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.

Breast and thyroid cancer: A multicenter study with Accrual to Clinical Trials Network.

OBJECTIVE: To investigate a possible link between breast and thyroid cancer. METHODS: A multicenter retrospective review of patients in the electronic medical records of six Accrual to Clinical Trial (ACT) institutions with both breast cancer and thyroid carcinoma. Each center queried its data using a predefined data dictionary. Information on thyroid and breast cancer included dates of diagnosis, histology, and patient demographics. RESULTS: A random-effects model was used. There were 4.24 million women's records screened, 44 605 with breast cancer and 11 846 with thyroid cancer. The relative risks observed at each institution ranged from 0.49 to 13.47. The combined risk ratio (RR) estimate was 1.77 (95% confidence interval: 0.50-5.18). CONCLUSION: There was no association between the risk of developing thyroid cancer and being a breast cancer survivor compared to no history of breast cancer, but the range of relative risks among the participating institutions was wide. Our findings warrant further study of more institutions with larger sample size. Additionally, further analysis of the significance of regional RR differences may be enlightening.

Improving on the Do-It-Yourself Ultrasound-Guided Fine-Needle Aspiration Simulation Phantom.

The increasing use of ultrasound (US) for the diagnostic workup of thyroid lesions has subsequently been met with an increasing demand for effective US and US-guided fine-needle aspiration models. Although numerous do-it-yourself phantoms have been previously described, to our knowledge, this is the first to describe a more realistic US thyroid model using inexpensive consumer-grade materials. A simple phantom was developed and successfully used to obtain US images that realistically mimic thyroid anatomy and echogenicity. The phantom was constructed for a total cost of $6.69. It served as an inexpensive and anatomically realistic means to simulate thyroid US and US-guided fine-needle aspiration.

Intraoperative use of optical coherence tomography to differentiate normal and diseased thyroid and parathyroid tissues from lymph node and fat.

The purpose of this study is twofold: (1) to determine the feasibility of optical coherence tomography (OCT) to differentiate normal and diseased tissue of the neck region intraoperatively and (2) to evaluate how accurately a cohort of test subjects can identify various tissue types when shown a sample set of OCT images. In this in vivo, prospective, single institutional study, an OCT imaging system (Niris, Imalux, Cleveland, OH) was used to image parathyroid, thyroid, lymph node, and fat tissue in 76 patients during neck surgery. Biopsies were performed for comparison of OCT images with histology in select cases (n = 20). Finally, a group of either surgeons or scientists familiar with OCT (n = 17) were shown a sample of OCT images and asked to identify the tissue. A total of 437 OCT images were analyzed, and characteristic features of each tissue type were identified. OCT demonstrated distinct differences in structural architecture and signal intensity that allows differentiation between thyroid and parathyroid tissues, lymph nodes, and fat. OCT images were also compared with histology with good correlation. There was no difference in correctly identifying OCT-imaged tissue type between surgeons and scientists. This study is the first in vivo OCT imaging study to evaluate both normal and diseased tissues that may be encountered during neck surgery. OCT has the potential to become a valuable intraoperative tool to differentiate diseased and normal thyroid tissue intraoperatively to obtain an "optical biopsy" in real time without fixation, staining, or tissue resection.

Hand Sanitizer in a Pandemic: Wrong Formulations in the Wrong Hands.

