Transoral robotic surgery in HPV+ oropharyngeal cancer of unknown primary.

PURPOSE: This study was designed to assess trends in and outcomes associated with TORS-treated HNCUP using a large national database. MATERIALS AND METHODS: HPV+ oropharyngeal HNCUPs were isolated from the 2004-2017 National Cancer Database. Overall survival (OS) was assessed, with patients stratified by 1) use of TORS and 2) whether the occult tumor was ultimately located. Demographic and oncologic predictors of survival were evaluated on regression. RESULTS: The cohort contained 284,734 cases, of which 8336 were HNCUPs. HNCUPs represented 2.49 % of all HNSCC in 2010 versus 3.13 % in 2017. 3897 (46.7 %) of these unknown primaries were ultimately identified. The proportion of cases treated with TORS increased from 6.9 % in 2010 to 18.1 % in 2017 (p < 0.001). Kaplan-Meier analysis of 2991 HPV+ oropharyngeal HNCUPs demonstrated higher 5-year overall survival (OS) for patients treated with robotic surgery versus no robotic surgery (95.4 % ± 1.7 % standard error [SE] versus 84.0 % ± 0.9 % SE; p < 0.001). Patients with primary tumors identified during treatment had improved OS compared to those whose tumors were not located (5-year OS was 90.5 % ± 0.9 % SE and 77.3 % ± 1.5 % SE, respectively; p < 0.001). For patients in which the primary tumor was found, those who received robotic surgery survived longer than those who did not (96.5 % ± 1.4 % SE versus 89.1 % ± 1.0 % SE 5-year OS; p < 0.001). The relationship between TORS and OS remained significant on Cox regression controlling for confounders. CONCLUSIONS: Use of TORS in the workup for HPV+ HNCUP is associated with higher rates of tumor identification and improved OS.

Variability of Guidelines and Disclosures for AI-Generated Content in Top Surgical Journals.

Background: When properly utilized, artificial intelligence generated content (AIGC) may improve virtually every aspect of research, from data gathering to synthesis. Nevertheless, when used inappropriately, the use of AIGC may lead to the dissemination of inaccurate information and introduce potential ethical concerns.Research Design: Cross-sectional. Study Sample: 65 top surgical journals. Data Collection: Each journals submission guidelines and portal was queried for guidelines regarding AIGC use.Results: We found that, in July 2023, 60% of the top 65 surgical journals had introduced guidelines for use, with more surgical journals (68%) introducing guidelines than surgical subspecialty journals (52.5%), including otolaryngology (40%). Furthermore, of the 39 with guidelines, only 69.2% gave specific use guidelines. No included journal, at the time of analysis, explicitly disallowed AIGC use.Conclusions: Altogether, this data suggests that while many journals have quickly reacted to AIGC usage, the quality of such guidelines is still variable. This should be pre-emptively addressed within academia.

A comparative analysis of treatment efficacy in intermediate-risk thyroid cancer.

PURPOSE: This study aimed to evaluate the efficacy of different treatment combinations on patient survival in intermediate-risk differentiated thyroid cancer (DTC). METHODS: The 2004-2017 National Cancer Database was queried for intermediate-risk papillary (PTC), follicular (FTC), or Hurthle cell (HTC) thyroid cancer patients. Four treatments were analyzed using Kaplan Meier and multivariable Cox regression: surgery, surgery with adjuvant radioiodine ablation (S + RAI), surgery with adjuvant thyroid-stimulating hormone suppression therapy (S + THST), and S + RAI + THST. Kaplan-Meier and multivariable Cox proportional-hazards analyses evaluated treatment-associated overall survival (OS). RESULTS: Of 65,736 patients, 72.2% were female and the average age was 45.4 ± 15.4 years. The 10-year OS rates for PTC, FTC, and HTC were 93.2%, 85.2%, and 78.5%, respectively. S + RAI + THST exhibited higher OS than surgery alone and S + RAI (all p < 0.05). Compared to surgery alone, S + RAI + THST demonstrated reduced mortality in PTC (Hazard Ratio [HR]: 0.628, p < 0.001), FTC (HR: 0.490, p < 0.001), and HTC (HR: 0.520, p = 0.006). Similarly, adjuvant RAI + THST reduced mortality regardless of lymphovascular invasion (HR: 0.490, p < 0.001), N1a (HR: 0.570, p < 0.001) or N1b metastasis (HR: 0.621, p < 0.001), or positive margin status (HR: 0.572, p < 0.001). CONCLUSIONS: Treatment combinations demonstrated varying efficacies in intermediate-risk DTC depending on histology and tumor characteristics, with S + RAI + THST exhibiting the greatest treatment response.

Artificial neural network prediction of post-thyroidectomy outcome.

OBJECTIVES: The goal of this study was to develop a deep neural network (DNN) for predicting surgical/medical complications and unplanned reoperations following thyroidectomy. DESIGN, SETTING, AND PARTICIPANTS: The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to extract patients who underwent thyroidectomy. A DNN consisting of 10 layers was developed with an 80:20 breakdown for training and testing. MAIN OUTCOME MEASURES: Three primary outcomes of interest, including occurrence of surgical complications, medical complications, and unplanned reoperation were predicted. RESULTS: Of the 21 550 patients who underwent thyroidectomy, medical complications, surgical complications and reoperation occurred in 1723 (8.0%), 943 (4.38%) and 2448 (11.36%) patients, respectively. The DNN performed with an area under the curve of receiver operating characteristics of .783 (medical complications), .709 (surgical complications) and .703 (reoperations). Accuracy, specificity and negative predictive values of the model for all outcome variables ranged 78.2%-97.2%, while sensitivity and positive predictive values ranged 11.6%-62.5%. Variables with high permutation importance included sex, inpatient versus outpatient and American Society of Anesthesiologists class. CONCLUSIONS: We predicted surgical/medical complications and unplanned reoperation following thyroidectomy via development of a well-performing ML algorithm. We have also developed a web-based application available on mobile devices to demonstrate the predictive capacity of our models in real time.

Mandibular Chondrosarcoma Reconstructed Using Custom Implant and Radial Forearm Free Flap.

ABSTRACT: We describe the case of a 40-year-old male presenting with an enlarging left facial and temporal chondrosarcoma centered on the left mandibular coronoid process resulting in pathologic fractures of the zygomatic arch and focal erosion of the temporal bone. The patient underwent surgical resection via a combined hemicoronal and parotidectomy approach. The zygomatic arch was reconstructed with a patient-specific polyetheretherketone implant, and temporal contour was restored with a buried de-epithelialized radial forearm free flap. Final pathology demonstrated conventional central chondrosarcoma. This case demonstrates an unusual presentation of a rare head and neck chondrosarcoma that originated from the mandibular coronoid process with the unique use of a custom polyetheretherketone implant and vascularized fat and fascial reconstruction.

Practice patterns and knowledge among California pediatricians regarding human papillomavirus and its relation to head and neck cancer.

OBJECTIVE: To identify practice patterns regarding human papillomavirus (HPV) vaccination efforts and vaccination rates in context of head and neck cancer prevention, identify barriers to vaccination, and identify gaps in knowledge regarding the link between HPV and head and neck cancer in the pediatrician population. STUDY DESIGN/METHODS: A 27-question cross-sectional survey was distributed to members of the four California chapters of the American Academy of Pediatrics. RESULTS: Of the completed responses, 89.4% identified as "always" recommending the HPV vaccine to patients, but only 19.5% of pediatricians estimated that >75% of their eligible patients had completed the HPV vaccination series. 71.5% of respondents felt that further education about HPV's link to head and neck cancer them more comfortable discussing vaccination. Physicians who were in practice longer were less likely to respond that additional education about HPV and its link to head and neck cancer would make them more comfortable discussing vaccination with patients (p = 0.043). Physicians who were in practice longer were more likely to correctly respond that HPV type 16 is the most common strain linked to head and neck cancer (p = 0.021). CONCLUSION: There is need to improve both the knowledge base and comfort level of pediatricians in counseling their patients during vaccine recommendations. Otolaryngologists have a critical role in providing education to physicians, trainees, and the general public in the effort to combat the epidemic of HPV-associated head and neck cancer.

