazards models were used to estimate the association between household income and survival. Income was regressed onto log-transformed FIT scores using linear models. The association between income and health utility was explored using generalized linear models. Generalized estimating equations were used to account for patient-level clustering. Results: There were 555 patients (mean [SD] age, 62.7 [10.7] years; 109 [20%] women and 446 [80%] men) included in this cohort. Two-year disease-free survival was worse for patients in the bottom income quartile (<$30 000: 67%; 95% CI, 58%-78%) compared with the top quartile (≥$90 000: 88%; 95% CI, 83%-93%). In risk-adjusted models, patients in the bottom income quartile had inferior disease-free survival (adjusted hazard ratio, 2.13; 95% CI, 1.22-3.71) and overall survival (adjusted hazard ratio, 2.01; 95% CI, 0.94-4.29), when compared with patients in the highest quartile. The average FIT score was 22.6 in the lowest income quartile vs 11.7 in the highest quartile. In adjusted analysis, low-income patients had 12-month FIT scores that were, on average, 134% higher (worse) (95% CI, 16%-253%) than high-income patients. Similarly, health utility scores were, on average, 0.104 points lower (95% CI, 0.026-0.182) for low-income patients in adjusted analysis. Conclusions and Relevance: In this cohort study, patients with head and neck cancer with a household income less than CAD$30 000 experienced worse financial toxicity, health status, and disease-free survival. Significant disparities exist for Ontario's patients with head and neck cancer.

Rationale for the Development of a Novel Clinical Grading Scale for Postoperative Facial Nerve Function: Results of a Multidisciplinary International Working Group.

OBJECTIVE: The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications. STUDY DESIGN: Survey. SETTING: A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery. RESULTS: House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting. CONCLUSIONS: Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland.

Oncological and functional outcomes following treatment of T1a glottic squamous cell carcinoma with transoral laser microsurgery.

BACKGROUND: Laryngeal cancers of glottic origin comprise a large proportion of head and neck malignancies. Transoral laser microsurgery (TLM) and radiation therapy are mainstays in the treatment of early stage glottic cancer, but debate persists as to which modality is functionally superior. Furthermore, there is a paucity of North American data related to functional and oncological outcomes in T1a glottic cancer. Here, we assessed oncological and functional outcomes of T1a glottic squamous cell carcinoma (SCC) with TLM to supplement evidence from jurisdictions outside North America. METHODS: This study is a retrospective cohort study performed from a prospectively collected tertiary center institutional TLM database. Patients who were diagnosed with T1a glottic SCC and underwent TLM as their primary treatment were included. Functional outcomes were analyzed using the Voice Handicap Index-10 (VHI-10) questionnaire. Ultimate control with TLM only was considered to be those patients with locoregional control with repeat TLM procedures, but without addition of other modalities. Student's t-test was used to test significance and Kaplan-Meier survival analysis was used to assess oncological outcomes. RESULTS: 48 patients met study criteria. The mean follow-up time was 74 months. The 5-year locoregional, ultimate control with TLM only and laryngeal preservation rates were 83.2%, 90.4% and 100%, respectively. The overall survival and disease-specific survival were 87.2% and 100%, respectively. VHI-10 scores were available for 13/48 patients and mean scores improved non-significantly from pre-op (mean: 11.23; range: 2 to 30; median: 10) and post op (mean: 7.92; range: 0 to 18; median: 8) scoring (p-value = 0.15). Sub-stratification of voice data revealed a significant improvement between pre and post-operative scores (mean difference - 10.6, 95% CI: - 0.99 to - 20.21, p-value = 0.035) for patients with abnormal pre-operative scores (VHI > 11). CONCLUSION: To our knowledge, the current work represents one of the first North American studies to report both functional and oncologic outcomes for TLM treatment of T1a glottic SCC. The oncologic and functional outcomes presented here add to existing evidence in favor of TLM as a safe and effective primary treatment option for early staged T1a glottic cancer.

The Multifocal Approach to Sharing in Shared Decision Making: A Critical Appraisal of the MAPPIN'SDM.

OBJECTIVE: Shared decision making integrates health care provider expertise with patient values and preferences. The MAPPIN'SDM is a recently developed measurement instrument that incorporates physician, patient, and observer perspectives during medical consultations. This review sought to critically appraise the development, sensibility, reliability, and validity of the MAPPIN'SDM and to determine in which settings it has been used. METHODS: This critical appraisal was performed through a targeted review of the literature. Articles outlining the development or measurement property assessment of the MAPPIN'SDM or that used the instrument for predictor or outcome purposes were identified. RESULTS: Thirteen studies were included. The MAPPIN'SDM was developed by both adapting and building on previous shared decision making measurement instruments, as well as through creation of novel items. Content validity, face validity, and item quality of the MAPPIN'SDM are adequate. Internal consistency ranged from 0.91 to 0.94 and agreement statistics from 0.41 to 0.92. The MAPPIN'SDM has been evaluated in several populations and settings, ranging from chronic disease to acute oncological settings. Limitations include high reading levels required for self-administered patient questionnaires and the small number of studies that have employed the instrument to date. CONCLUSION: The MAPPIN'SDM generally shows adequate development, sensibility, reliability, and validity in preliminary testing and holds promise for shared decision making research integrating multiple perspectives. Further research is needed to develop its use in other patient populations and to assess patient understanding of complex item wording.

Readability of the American, Canadian, and British Otolaryngology-Head and Neck Surgery Societies' Patient Materials.

OBJECTIVE: Patient education materials across 3 national English otolaryngology-head and neck surgery (OHNS) societies: the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), the Canadian Society of Otolaryngology-Head and Neck Surgery (CSOHNS), and Ear, Nose, and Throat United Kingdom (ENT UK) were examined to determine whether they are written at a level suitable for patient comprehension. STUDY DESIGN: Cross-sectional study. SETTING: Online patient materials presented through OHNS national societies. METHODS: Readability was calculated using the Flesch-Kincaid Grade Level, Flesch-Kincaid Reading Ease Score, and Simple Measure of Gobbledygook Index. All public patient education materials available through the CSOHNS, AAO-HNS, and ENT UK websites were assessed. Patient education materials were grouped into categories by subspecialty. RESULTS: In total, 128 patient materials from the 3 societies were included in the study. All 3 societies required a minimum grade 9 reading comprehension level to understand their online materials. According to Flesch-Kincaid Grade Level, the CSOHNS required a significantly higher reading grade level to comprehend the materials presented when compared to AAO-HNS (11.3 vs 9.9; 95% CI, 0.5-2.4; P < .01) and ENT UK (11.3 vs 9.4; 95% CI, 0.9-2.9; P < .01). Patient education materials related to rhinology were the least readable among all 3 societies. CONCLUSION: This study suggests that the reading level of the current patient materials presented through 3 national OHNS societies are written at a level that exceeds current recommendations. Promisingly, it highlights an improvement for the readability of patient materials presented through the AAO-HNS.

Development and Validation of a Machine Learning Algorithm Predicting Emergency Department Use and Unplanned Hospitalization in Patients With Head and Neck Cancer.

Importance: Patient-reported symptom burden was recently found to be associated with emergency department use and unplanned hospitalization (ED/Hosp) in patients with head and neck cancer. It was hypothesized that symptom scores could be combined with administrative health data to accurately risk stratify patients. Objective: To develop and validate a machine learning approach to predict future ED/Hosp in patients with head and neck cancer. Design, Setting, and Participants: This was a population-based predictive modeling study of patients in Ontario, Canada, diagnosed with head and neck cancer from January 2007 through March 2018. All outpatient clinical encounters were identified. Edmonton Symptom Assessment System (ESAS) scores and clinical and demographic factors were abstracted. Training and test cohorts were randomly generated in a 4:1 ratio. Various machine learning algorithms were explored, including (1) logistic regression using a least absolute shrinkage and selection operator, (2) random forest, (3) gradient boosting machine, (4) k-nearest neighbors, and (5) an artificial neural network. Data analysis was performed from September 2021 to January 2022. Main Outcomes and Measures: The main outcome was any 14-day ED/Hosp event following symptom assessment. The performance of each model was assessed on the test cohort using the area under the receiver operator characteristic (AUROC) curve and calibration plots. Shapley values were used to identify the variables with greatest contribution to the model. Results: The training cohort consisted of 9409 patients (mean [SD] age, 63.3 [10.9] years) undergoing 59 089 symptom assessments (80%). The remaining 2352 patients (mean [SD] age, 63.3 [11] years) and 14 193 symptom assessments were set aside as the test cohort (20%). Several models had high predictive accuracy, particularly the gradient boosting machine (validation AUROC, 0.80 [95% CI, 0.78-0.81]). A Youden-based cutoff corresponded to a validation sensitivity of 0.77 and specificity of 0.66. Patient-reported symptom scores were consistently identified as being the most predictive features within models. A second model built only with symptom severity data had an AUROC of 0.72 (95% CI, 0.70-0.74). Conclusions and Relevance: In this study, machine learning approaches predicted with a high degree of accuracy ED/Hosp in patients with head and neck cancer. These tools could be used to accurately risk stratify patients and may help direct targeted intervention.

Volume-outcome relationships in laryngeal trauma processes of care: a retrospective cohort study.

PURPOSE: The extent to which patients with laryngeal trauma undergo investigation and intervention is largely unknown. The objective of this study was to therefore determine the association between hospital volume and processes of care in patients sustaining laryngeal trauma. METHODS: This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database. Adult patients (≥ 18) who sustained traumatic laryngeal injuries between 2012 and 2016 were eligible. The exposure of interest was average annual laryngeal trauma volume categorized into quartiles. The primary and secondary outcomes of interest were the performances of diagnostic and therapeutic laryngeal procedures respectively. Multivariable logistic regression under a generalized estimating equations approach was utilized. RESULTS: In total, 1164 patients were included. The average number of laryngeal trauma cases per hospital ranged from 0.2 to 7.2 per year. Diagnostic procedures were performed in 31% of patients and therapeutic in 19%. In patients with severe laryngeal injuries, diagnostic procedures were performed on a higher proportion of patients at high volume centers than low volume centers (46% vs 25%). In adjusted analysis, volume was not associated with the performance of diagnostic procedures. Patients treated at centers in the second (OR 1.94 [95% CI 1.29-2.90]) and third (OR 1.67 [95% CI 1.08-2.57]) volume quartiles had higher odds of undergoing a therapeutic procedure compared to the lowest volume quartile. CONCLUSION: Hospital volume may be associated with processes of care in laryngeal trauma. Additional research is required to investigate how these findings relate to patient and health system outcomes.

Psychosocial Distress in Parents with Children Awaiting Surgery during the COVID-19 Pandemic.

Due to resource restrictions related to the COVID-19 pandemic, many pediatric patients are facing substantial delays for surgery, potentially resulting in additional distress for caregivers. We aimed to assess the experiences and psychosocial distress of parents during COVID-19 as they relate to the pandemic, waiting for surgery, and the combined effects of both events. The was a cross-sectional qualitative study. Parents with children who faced treatment delays during the initial wave of the COVID-19 pandemic for elective, non-emergent procedures across a variety of surgical specialties were recruited. Semi-structured telephone interviews and thematic analysis were utilized. Thematic saturation was reached with eighteen participants. Four themes were identified: coping with COVID-19, distress levels, quality and nature of communication with the surgical team, and the experience of COVID-19 related hospital restrictions. Participants reported varying levels of distress due to the delay in surgery, such as the fear of developmental delay or disease progression for their child. They also indicated their own physical and mental health had been impacted by emotional distress related to both COVID-19 and delays in treatment. Most participants experienced the COVID-19-related hospital restrictions as distressing. This related predominantly to limiting in-hospital caregivers to only one caregiver. Participants were found to have substantial levels of psychosocial distress. Targeted social and emotional support may be helpful in reducing parental distress as the pandemic timeframe continues. Within the limits of individual health systems, reducing restrictions to the number of allowed care givers may help allay distress felt by parents.

Construct Validity of the EuroQoL-5 Dimension and the Health Utilities Index in Head and Neck Cancer.

OBJECTIVE: The objective of this study was to evaluate the construct validity of 2 health utility instruments-the EuroQoL-5 Dimension (EQ-5D) and the Health Utilities Index-Mark 3 (HUI-3)-and to compare them with disease-specific measures in patients with head and neck cancer. STUDY DESIGN: Prospective cross-sectional analysis. SETTING: Princess Margaret Cancer Centre. METHODS: Patients were administered the EQ-5D, HUI-3, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its head and neck cancer module (EORTC QLQ-H&N35), and the University of Washington Quality of Life Questionnaire (UWQoL). Several a priori expected relations were examined. The correlative and discriminative properties of the various instruments were examined. RESULTS: A total of 209 patients completed the 4 questionnaires. A significant ceiling effect was observed among EQ-5D responses (23% reported a maximum score of 1). The EQ-5D (rho = 0.79) and HUI-3 (rho = 0.60) had a strong correlation with the social-emotional domain of the UWQoL. The EQ-5D had a moderate correlation with the physical domain of the UWQoL (rho = 0.42), whereas the HUI-3 had a weak correlation (rho = 0.29). The EQ-5D and HUI-3 were able to distinguish among levels of health severity measured on the EORTC QLQ-C30 though not the QLQ-H&N35. Comparatively, the UWQoL was able to distinguish levels of disease severity on the EORTC QLQ-C30 and QLQ-H&N35. CONCLUSION: The results of this study demonstrate that disease-specific domains from head and neck quality-of-life instruments are not strongly correlated with the EQ-5D and HUI-3. Consideration should be put toward development of a disease-specific preference-based measure for health economic evaluation. LEVEL OF EVIDENCE: 4.

Ultrasonography and Fine-Needle Aspiration in Indeterminate Thyroid Nodules: A Systematic Review of Diagnostic Test Accuracy.

OBJECTIVES/HYPOTHESIS: Sonographic risk criteria may assist in further prognostication of indeterminate thyroid nodules (ITNs). Our aim was to determine whether sonographic criteria could further delineate the post-test probability of malignancy in ITNs. STUDY DESIGN: Meta-analysis of diagnostic test accuracy. METHODS: A systematic review of Web of Science, MEDLINE, EMBASE, and CINAHL was performed from inception to April 15, 2021. Eligible studies included those which reported ultrasonographic evaluations with the American Thyroid Association (ATA) or the Thyroid Imaging Reporting and Data System (TIRADS) in adult patients with ITNs. ATA or TIRADS were scored as low (negative) or high (positive) malignancy risk using a previously validated binary classification. Primary outcomes included pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratio for all sonographic criteria. Studies were appraised using Quality Assessment of Diagnostic Accuracy Studies and the data were pooled using bivariate random-effects models. RESULTS: Seventeen studies were included in the analysis. For Bethesda III, ATA had a specificity (0.90, 95% confidence interval (CI): 0.74-0.94), but a sensitivity of 0.52 (95% CI: 0.25-0.77). Conversely, K-TIRADS had the highest sensitivity (0.78, 95% CI: 0.62-0.89) with a specificity of 0.53 (95% CI: 0.31-0.74). Furthermore, American College of Radiology and EU TIRADS had specificities of 0.60 (95% CI: 0.36-0.80) and 0.81 (95% CI: 0.73-0.87) with sensitivities of 0.70 (95% CI: 0.37-0.90) and 0.38 (95% CI: 0.20-0.60), respectively. There were few studies with Bethesda IV nodules. CONCLUSIONS: Though dependent on malignancy rates, Bethesda III nodules with low-suspicion TIRADS features may benefit from clinical observation, whereas nodules with high-suspicion ATA features may require molecular testing and/or surgery. LEVEL OF EVIDENCE: NA Laryngoscope, 132:242-251, 2022.