BACKGROUND: Households are increasingly stockpiling and producing hand sanitizer amid the coronavirus disease 2019 (COVID-19) pandemic, which can pose an increased risk for unintentional toxicity among children. Despite guidelines for hand sanitizer production published by the World Health Organization, many turn to streaming media for instruction. OBJECTIVE: The purpose of this investigation was to evaluate hand sanitizer formulations and safety precautions discussed in popular do-it-yourself (DIY) YouTube videos, and to assess the frequency of calls to poison control centers for pediatric hand sanitizer exposure before and after the arrival of COVID-19 in the United States. METHODS: The first 100 videos on YouTube with the most views using the search term "DIY hand sanitizer" were evaluated for accuracy compared with the World Health Organization local hand sanitizer production guidelines. The incidence of pediatric hand sanitizer exposure reported to participating U.S. poison control centers from January 2018 through May 2020 was reviewed from the American Association of Poison Control Centers National Poison Data System. The average number of calls between January 2020 and May 2020 was compared, and the average number of calls in March 2020 was compared with March 2019 and March 2018. RESULTS: Of the YouTube videos that met inclusion criteria, 27% discussed the use of at least 96% ethanol or 99.8% isopropyl alcohol, 4.1% incorporated 3% hydrogen peroxide, 82% used glycerol or an alternative humectant, and 4.1% specified the need for distilled or previously boiled water. Most of the videos failed to describe labeling storage containers, 69% of videos encouraged the use of oils or perfumes to enhance hand sanitizer scent, and 2% of videos promoted the use of coloring agents to be more attractive for use among children specifically. There was a significantly increased average number of daily calls to poison control centers regarding unsafe pediatric hand sanitizer exposure since the first confirmed COVID-19 patient in the United States. There was a significantly increased average number of daily calls in March 2020 compared with the previous 2 years. CONCLUSIONS: YouTube may not be an accurate source for effective hand sanitizer concoction. Health care providers and parents should be aware of the increased surge in hand sanitizer exposure among children and should take proper precautionary measures.

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.

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.

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.

Posttreatment Surveillance Imaging After Radiation for Head and Neck Cancer.

Importance: The role of surveillance imaging after treatment for head and neck cancer is controversial and evidence to support decision-making is limited. Objective: To determine the use of surveillance imaging in asymptomatic patients with head and neck cancer in remission after completion of chemoradiation. Design, Setting, and Participants: This was a retrospective, comparative effectiveness research review of adult patients who had achieved a complete metabolic response to initial treatment for head and neck cancer as defined by having an unequivocally negative positron emission tomography (PET) scan using the PET response criteria in solid tumors (PERCIST) scale within the first 6 months of completing therapy. The medical records of 501 consecutive patients who completed definitive radiation therapy (with or without chemotherapy) for newly diagnosed squamous cell carcinoma of the head and neck between January 2014 and June 2022 were reviewed. Exposure: Surveillance imaging was defined as the acquisition of a PET with computed tomography (CT), magnetic resonance imaging (MRI), or CT of the head and neck region in the absence of any clinically suspicious symptoms and/or examination findings. For remaining patients, subsequent surveillance after the achievement of a complete metabolic response to initial therapy was performed on an observational basis in the setting of routine follow-up using history-taking and physical examination, including endoscopy. This expectant approach led to imaging only in the presence of clinically suspicious symptoms and/or physical examination findings. Main Outcome and Measures: Local-regional control, overall survival, and progression-free survival based on assignment to either the surveillance imaging or expectant management cohort. Results: This study included 340 patients (mean [SD] age, 59 [10] years; 201 males [59%]; 88 Latino patients [26%]; 145 White patients [43%]) who achieved a complete metabolic response during this period. There was no difference in 3-year local-regional control, overall survival, progression-free survival, or freedom from distant metastasis between patients treated with surveillance imaging vs those treated expectantly. Conclusions and Relevance: In this comparative effectiveness research, imaging-based surveillance failed to improve outcomes compared with expectant management for patients who were seemingly in remission after completion of primary radiation therapy for head and neck cancer.

Otolaryngology residency programs' perspectives on virtual interviews during the COVID-19 pandemic.

Objective: To evaluate perceptions of otolaryngology residency program directors (PDs) and department chairs (DCs) on virtual interviews (VIs) at the conclusion of the 2021 residency match. Study design: Cross-sectional survey study. Methods: An anonymous and voluntary survey was administered to PDs and DCs of U.S. otolaryngology residency programs from March 1, 2021 to April 11, 2021. Utilizing Likert scale ratings, the survey measured overall satisfaction with the VI format, perceived ability to assess key candidate attributes, relative importance of traditional candidate metrics, and likelihood to implement VIs in future cycles. Results: Ninety-four surveys were completed by PDs (48.9%) and DCs (51.1%). Sixty (63.8%) respondents found the VI experience to be satisfactory or strongly satisfactory. Sixty-six (70.2%) respondents felt confident in their ability to assess a candidate's professionalism and communication skills through VIs; however, confidence in gauging an applicant's clinical skills/knowledge (41.2%) and overall program fit (47.3%) was lower. Regarding candidate metrics, 64 (68.1%) respondents believed that personal prior knowledge of the applicant gained increased importance with VIs. Forty-four (46.8%) and 45 (47.9%) participants believed that letters of recommendation in the specialty and perceived commitment to their program similarly attained increased significance in evaluating applicants, respectively. Conclusion: Most PDs and DCs were satisfied with their VI experiences and expect the quality of interns to be unaffected by virtual assessment modalities. Majority opinion on the relative importance of traditional applicant metrics remained largely unchanged, the exception being an increase in importance of prior knowledge of the applicant.Level of Evidence: N/A.

Transoral laser microsurgery for laryngeal cancer: a primer and review of laser dosimetry.

Transoral laser microsurgery (TLM) is an emerging technique for the management of laryngeal and other head and neck malignancies. It is increasingly being used in place of traditional open surgery because of lower morbidity and improved organ preservation. Since the surgery is performed from the inside working outward as opposed to working from the outside in, there is less damage to the supporting structures that lie external to the tumor. Coupling the laser to a micromanipulator and a microscope allows precise tissue cutting and hemostasis; thereby improving visualization and precise ablation. The basic approach and principles of performing TLM, the devices currently in use, and the associated dosimetry parameters will be discussed. The benefits of using TLM over conventional surgery, common complications and the different settings used depending on the location of the tumor will also be discussed. Although the CO(2) laser is the most versatile and the best-suited laser for TLM applications, a variety of lasers and different parameters are used in the treatment of laryngeal cancer. Improved instrumentation has lead to an increased utilization of TLM by head and neck cancer surgeons and has resulted in improved outcomes. Laser energy levels and spot size are adjusted to vary the precision of cutting and amount of hemostasis obtained.

Increased PD-L1 and p16 expression are common in oropharyngeal squamous cell carcinoma.

Overexpression of p16 is closely related to human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (SCC) and pertains a prognostic relevance. Programmed cell death 1-ligand 1 (PD-L1) is another important marker, as anti-PD-L1 immunotherapy is available. Retrospective analysis of 57 cases of the SCC involving oropharynx (27 cases), hypopharynx (5 cases), larynx (11 cases), and oral cavity (14 cases) was performed. Each case was scrutinized for the basaloid morphology, p16, and PD-L1 expression. Basaloid morphology was identified in 47% of total cases. The majority of basaloid SCC variants were located in the oropharynx (89%). High expression of p16 was mostly observed in the oropharynx. High PD-L1 expression was seen predominantly in oropharyngeal and hypopharyngeal locations. Further studies in a larger cohort are necessary to correlate PD-L1 and p16 expression with survival.

Machine learning models to predict length of stay and discharge destination in complex head and neck surgery.

BACKGROUND: This study develops machine learning (ML) algorithms that use preoperative-only features to predict discharge-to-nonhome-facility (DNHF) and length-of-stay (LOS) following complex head and neck surgeries. METHODS: Patients undergoing laryngectomy or composite tissue excision followed by free tissue transfer were extracted from the 2005 to 2017 NSQIP database. RESULTS: Among the 2786 included patients, DNHF and mean LOS were 421 (15.1%) and 11.7 ± 8.8 days. Four classification models for predicting DNHF with high specificities (range, 0.80-0.84) were developed. The generalized linear and gradient boosting machine models performed best with receiver operating characteristic (ROC), accuracy, and negative predictive value (NPV) of 0.72-0.73, 0.75-0.76, and 0.88-0.89. Four regression models for predicting LOS in days were developed, where all performed similarly with mean absolute error and root mean-squared errors of 3.95-3.98 and 5.14-5.16. Both models were developed into an encrypted web-based interface: https://uci-ent.shinyapps.io/head-neck/. CONCLUSION: Novel and proof-of-concept ML models to predict DNHF and LOS were developed and published as web-based interfaces.

Surface kinematic and depth-resolved analysis of human vocal folds in vivo during phonation using optical coherence tomography.

SIGNIFICANCE: The human vocal fold (VF) oscillates in multiple vectors and consists of distinct layers with varying viscoelastic properties that contribute to the mucosal wave. Office-based and operative laryngeal endoscopy are limited to diagnostic evaluation of the VF epithelial surface only and are restricted to axial-plane characterization of the horizontal mucosal wave. As such, understanding of the biomechanics of human VF motion remains limited. AIM: Optical coherence tomography (OCT) is a micrometer-resolution, high-speed endoscopic imaging modality which acquires cross-sectional images of tissue. Our study aimed to leverage OCT technology and develop quantitative methods for analyzing the anatomy and kinematics of in vivo VF motion in the coronal plane. APPROACH: A custom handheld laryngeal stage was used to capture OCT images with 800 A-lines at 250 Hz. Automated image postprocessing and analytical methods were developed. RESULTS: Novel kinematic analysis of in vivo, long-range OCT imaging of the vibrating VF in awake human subjects is reported. Cross-sectional, coronal-plane panoramic videos of the larynx during phonation are presented with three-dimensional videokymographic and space-time velocity analysis of VF motion. CONCLUSIONS: Long-range OCT with automated computational methods allows for cross-sectional dynamic laryngeal imaging and has the potential to broaden our understanding of human VF biomechanics and sound production.

The use of optical coherence tomography and convolutional neural networks to distinguish normal and abnormal oral mucosa.

Incomplete surgical resection of head and neck squamous cell carcinoma (HNSCC) is the most common cause of local HNSCC recurrence. Currently, surgeons rely on preoperative imaging, direct visualization, palpation and frozen section to determine the extent of tissue resection. It has been demonstrated that optical coherence tomography (OCT), a minimally invasive, nonionizing near infrared mesoscopic imaging modality can resolve subsurface differences between normal and abnormal head and neck mucosa. Previous work has utilized two-dimensional OCT imaging which is limited to the evaluation of small regions of interest generated frame by frame. OCT technology is capable of performing rapid volumetric imaging, but the capacity and expertise to analyze this massive amount of image data is lacking. In this study, we evaluate the ability of a retrained convolutional neural network to classify three-dimensional OCT images of head and neck mucosa to differentiate normal and abnormal tissues with sensitivity and specificity of 100% and 70%, respectively. This method has the potential to serve as a real-time analytic tool in the assessment of surgical margins.

Free Flap Versus Pedicled Flap Reconstruction of Laryngopharyngeal Defects: A 10-Year National Surgical Quality Improvement Program Analysis.

OBJECTIVES/HYPOTHESIS: Large defects after total laryngectomy (TL) and total laryngopharyngectomy (TLP) often benefit from free flap (FF) or pedicled flap (PF) reconstruction to maintain continuity of the aerodigestive tract, protect great vessels, or reinforce pharyngeal closure. Although both techniques are commonly used, no consensus exists as to which results in fewer complications. The goal of this study was to determine if 30-day morbidity/mortality outcomes differ between PF and FF reconstruction in patients undergoing TL/TLP. STUDY DESIGN: Retrospective cohort study. METHODS: Patients were analyzed who underwent TL/TLP with reconstruction using records from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015). RESULTS: A total of 347 patients were included; 204 received FF reconstruction, whereas 143 received PF reconstruction. FF reconstruction was more commonly used with TLP defects (P = .001). The total operative time in the FF (590 ± 140 minutes) was longer than the PF (441 ± 125 minutes) group (P < .0001). There was a higher rate of postoperative transfusions in those undergoing FF reconstruction (P = .022). There was no significant difference in complication rates among TLP patients. Among TL patients only, FF reconstruction had a higher association with wound infections than PFs (P = .040). On multivariate analysis, low hematocrit was associated with complications (P = .031). Age (P = .031) and congestive heart failure exacerbation (P < .001) were associated with increased hospital stay. Overall, there were no differences in readmissions, reoperations, or deaths between the groups. CONCLUSIONS: Reported complication rates after TL/TLP remain high, despite widespread usage of vascularized flaps in reconstruction. This comparison reveals no significant difference in postoperative complications between patients who received PF and FF laryngopharyngeal reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:105-112, 2019.