Refining Target Volume Coverage After Parotidectomy for Cutaneous Squamous Cell Carcinoma: Omission of the Cervical Neck From the Radiation Field.

Purpose: For patients without pathologic evidence of cervical disease after neck dissection for cutaneous squamous cell carcinoma involving the parotid region, inclusion of the ipsilateral cervical neck in the postparotidectomy radiation volume is routinely performed. We report our experience with selective avoidance of the ipsilateral neck for patients undergoing postoperative radiation to the parotid bed. Methods and Materials: From January 2014 to December 2023, a total of 30 consecutive patients underwent postoperative radiation after parotidectomy for cutaneous squamous cell carcinoma involving the parotid area. All patients had previously had a neck dissection confirming pathologic N0 disease. Treatment was delivered using intensity modulated radiation therapy to a median dose of 60 Gy (range, 56-66 Gy). The radiation target volumes included the parotid bed only, with deliberate avoidance of the ipsilateral cervical neck. The median pathologic tumor size of the parotid tumor was 3.3 cm (range, 0.2-9.4 cm). Final pathologic evaluation showed positive microscopic margins in 8 patients (27%), perineural invasion in 17 patients (57%), and facial nerve involvement in 6 patients (20%). Results: There were no isolated nodal failures. One patient developed an ipsilateral neck recurrence approximately 8 months after completion of radiation therapy. This occurred 2 months subsequent to the development of local recurrence. The 5-year actuarial rates of local (parotid) control, neck control, and overall survival were 87%, 97%, and 76%, respectively. Conclusions: Omission of the ipsilateral neck from the parotid volume does not compromise disease control for pathologically N0 patients undergoing postoperative radiation for cutaneous squamous cell carcinoma involving the parotid region. Practical implications are discussed.

Re-irradiation versus systemic therapy for the management of local-regionally recurrent head and neck cancer.

PURPOSE: The optimal management of local-regionally recurrent head and neck cancer that is not amenable to surgical resection is uncertain. We sought to compare outcomes among patients treated with and without re-irradiation in this setting. METHODS AND MATERIALS: A review of institutional registries identified 65 patients with local-regionally recurrent squamous cell carcinoma of the head and neck who were ineligible for surgery. Forty patients (62 %) opted for re-irradiation with the remaining 25 patients (38 %) undergoing initial systemic therapy alone. All patients had measurable disease. Forty-three patients (66 %) were male and twenty-two (33 %) were female. The median age at the time of recurrence was 59 years (range, 39-84 years). The most common primary sites of disease were the oropharynx, (n = 25), oral cavity (N = 19), and nasopharynx (n = 11). The median interval from completion of prior radiation to the diagnosis of recurrent disease was 35 months (range, 2-102 months). RESULTS: Re-irradiation improved 2-year overall survival, (32 % versus 11 %), progression-free survival (31 % versus 7 %), and local-regional control (39 % versus 3 %) compared to systemic therapy alone (p < 0.05, for both). The likelihood of developing any new grade 3+ toxicity was significantly higher among patients treated by re-irradiation compared to those treated by systemic therapy (53 % vs. 28 %, p < 0.001). There were 3 treatment-related fatalities, all of which occurred in the re-irradiation group. The incidence of grade 3+ late toxicity was 48 % and 12 % for patients in the re-irradiation and systemic therapy cohorts, respectively (p < 0.001). CONCLUSION: Although re-irradiation improved overall survival compared to systemic therapy for appropriately selected patients with local-regionally recurrent head and neck cancer, the relatively high risk of toxicity must be considered.

Online ratings and narrative comments of American Head and Neck Society surgeons.

