Systematic Review: Evaluating the Efficacy of Intrathecal Fluorescein for Localizing Cerebrospinal Fluid Rhinorrhea.

OBJECTIVES: A defect in the skull base can result in leakage of cerebrospinal fluid (CSF) out of the subarachnoid space into the sinonasal cavities, termed CSF rhinorrhea. Patients presenting with CSF rhinorrhea often require surgical repair, typically performed endoscopically. Successful surgical intervention is highly reliant on accurate identification of the leak site. Identification can be enhanced by the administration of intrathecal fluorescein (IF) via a lumbar drain before surgery. The objective of this systematic review is to better characterize the benefits and limitations of IF administration. METHODS: A systematic search was conducted for literature documenting the use of IF for CSF leak localization. The results of this search were subjected to initial review, followed by full-text evaluation of selected texts, and final inclusion based on predetermined selection criteria. Primary outcomes were specificity and sensitivity of IF administration in identifying CSF leak sites. Secondary outcomes included administration technique and safety data. RESULTS: A total of 25 studies representing 3801 instances of IF administration met inclusion criteria. When injected slowly for up to 30 minutes at doses of <50 mg, IF administration results in minimal complications. A total of 25 mg doses (92.36%) of IF appear more sensitive than 10 mg (71.88%) doses of IF while maintaining a similar safety profile. Mixing fluorescein with double distilled water instead of CSF or saline may decrease waiting times before fluorescein can be identified and increase its safety profile. CONCLUSIONS: Intrathecal fluorescein may play an important role in the identification of CSF leak site during endoscopic repair.

Addressing the Nasal Valves: The Endonasal Approach.

The external and internal nasal valves are directly implicated in nasal valve collapse. A variety of endonasal techniques have been developed to address nasal dysfunction while maintaining or improving aesthetic appearance. This review discusses the biomechanics, surgical approach, indications, and evidence of functional and aesthetic results for each maneuver. While the endonasal approach is safe and effective, a thorough understanding of the advantages and limitations is fundamental to selecting the most appropriate surgery for the individual patient.

Endocrine Surgical Procedures During COVID-19: Patient Prioritization and Time to Surgery.

BACKGROUND: We tracked endocrine surgery patients with treatment delays due to COVID-19 to investigate the relationship between physician assigned priority scoring (PAPS), the Medically Necessary, Time Sensitive (MeNTS) scoring system and delay to surgery. MATERIAL & METHODS: Patients scheduled for endocrine surgery or clinically evaluated during COVID-19-related elective surgery hold at our institution (2/26/20-5/1/20) were prospectively enrolled. PAPS was assigned based on categories of high, moderate, or low risk, consistent with the American College of Surgeons' priority system. MeNTS scores were calculated. The primary outcome was delay to surgery. Descriptive statistics were performed, and receiver operator characteristic (ROC) curves and area under the curve (AUC) values were calculated for PAPS and MeNTS. RESULTS: Of 146 patients included, 68% (n = 100) were female; the median age was 60 years (IQR:43,67). Mean delay to surgery was significantly shorter (P = 0.01) in patients with high PAPS (35 d), compared with moderate (61 d) and low (79 d) PAPS groups. MeNTS scores were provided for 105 patients and were analyzed by diagnosis. Patients with benign thyroid disease (n = 17) had a significantly higher MeNTS score than patients with thyroid disease which was malignant/suspicious for malignancy (n = 44) patients (51.5 versus 47.6, P = 0.034). Higher PAPS correlated well with a delay to surgery of <30 d (AUC: 0.72). MeNTS score did not correlate well with delay to surgery <30 d (AUC: 0.52). CONCLUSION: PAPS better predicted delay to surgery than MeNTS scores. PAPS may incorporate more complex components of clinical decision-making which are not captured in the MeNTS score.

A critical appraisal of surgical outcomes following orbital hypertelorism correction: what is the incidence of true bony relapse versus soft tissue telecanthus?

BACKGROUND: Orbital hypertelorism (OHT) represents a congenital condition defined by lateralization of the bony orbit, unlike soft tissue telecanthus in which there is an increase in intercanthal distance without true bony lateralization. Existing literature remains very limited in its postoperative assessment of bony versus soft tissue relapse, which may both clinically present as telecanthus. We performed a critical appraisal of the literature to determine the postoperative incidence of bony versus soft tissue relapse following OHT repair. METHODS: The PubMed, MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and clinicaltrials.org were searched systematically for all English studies published in any time frame reporting relapse rates following primary OHT repair. The primary outcome was incidence of bony and soft tissue relapse defined as orbital lateralization and medial canthal drift, respectively. The secondary outcome measures include postoperative complications, predictors of postoperative complications, timing and type of surgery, and revision rates. RESULTS: Eleven articles were included. A total of 84 (35.3%) patients experienced bony relapse while 43 (27.2%) patients experienced soft tissue relapse. Age at time of intervention (p < 0.92), severity at presentation (p < 0.90), and surgical technique (p < 0.09) were not found be significantly associated with relapse rate. Methods for long-term follow-up were not standardized, and there was no consistent measure to objectively assess telecanthus. CONCLUSIONS: There is no general consensus on predictive factors of long-term relapse following OHT repair in the form of box osteotomy or facial bipartition. These findings call for cross-sectional outcome standardization to better understand long-term outcomes across institutional, provider, and patient differences.

Outcomes After Tracheostomy in COVID-19 Patients.

OBJECTIVE: To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. BACKGROUND: Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure. METHODS: A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19. RESULTS: Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ±â€Š6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ±â€Š6.9 days (range 2-32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. CONCLUSIONS: Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

The lack of standardized outcome measures following lower extremity injury in elite soccer: a systematic review.

PURPOSE: Sport-specific, performance-based outcomes are increasingly used to improve evaluation of treatment efficacy in elite athletes; however, its usage in elite soccer may be limited. The purpose of this investigation is to (1) assess current outcome reporting in elite soccer; (2) identify any variability in reporting of outcomes; and (3) determine how sport-specific performance-based outcomes are utilized to assess treatment efficacy in elite soccer. METHODS: A systematic review of the Pubmed, MEDLINE, and Embase, Scopus, SportDiscus, CINAHL and HealthSource: Nursing databases was performed without limitation on publication year. Inclusion criteria were (1) reporting of outcomes after a (2) lower extremity injury in (3) elite soccer players. The study's population, type of injury, return to play, as well as functional, objective, and sport-specific performance-based outcomes were extracted from each article. The methodological index for nonrandomized studies was used for quality assessment. RESULTS: Twenty-one studies were selected after application of the inclusion and exclusion criteria. Objective outcomes were reported by 6 (29%) studies, and 6 (29%) employed patient-reported outcomes. The visual analog scale, Lysholm, and Tegner scores were the most common patient-reported outcomes (PROs). Return to play was reported by 18 (86%) studies, and only 2 (10%) utilized sport-specific performance-based outcomes. Despite the majority of studies reporting return to play, variation was seen in the definitions, and 15 (71%) studies reported the activity level of the players at final follow-up. CONCLUSION: Assessment of treatment efficacy is limited in elite athletes, and PROs lack the sensitivity to identify residual performance deficits after an injury. Although performance-based measures are available at the elite level, these outcomes were seldom used for evaluation of treatment efficacy. CLINICAL RELEVANCE: When treating elite soccer players, patient-reported outcome measures lack the sensitivity to detect changes in patient function, thus performance-based metrics may be more efficacious in assessing return from injury in these patients. LEVEL OF EVIDENCE: IV.

Does early motion lead to a higher failure rate or better outcomes after arthroscopic rotator cuff repair? A systematic review of overlapping meta-analyses.

BACKGROUND: The aims of the study were as follows: to perform a systematic review of meta-analyses comparing "early motion" and "delayed motion" after arthroscopic rotator cuff repair; to provide a framework to analyze the best available evidence to develop recommendations; and to identify gaps where suggestions could be made for future investigations. METHODS: Literature searches were performed to identify meta-analyses examining arthroscopic rotator cuff repair with early-motion vs. delayed-motion rehabilitation protocols. Clinical data were extracted, and meta-analysis quality was assessed using the Quality of Reporting of Meta-analyses and Oxman-Guyatt scales. RESULTS: Nine meta-analyses met inclusion criteria. No clear superiority was noted in clinical outcome scores for early-motion or delayed-motion rehabilitation. Results of tendon healing were found to be either no different or in favor of delayed motion, but no differences were noted in rotator cuff tear recurrence rates postoperatively. The majority of meta-analyses found significantly better range of motion with early motion up to a year postoperatively for forward elevation and up to 6 months for external rotation, but significant differences were not reported for functional improvements and strength at 12 months postoperatively. Subgroup analyses suggested that larger preoperative tear sizes have significantly greater retear rates with early-motion rehabilitation. CONCLUSIONS: The current highest level of evidence suggests that early-motion rehabilitation after rotator cuff repair results in superior postoperative range of motion up to 1 year. Whereas early motion and delayed motion after cuff repair may lead to comparable functional outcomes and retear rates, concern exists that early motion may result in greater retear rates, particularly with larger tear sizes.

