Neck dissection does not add to morbidity or mortality of laryngectomy.

OBJECTIVES: To examine the national rates of complications, readmission, reoperation, death and length of hospital stay after laryngectomy. To explore the risks of neck dissection with laryngectomy using outcomes. METHODS: The American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database was reviewed retrospectively. The database was analyzed for patients undergoing laryngectomy with and without neck dissection. Demographic, perioperative complication, reoperation, readmission, and death variables were analyzed. RESULTS: 754 patients who underwent total laryngectomy during this time were found. Demographic analysis showed average age was 63 years old, 566 (75.1%) were white, and 598 (79.3%) were male. Of these patients, 520 (69.0%) included a neck dissection while 234 (31.0%) did not. When comparing patients who received a neck dissection to those who did not, there were no significant differences in median length of hospital stay (12.5 days w/vs. 13.3 days w/o, P = 0.99), rates of complication (40% w/vs. 35% w/o, P = 0.23), reoperation (13.5% w/vs. 14% w/o, P = 0.81), readmission (14% w/vs. 18% w/o, P = 0.27), and death (1.3% w/vs. 1.3% w/o, P > 0.99). Furthermore, neck dissection did not increase the risk of complication (P = 0.23), readmission (P = 0.27), reoperation (P = 0.81), death (P = 0.94), or lengthened hospital stay (P = 0.38). CONCLUSIONS: Concurrent neck dissection does not increase postoperative morbidity or mortality in patients undergoing total laryngectomies. These results may help physicians make decisions regarding concurrent neck dissection with total laryngectomy.

Assessment of weight gain following adenotonsillectomy in children with Down syndrome.

INTRODUCTION: Adenotonsillectomy (T&A) has been associated with postoperative weight gain in children. The purpose of this study is to determine whether a similar association exists in children with Down syndrome (DS). METHODS: The medical records of 311 DS patients were reviewed. Subjects were classified into either a control group or surgical group based on whether they had undergone adenotonsillectomy (T&A). Subjects were excluded if they only had one recorded BMI. