Indocyanine green near infrared-guided surgery in children, adolescents, and young adults with otolaryngologic malignancies.

OBJECTIVE: Head and neck cancers represent critical challenges due to the restricted anatomical space in children and the proximity of critical neurovascular structures which can compromise complete tumor resection. Applications of Indocyanine green (ICG) near infrared (NIR) fluorescent image-guided surgery (FGS) have recently expanded into the pediatric population, emphasizing its relevance for tumor delineation and evaluation of tissue perfusion. The objectives of the present study are twofold. First, we aim to assess the role of ICG NIR imagery in identifying neoplastic disease and second, to evaluate its role as an adjunct to identify metastatic deposits in cervical lymph node in children, adolescents, and young adults with head and neck cancers. METHODS: Eight patients with head and neck malignancies underwent ICG NIR FGS, between January 2019 and November 2021. ICG NIR findings were compared with preoperative cross-sectional imaging and results of operative tissue pathology analyses. RESULTS: All primary tumors were identified on preoperative imaging and intraoperatively with ICG NIR; however, for one case, extension of tumor was revealed with ICG NIR and confirmed by histopathological examination but was not otherwise visible on preoperative imaging or with naked eye visual and tactile assessment. ICG NIR assisted the decision process in a difficult case for which curative resection, without significant functional morbidity and potential mortality, was unrealistic. Although ICG NIR evaluation of the surgical bed did not display residual tumor, margins were found positive in two cases. ICG NIR evaluation for local metastases changed the surgical strategy in one patient by prompting conversion to bilateral neck dissections. The sensitivity of preoperative multimodality imaging to identify cervical levels of invasion was 75% with a specificity of 70%, a PPV of 33%, a NPV of 78% and an accuracy of 72%. The ICG NIR sensitivity was 83%, its specificity was 88% with a PPV of 91%, a NPV of 80% and an accuracy of 86%. The combination of preoperative multimodality imaging with ICG NIR findings led to a sensitivity of 83%, specificity of 88% and accuracy of 86%. CONCLUSION: This case series provides a proof of concept of the feasibility of ICG NIR, as an adjunct in tumor and local metastases identification in young patients with head and neck tumors. It revealed to be feasible and safe for intra-operative tumor identification, thus guiding and facilitating resection. However, it showed some limitations in precise tumor margin assessment. The combination of preoperative multimodality imaging with ICG NIR findings improved local metastases localization.

The effect of nutritional status on post-operative outcomes in pediatric otolaryngology-head and neck surgery.

INTRODUCTION: Nutritional status can affect surgical patients in terms of stress response, healing time, and outcomes. Several abnormalities are known to have a high prevalence in the general population such as vitamin D deficiency (VDD) and subclinical hypothyroidism. We hypothesized that there will be elevated rates of nutritional deficiencies in preoperative patients which may adversely affect postoperative outcomes following pediatric otolaryngology surgery. METHODS: IRB approval was obtained for a cross-sectional cohort study. Consecutive patients underwent nutritional evaluation when being scheduled for surgery including TSH, albumin and vitamin D. Demographic data, supplementation, and early complication rates were collected. RESULTS: 125 patients were included in the final cohort with adequate demographic distribution. Based on anthropometric data, 12% of our cohort was found to be undernourished, and 40% of our cohort with elevated BMI. However, there was no relationship found between Z-scores and complications. VDD was noted in 83/125 (66.4%) patients. Our cohort had increased rates of VDD in patients with elevated BMI and African American ethnicity. Thyroid hormone abnormalities were present in 12 patients. Mean serum albumin level was 4.29 in our cohort all within normal range. We did find increased risk of postoperative complications in patients with previously diagnosed comorbidities. (p=0.006). CONCLUSION: There is no current recommendation or consensus for nutritional assessment in preoperative pediatric patients. Our study did not show statistically significant correlation with z-scores, low vitamin D levels with supplementation, albumin, or TSH to postoperative complications. However, our patient cohort had higher than average rates of VDD compared to the many studies of the general pediatric population and significant negative correlation between vitamin D levels and z-scores. By early preoperative identification of VDD and supplementation with calciferol, we found no significant difference in complication rates in patients based on their initial vitamin D status. We suggest screening preoperative patients using z-score calculations and vitamin D levels based on individual patient risk factors including atrisk patient populations such as African American children, and obese children.

Factors Correlating to Burnout among Otolaryngology Residents.

OBJECTIVES: Physicians have high rates of burnout with an Otolaryngology burnout rate of 42%. The most studied burnout correlation is increased work hours. More recently, mindfulness training programs have been shown to decrease burnout and increase self-compassion. Regarding burnout studies specific to Otolaryngology residents, there have been few in the past decade. This study explores correlations between burnout and procedure involvement, non-clinical responsibilities and mindfulness practices along with gathering updated work hours data. METHODS: A single survey question was shown to be a reliable substitute for Maslach Burnout Inventory in assessing burnout. A survey was sent to all US Otolaryngology residents to investigate the correlation of burnout to post-graduate year, work hours, procedure involvement, non-clinical responsibilities, and mindfulness practices. Residents were asked to answer questions regarding their previous year of training. RESULTS: Overall burnout was 50%. PGY-1 and PGY-5 were completed with a low burnout rate compared to other years. Increased work hours were confirmed to increase burnout. Increased involvement in procedures, decreased exercise, and increased time completing paperwork correlated with increased burnout. No other factors including mindfulness correlated with increased or decreased burnout. However, only 20% who practiced mindfulness training had this training offered by their department or university. CONCLUSION: Annals of Otology, Rhinology & Laryngology A 50% burnout rate is a concerning rate. Increased work hours and PGY-2 through PGY-4 correlated with increased burnout. Accessibility to mindfulness training was low. As mindfulness training is a proven activity to decrease burnout, more departments could benefit from providing these experiences to their residents.