Accuracy of Salivary Circulating Tumor Human Papillomavirus DNA in Detecting Oropharyngeal Cancer: A Systematic Review and Meta-Analysis.

Importance: Circulating tumor human papillomavirus DNA (ctHPV DNA) has shown potential as a biomarker capable of improving outcomes in patients with HPV-related oropharyngeal (OP) cancer. It can be isolated from plasma or saliva, with the latter offering reduced invasiveness and theoretic reduction of lead time. Objective: To perform a systematic review and meta-analysis on the accuracy of salivary ctHPV DNA for detecting HPV-associated OP cancer. Data Sources: Cochrane Library, Embase, PubMed, and Web of Science databases were searched from inception through October 2023. Study Selection: All patients who underwent salivary ctHPV DNA testing at presentation for possible or diagnosed HPV-related OP cancer were included. Non-English and review publications were excluded. Two authors independently voted on article inclusion with a third resolving conflicting votes. Data Extraction and Synthesis: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, multiple authors independently abstracted data and assessed bias of included articles. Bivariate random-effects meta-analysis was performed with I2 to assess for study heterogeneity. Main Outcomes and Measures: Sensitivities, specificities, positive likelihood ratios (PLR), negative likelihood ratios (NLR), and diagnostic odds ratios (DOR) with 95% CIs alongside area under the curve (AUC) of a summary receiver operating characteristic (SROC) curve were calculated. The initial analysis took place throughout December 2023. Results: Of 440 initially identified articles, 6 met inclusion criteria and demonstrated moderate heterogeneity (I2 = 36%) with low risk of bias and low applicability concerns. Overall, 263 total patients were included with a median (range) age of 58 (39-86) years, and 228 (87%) were male patients. Per updated prognostic staging criteria, localized tumors (ie, stages 1 or 2) comprised most cancers at 139 (77%), whereas advanced ones (ie, stages 3 or 4) comprised the remaining 41 (23%). Pooled sensitivity, specificity, PLR, NLR, and DOR values were 64% (95% CI, 36%-85%), 89% (95% CI, 46%-99%), 11.70 (95% CI, 0.37-77.00), 1.21 (95% CI, 0.08-7.00), and 139.00 (95% CI, 0.05-837.00), respectively. The AUC of the SROC curve was 0.80. Conclusions and Relevance: This study supports salivary ctHPV DNA as an acceptably specific test in detecting HPV-associated OP cancer that would benefit from testing in clinical trials prior to real-time implementation.

Systematic evaluation of Merkel cell carcinoma clinical practice guidelines using the AGREE II instrument.

Merkel cell carcinoma (MCC) is a rare type of skin cancer that requires a multidisciplinary approach with a variety of specialists for management and treatment. Clinical practice guidelines (CPGs) have recently been established to standardize management algorithms. The objective of this study was to appraise such CPGs via the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Eight CPGs were identified via systematic literature search following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Four appraisers trained in AGREE II protocols evaluated each CPG and deemed two CPGs as high quality, five as moderate quality, and one as low quality. Intraclass correlation coefficients (ICCs) were calculated to verify reviewer consistency as excellent, good, and moderate across four, one, and one domain, respectively. The majority of MCC CPGs are lacking in specifying stakeholder involvement, applicability, and rigor of development. The two high quality CPGs are from the Alberta Health Services (AHS) and the collaboration between the European Dermatology Forum, the European Association of Dermato-Oncology, and the European Organization of Research and Treatment of Cancer (EDF/EADO/EORTC). The EDF/EADO/EORTC CPG had the highest overall score with no significant deficiencies across any domain. An important limitation is that the AGREE II instrument is not designed to evaluate the validity of each CPG's recommendations; conclusions therefore can only be drawn about each CPG's developmental quality. Future MCC CPGs may benefit from garnering public perspectives, inviting external expert review, and considering available resources and implementation barriers during their developmental stages.

The fragility index: how robust are the outcomes of head and neck cancer randomised, controlled trials?

BACKGROUND: The fragility index represents the minimum number of patients required to convert an outcome from statistically significant to insignificant. This report assesses the fragility index of head and neck cancer randomised, controlled trials. METHODS: Studies were extracted from PubMed/Medline, Scopus, Embase and Cochrane databases. RESULTS: Overall, 123 randomised, controlled trials were included. The sample size and fragility index medians (interquartile ranges) were 103 (56-213) and 2 (0-5), respectively. The fragility index exceeded the number of patients lost to follow up in 42.3 per cent (n = 52) of studies. A higher fragility index correlated with higher sample size (r = 0.514, p < 0.001), number of events (r = 0.449, p < 0.001) and statistical significance via p-value (r = -0.367, p < 0.001). CONCLUSION: Head and neck cancer randomised, controlled trials demonstrated low fragility index values, in which statistically significant results could be nullified by altering the outcomes of just two patients, on average. Future head and neck oncology randomised, controlled trials should report the fragility index in order to provide insight into statistical robustness.

Reassessing the Utility of Surgical Intervention for Skull Base Osteomyelitis: A 16-Year Experience.

OBJECTIVE: The role of surgery in lateral skull base osteomyelitis (SBO) is controversial. Surgical intervention is often requested by consulting services in the interest of additional culture data to inform medical management. However, whether surgery alters subsequent antibiotic treatment or modifies disease outcome remains unknown. The aim of this study was to investigate the role of surgical intervention in the treatment of SBO by (1) comparing nonsurgical and surgical culture data and (2) assessing clinical outcomes and treatment course following surgical intervention. STUDY DESIGN: Retrospective. SETTING: Tertiary care center. METHODS: The electronic record was queried for all patients with SBO who presented to a single institution over a 16-year period (2007-2023). Information recorded included history and exam, bedside and intraoperative culture data, antibiotic course, and disease outcomes. Primary outcome measures included change in medical management based on intraoperative cultures, recurrence rates, and mortality rates. RESULTS: Forty patients (41 ears, average age 73 ± 13 years) met inclusion criteria. Out of 13 (32%) patients who underwent surgical intervention, one intraoperative culture changed the antibiotic course due to identification of resistance to the original antibiotic used. Surgery did not demonstrate a benefit in overall mortality (23% vs 18%, P = 0.36) or facial nerve function (33% vs 50%, P = 0.56) compared to medical management, and was associated with increased recurrence rates (54% vs 11%, P = 0.05). CONCLUSION: Surgical cultures rarely changed antibiotic selection. Surgical debridement in treatment-refractory SBO was also not associated with improvement in recurrence or mortality rates, though this may reflect underlying differences in disease severity.

Home Sleep Testing versus Traditional Polysomnography: Pros and Cons.

Obstructive sleep apnea (OSA) is associated with long-term cardiovascular and respiratory comorbidities and increased burden on the health-care system. Early and accurate diagnosis is essential to reduce physical and financial implications of the disease. Polysomnography uses neurophysiologic channels as well as basic respiratory and sleep parameters to best estimate the presence and/or severity of OSA. Although home sleep testing may have the potential for more variable results, it is a viable alternative to increase access to diagnosis of OSA and facilitate initiation of positive airway pressure.

The Use of Endonasal Spreader Grafts in Preservation Rhinoplasty.

SUMMARY: Rhinoplasty is a complicated procedure that requires surgical finesse and precision to sculpt a framework that suits each patient's unique anatomical needs. Extensive resection may lead to nasal valve incompetence, causing obstructive symptoms associated with reduced quality of life. Numerous techniques have been described to help preserve and open the nasal airway, thereby mitigating valvular obstructive problems. In particular, the endonasal spreader graft is a common technique used to widen the internal nasal valve cross-sectional area while limiting external incisions and preserving local nasal structures. Preservation rhinoplasty is a variation of the traditional rhinoplasty that can lower the nasal dorsum without causing major disruption to the nasal keystone area, the junction between the middle and upper thirds of the nose. This study describes the successful and safe combination of these two surgical operations, demonstrating three case examples in which all patients reported improved postoperative nasal obstruction symptoms. Using endonasal spreader grafts in preservation rhinoplasty allows providers to manage the nasal valve and nasal dorsum similarly to the external approach without extensive deconstruction and reconstruction.