BACKGROUND: We analyzed online rating scores and comments of head and neck surgeons to understand factors that contribute to higher ratings. METHODS: Numerical ratings and comments for American Head and Neck Society physicians were extracted from Healthgrades, Vitals, RateMDs, and Yelp, with narrative comments categorized based on content. Physician practice location, education, and residency training were also compiled. RESULTS: Patient ratings were significantly higher with supportive staff and affable physician demeanor but showed significant drops with longer wait times and difficulties scheduling appointments or follow-ups. Physician education and postgraduate training did not significantly affect ratings. CONCLUSION: Online ratings and comments correlated to modifiable factors in clinical practice and may be informative in understanding patient needs.

Association Between Metabolic Syndrome and Outcomes in Complex Head and Neck Surgery.

OBJECTIVES: We aim to evaluate the impact of MetS on the short-term postoperative outcomes of complex head and neck surgery patients. METHODS: This is a retrospective cohort analysis of the 2005 to 2017 National Surgical Quality Improvement Program (NSQIP) database. NSQIP database was queried for 30-day outcomes of patients undergoing complex head and neck surgeries, defined as laryngectomy or mucosal resection followed by free tissue transfer, similar to prior NSQIP studies. Patients with hypertension, diabetes, and body mass index (BMI) >30 kg/m2 were defined as having MetS. Adverse events were defined as experiencing readmission, reoperation, surgical/medical complications, or mortality. RESULTS: A total of 2764 patients (27.0% female) with a mean age of 62.0 ± 11.7 years were included. Patients with MetS (n = 108, 3.9%) were more likely to be female (P = .017) and have high ASA classification (P = .030). On univariate analysis, patients with MetS were more likely to require reoperation (25.9% vs 16.7%, P = .013) and experience medical complications (26.9% vs 15.4% P = .001) or any adverse events (61.1% vs 48.7%, P = .011) compared to patients without MetS. On multivariate logistic regression after adjusting for age, sex, race, ASA classification, and complex head and neck surgery type, MetS was an independent predictor of medical complications (odds ratio 2.34, 95% CI 1.28-4.27, P = .006). CONCLUSION: Patients with MetS undergoing complex head and neck surgery are at increased risk of experiencing medical complications. Identifying patients with MetS can therefore aid surgeons in preoperative risk assessment and help improve postoperative management. LEVEL OF EVIDENCE: N/A.

Racial disparities in the timely receipt of adjuvant radiotherapy for head and neck cancer.

PURPOSE: To evaluate the influence of socioeconomic and demographic factors which might predict for excessive delays in the receipt of adjuvant radiotherapy for head and neck cancer. METHODS AND MATERIALS: The medical records of 430 consecutive patients referred for adjuvant radiation after surgical resection for squamous cell carcinoma of the head and neck were reviewed. The number of days from surgery to initiation of radiation was recorded. To study the variability in which adjuvant radiation was delivered, descriptive statistics were used to determine the percentage of patients who deviated from starting treatment beyond the recommended benchmark of 42 days. The chi-square statistic was used to compare differences in proportion among subsets. A Cox proportional hazards model was constructed to perform a multi-variate analysis to identify factors which independently influenced the likelihood for non-adherence. RESULTS: The interval between surgery and the start of radiation therapy ranged from 5 to 128 days (mean, 36 days). The mean number of days from surgery to radiation therapy was 31 days, 35 days, 40 days, and 42 days for Caucasians, Asians, Latino, and Black patients (p = 0.01). In all, 359 of 430 patients (83 %) started adjuvant radiation within 42 days. The proportion of patients who initiated radiation therapy within 42 days of surgery was 91 %, 86 %, 71 %, 65 %, and 80 % for Caucasians, Asians, Latinos, Blacks, and Native Hawaiian/Pacific Islanders, respectively (p < 0.001). Patient characteristics associated with higher odds of non-adherence to the timely receipt of adjuvant radiation therapy within then 42-day benchmark from surgery to radiation included race ([OR] = 4.23 95 % CI (1.30-7.97), non-English speaking status ([OR] = 2.38, 95 % CI: 0.61-4.50), and low socioeconomic status ([OR] = 1.21, 95 % CI: 1.01-1.86). CONCLUSION: Underrepresented minorities are more likely to experience delays in the receipt of adjuvant radiation for head and neck cancer. The potential underlying reasons are discussed.

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.

Prognostic Utility of Tumor Stage versus American Thyroid Association Risk Class in Thyroid Cancer.

OBJECTIVE: To evaluate the prognostic strengths of American Joint Committee on Cancer (AJCC) staging and American Thyroid Association (ATA) risk classification in well-differentiated thyroid cancer (DTC), and their implications in guiding medical decision-making and epidemiological study designs. METHODS: The 2004-2017 National Cancer Database was queried for DTC patients. Cox proportional hazards (CPH) and Kaplan-Meier analyses modeled patient mortality and overall survival, respectively. Each CPH model was evaluated by its concordance index, measure of explained randomness (MER), Akaike information criterion (AIC), and area under receiver operating characteristic curve (AUC). RESULTS: Overall, 134,226 patients were analyzed, with an average age of 48.1 ± 15.1 years (76.9% female). Univariate CPH models using AJCC staging demonstrated higher concordance indices, MERs, and AUCs than those using ATA risk classification (all p < 0.001). Multivariable CPH models using AJCC staging demonstrated higher concordance indices (p = 0.049), MERs (p = 0.046), and AUCs (p = 0.002) than those using ATA risk classification. The AICs of multivariable AJCC staging and ATA risk models were 7.564 × 104 and 7.603 × 104 , respectively. AJCC stage I tumors were associated with greater overall survival than those classified as ATA low risk, whereas AJCC stages II-III and stage IV tumors demonstrated worse survival than ATA intermediate- and high-risk tumors, respectively (all p < 0.001). CONCLUSION: AJCC staging may be a more predictive system for patient survival than ATA risk. The prognostic utility of these two systems converges when additional demographic and clinical factors are considered. AJCC staging was found to classify patients across a wider range of survival patterns than the ATA risk stratification system. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:205-211, 2023.

Outcomes and Trends of Treatments in High-Risk Differentiated Thyroid Cancer.

OBJECTIVES: To analyze the variant-specific survival benefits and usage patterns of standardized treatment combinations of surgery (S), radioactive iodine ablation (RAI), and thyroid-stimulating hormone suppression therapy (THST) for high-risk differentiated thyroid cancer. STUDY DESIGN: Retrospective cohort study. SETTING: National Cancer Database. METHODS: The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for high-risk papillary, follicular, or Hurthle cell thyroid cancer. Cox proportional hazards and Kaplan-Meier analyses assessed for treatment-associated survival. RESULTS: Of 21,076 cases, 18,214 underwent survival analysis with a mean ± SD age of 50.6 ± 17.1 years (71.3% female). When compared with surgery alone, S + RAI was associated with reduced mortality in papillary (hazard ratio [HR], 0.574; P < .001) and follicular (HR, 0.489; P = .004) thyroid cancer. S + RAI + THST was associated with reduced mortality in papillary (HR, 0.514; P < .001), follicular (HR, 0.602; P = .016), and Hurthle cell (HR, 0.504; P = .021) thyroid cancer. In papillary thyroid cancer, S + RAI (91.3%), S + THST (89.2%), and S + RAI + THST (92.7%) were associated with higher 5-year overall survival rates than surgery (85.4%, all P < .001). Papillary thyroid cancer treatments involving THST were associated with higher 5-year overall survival rates than corresponding regimens without THST (all P < .001). In follicular thyroid cancer, S + RAI (73.9%) and S + RAI + THST (78.7%) were associated with higher 5-year overall survival rates than surgery (65.6%, all P < .05). In Hurthle cell thyroid cancer, S + RAI (66.5%) and S + RAI + THST (73.4%) were associated with higher 5-year overall survival rates than surgery (53.7%, all P < .05). On linear regression, THST usage increased by 77.5% (R2 = 0.944, P < .001), while RAI usage declined by 11.3% (R2 = 0.320, P = .035). CONCLUSIONS: High-risk differentiated thyroid cancer exhibited varying susceptibilities to different treatment combinations depending on histology, with greatest responses to regimens that included RAI. Physician practices have trended toward decreased RAI and increased THST usage.

Timing of chemotherapy and radiation delivery for patients receiving chemoradiation for head and neck cancer: When does "concurrent" mean concurrent?

PURPOSE: To analyze practice patterns focusing on variations in the timing of chemotherapy relative to radiation in patients treated with concurrent chemoradiation for head and neck cancer. METHODS AND MATERIALS: The medical records of 302 consecutive adult patients treated with concurrent chemoradiation for head and neck cancer between April 2014 and February 2022 were reviewed. After excluding 38 patients who received non-platinum-based regimens, induction chemotherapy, and/or had non-squamous cell histology, a total of 264 patients formed the primary population. To study the variability in which concurrent chemoradiation was delivered, descriptive statistics were used to determine the percentage of patients who deviated from starting chemotherapy and radiation on the same day. The chi-square statistic was used to compare differences in proportion among various subsets. A Cox proportional hazards model was then used to perform a multi-variate analysis to identify factors which independently influenced the likelihood for non-adeherence. RESULTS: Among the 264 patients, a total of 187 patients (70.8%) had chemotherapy and radiation started on the same day with 171 of these (91.4%) receiving chemotherapy prior to radiation delivery. On multivariate analysis, both non-Caucasian ethnicity (OR: 1.13, 95% C.I. 1.01-1.20) and being non-English speaking (OR: 1.39; 95% C.I. 1.18--1.51) was significantly associated with greater likelihood of the receipt of radiation and chemotherapy on different days. CONCLUSION: Significant variation exists in the timing of chemotherapy relative to radiation for concurrent chemoradiation in the clinical setting. The potential repercussions on outcome warrante further invesigtation and are discussed.

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.

One hundred most-cited articles in head and neck surgery and analysis of female authorship.

BACKGROUND: While female head and neck surgeons have made significant contributions to the field, women's achievements in scientific communication have traditionally been underreported. METHODS: A search of high-impact journals in the field of head and neck surgery was performed in the Elsevier's Scopus database to identify the top 100 most-cited articles. RESULTS: The top 100 most-cited articles (during the span of 1953 and 2016) had the highest total number of citations between 2005 and 2009. Women accounted for 36% of first authors and 25% of corresponding authors. Change in the relative number of first female authors in these top 100 articles did not increase significantly between 1950 and 2019. CONCLUSION: The proportion of female first authors in head and neck surgery has not significantly increased over the past several decades, despite greater numbers of female trainees. Our findings support the need for additional research on female representation in head and neck surgery.

Identifying Core Journals in Otolaryngology: A Bibliometric Analysis.

OBJECTIVES: As research in otolaryngology continues to expand rapidly, it is important to identify core journals to keep clinicians updated with the latest advances. This study is the first to characterize core journals in otolaryngology. METHODS: Using h-index and impact factor (IF), the top 15 NLM-indexed otolaryngology journals were selected for analysis. The references from all articles published in these journals in one randomized quarter were compiled into a citation rank list, with the most cited journal ranked the highest. Citation zonal distribution analysis was conducted to identify the zonal distribution of otolaryngology journals. RESULTS: A total of 3150 journals containing 26876 articles were cited in otolaryngology literature in April-June 2019. Laryngoscope was the most cited journal containing 1762 citations. IF is significantly associated with the h-index for the top 10 otolaryngology journals (p = 0.032). Three core journal zones were identified, with Zone 1 containing 8 journals, Zone 2 containing 36 journals, and Zone 3 containing 189 journals. A linear relationship between the log journal rank for Zones 1-3 and a cumulative number of citations was found (R2 = 0.9948). CONCLUSION: Eight core journals for otolaryngology were identified: Laryngoscope, Otolaryngology-Head and Neck Surgery, Otology & Neurotology, JAMA Otolaryngology-Head & Neck Surgery, Head & Neck, European Archives of Oto-Rhino-Laryngology, International Journal of Pediatric Otorhinolaryngology, Annals of Otology, Rhinology & Laryngology. In the face of rapidly evolving research and a multitude of journals, the high citation density within these core journals highlights their utility in updating busy clinicians. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3346-3352, 2023.

Frailty, Age, ASA Classification, and BMI on Postoperative Morbidity in Mandibular Fracture ORIF.

OBJECTIVE: To assess how traditional, simple markers of health independently affect postoperative morbidity of mandibular fracture open reduction-internal fixations (ORIFs). STUDY DESIGN: Cohort study. SETTING: National Surgical Quality Improvement Project (NSQIP) Database. METHODS: The 2005 to 2017 NSQIP database was queried for patients who underwent mandibular ORIF. To control for the severity of the trauma, an additional "concurrent surgery" variable was created. A modified 5-item frailty index was calculated based on the following: presurgery-dependent functional status, chronic hypertension, diabetes mellitus, history of chronic obstructive pulmonary disease, and history of congestive heart failure. RESULTS: Among 1806 patients with mandibular ORIFs (mean age 34.8 ± 15.4 years), modified frailty index (mFI) was associated with 30-day medical complications (p < .001), reoperation (p < .001), and readmission (p = .005) on univariate analysis. Increased age was associated with prolonged hospitalization (p < .001) and medical complications (p < .001). The increased American Society of Anesthesiologists (ASA) score was associated with all endpoints (p ≤ .003), while increased body mass index (BMI) was associated with none. On multivariate analysis, only increased ASA was associated with any adverse event (reference: ASA 1; ASA 2, odds ratio [OR]: 2.17 [95% confidence interval, CI: 2.17-3.71], p = .004; ASA 3-4, OR: 3.63 [95% CI: 1.91-6.91], p < .001). Similarly, mFI and BMI were not independently associated with prolonged hospitalization (≥2 days) (p ≥ .015), but 65+ age (reference: 18-49; OR: 2.33 [95% CI: 1.40-3.86], p = .001) and ASA 3 to 4 groups (reference: ASA 1; OR: 3.26 [95% CI: 2.06-5.14], p < .001) were. CONCLUSION: ASA status and age are more useful modalities than mFI or BMI in predicting poor postoperative morbidity in mandibular ORIF. These simple metrics can assist with managing surgeons' expectations for mandibular ORIF patients.

The Impact of Facility Type and Volume on Outcomes in Head and Neck Mucosal Melanoma.

OBJECTIVE: To evaluate differences in treatment outcomes for head and neck mucosal melanoma (HNMM) patients seen at academic versus nonacademic centers and high versus low volume facilities. STUDY DESIGN: Retrospective cohort study. SETTING: National Cancer Database. METHODS: Differences in treatment course and overall survival (OS) by facility type and volume were assessed for 2772 HNMM cases reported by the 2004 to 2017 National Cancer Database. A subgroup analysis was performed with a smaller cohort containing staging data. The analysis employed Kaplan-Meier and Cox proportional hazards models. RESULTS: A higher proportion of patients treated at academic centers within the HNMM cohort waited longer for surgery after diagnosis (p < .001), had negative surgical margins (p < .001), and were readmitted to the hospital within 30 days of surgery (p = .001); these relationships remained significant when controlling for cancer stage. Kaplan-Meier analysis demonstrated higher 5-year OS for patients treated at academic versus nonacademic facilities within the main cohort (32.5% ± 1.3% vs 27.3% ± 1.5%; p = .006) and within the stage-controlled subgroup (34.8% ± 2.1% vs 27.2% ± 2.6%; p = .003). Treatment at high volume versus low volume facilities was associated with improved 5-year OS for main cohort patients (33.5% ± 1.7% vs 28.8% ± 1.2%; p = .016) but not for subgroup patients (35.3% ± 2.7% vs 30.1% ± 2.1%; p = .100). Upon multivariate analysis controlling for demographic and oncologic factors, there was no significant difference in OS by facility type (main cohort: odds ratio [OR] = 1.07, 95% confidence interval [CI] = 1.01-1.21; subgroup: OR = 1.13, 95% CI = 0.97-1.32). CONCLUSION: Neither facility type nor surgical volume predicts overall survival in HNMM.