Using injectable fillers for chin and jawline rejuvenation.

Objective: As the population ages, facial plastic providers must remain aware of the treatments to prevent and reverse the external signs of aging. In the mandibular region, skin laxity and soft tissue sagging in the jawline may lead to jowling and chin ptosis along with reduced chin projection. While surgical procedures, including chin implantation, may be performed, nonsurgical procedures are becoming increasingly popular due to their temporary, noninvasive, yet effective methods. This review covers the use of hyaluronic acid, calcium hydroxylapatite, poly-l-lactic acid, and polymethyl methacrylate in the jawline. Methods: PubMed was searched for data on the mechanism of action, pertinent anatomy, indications, contraindications, technique, and evidence supporting the safety and efficacy of the fillers. Results: There are a wide variety of fillers available for use in the lower face with unique characteristics and application methods. While the advantages of injectable fillers include relatively affordable cost, minimal patient discomfort, and limited recovery times, taking measures to prevent short- and long-term complications is necessary for optimal results. Conclusions: Understanding the benefits and limitations of injectable fillers in the jawline can help providers appropriately counsel and treat patients.

Gender analysis of the top classic papers in otolaryngology head and neck surgery.

Objective: The aim of this study was to identify and analyze the gender breakdown of first authorship contributing to the most-cited papers in the field of otolaryngology, with a goal of identifying trends in gender representation in publishing. Methods: The top 150 most-cited papers were identified using the Science Citation Index of the Institute for Scientific Information. Among the first authors, gender, h-index, percentage of first, last, and corresponding authorship positions, total publications, and citations were analyzed. Results: The majority of papers were in the English language, from the United States, of clinical nature, and on otologic topics. Eighty-one percent of papers (n = 122) had men who were first authors, although there was no difference in h-index score, authorship position, number of publications, citations, and average citations/year between men and women first authors. Upon subgroup analysis by decade (1950s-2010s), there was no difference in the number of articles by women first authors (P = 0.11); however, there was a statistically significant increase in the percentage of women authors (P = 0.001) in papers published later compared to those published earlier. Conclusions: While a promising number of women otolaryngologists are publishing high-powered articles, future initiatives to promote academic inclusivity of women should be considered.

A quiet place: The impact of the word "quiet" on clinical workload.

Purpose: This study aimed to determine the impact of uttering the word "quiet" on clinical workload during the overnight otolaryngology call shift and understand the factors contributing to resident busyness. Materials and Methods: A multicenter, single-blind, randomized-controlled trial was conducted. A total of 80 overnight call shifts covered by a pool of 10 residents were randomized to the quiet or to the control group. At the start of shift, residents were asked to state aloud, "Today will be a quiet night" (quiet group) or "Today will be a good night" (control group). Clinical workload, as measured by number of consults, was the primary outcome. Secondary measures included number of sign-out tasks, unplanned inpatient and operating room visits, number of phone calls and hours of sleep, and self-perceived busyness. Results: There was no difference in the number of total (P = 0.23), nonurgent (P = 0.18), and urgent (P = 0.18) consults. Tasks at signout, total phone calls, unplanned inpatient visits, and unplanned operating room visits did not differ between the control and quiet groups. While there were more unplanned operating room visits in the quiet group (29, 80.6%) compared to the control group (34, 94.4%), this was not found to be significant (P = 0.07). The majority of residents reported feeling "not busy" during control nights (18, 50.0%) compared to feeling "somewhat busy" during quiet nights (17, 47.2%; P = 0.42). Conclusion: Contrary to popular belief, there is no clear evidence that uttering the word "quiet" significantly increases clinical workload.

ERAS Protocols for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: Enhanced recovery after surgery (ERAS) protocols are evidenced-based multidisciplinary programs implemented in the perioperative setting to improve postoperative recovery and attenuate the surgical stress response. However, evidence on their effectiveness in thyroid and parathyroid surgery remains sparse. Therefore, our goal was to investigate the clinical benefits and cost-effectiveness of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy. DATA SOURCE: A systematic review of Medline, Scopus, Embase, and gray literature was performed to identify studies of ERAS or clinical care protocols for thyroidectomy and parathyroidectomy. REVIEW METHODS: Two reviewers screened studies using predetermined inclusion criteria. Our primary outcomes included hospital length of stay and hospital costs. Readmission and postoperative complication rates composed our secondary outcomes. Meta-analysis was performed to compare outcomes for patients enrolled in the ERAS protocol versus standard of care. RESULTS: A total of 450 articles were identified; 7 (1.6%) met inclusion criteria with a total of 3082 patients. Perioperative components in ERAS protocols varied across the studies. Nevertheless, patients enrolled in ERAS protocols had reduced hospital length of stay (mean difference, -0.64 days [95% CI, -0.92 to -0.37]) and hospital costs (in US dollars; mean difference, -307.70 [95% CI, -346.49 to -268.90]), without an increase in readmission (odds ratio, 0.75 [95% CI, 0.29-1.94]) or complication rates (odds ratio, 1.14 [95% CI, 0.82-1.57]). CONCLUSION: There is growing literature supporting the role of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy. These protocols significantly reduce hospital length of stay and costs without increasing complications or readmission rates.

Critical review of clinical practice guidelines for evaluation of neck mass in adults.

OBJECTIVE: Several clinical practice guidelines have been produced and disseminated for the evaluation of a neck mass. However, to date, the quality and methodologic rigor of these clinical practice guidelines have not been appraised. Therefore, this study set out to identify and assess the methodologic quality of national and international guidelines for the evaluation and management of neck masses in adults. METHODS: We conducted a comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS and grey literature sources until September 2020. The quality of these guidelines was assessed by four reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered acceptable quality if they scored >60%, and Intraclass Correlation Coefficients (ICC) were calculated to assess agreement among the appraisers. RESULTS: Seven guidelines were assessed for evaluation. Among these, only the American Academy of Otolaryngology (AAO), Cancer Care Manitoba (CCMB), and the American Society of Clinical Oncology (ASCO) achieved an overall rating of "high". The remaining four guidelines achieved ratings of either "average" or "low". The "Scope and Purpose" domain achieved the highest mean score (94.4%±5.0%), and lowest was "Applicability" (51.5%±29.2%). ICC analysis showed substantial to very good agreement across all domains (0.75-0.98). CONCLUSION: These findings highlight the variability in methodologic quality of guidelines for the evaluation and management of adult neck mass. The results from this analysis highlight the need to improve guidelines development process for this topic and may guide the selection and use of these guidelines in clinical practice.

Clinicopathologic Characteristics and Prognostic Factors Impacting Survival in Melanoma of the Eyelid.

PURPOSE: To examine prognostic factors for survival in patients with melanoma of the eyelid. DESIGN: Retrospective cohort study. METHODS: This population-based study reviewed patients with primary melanoma of the eyelid diagnosed in the Surveillance, Epidemiology and End Results database between 1975 and 2016. The primary outcomes included survival rates estimated by Kaplan-Meier analysis and mortality hazard ratios (HRs) for overall survival and disease-specific survival (DSS). RESULTS: The cohort consisted of 2257 patients with cutaneous melanoma of the eyelid, representing 1380 cases of melanoma in situ and 877 cases of invasive melanoma. For melanoma in situ and invasive melanoma respectively, at 5 years, the overall survival rates were 88.6% and 77.1%, while DSS rates were 99.4% and 91.0%. Cox regression analysis for eyelid melanoma indicated that for invasive melanoma, age at diagnosis ≥75 years (HR 2.17 [95% confidence interval {CI} 1.02-4.60]; P = .04), T4 staging (HR 8.45 [95% CI 2.96-25.31]; P < .001), lymph node involvement (HR 3.61 [95% CI 1.12-11.60]; P = .03), and nodular melanoma (HR 3.31 [95% CI 1.50-7.32]; P = .003) histologic subtype were associated with decreased rates of survival. Sex and tumor ulceration did not impact survival. CONCLUSIONS: This study is the largest analysis to date that focuses on DSS for cutaneous melanoma of the eyelid. The most significant predictors for invasive melanoma survival are age ≥75 years at diagnosis, T4 staging, lymph node involvement, and the nodular melanoma histologic subtype. Patients with these attributes are at higher risk and should be counseled regarding prognosis.

Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review.

OBJECTIVE: Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction. DATA SOURCES: A systematic search was conducted in PubMed, Cochrane, Embase, Scopus, and clinicaltrials.gov. REVIEW METHODS: All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes. RESULTS: A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. CONCLUSION: With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.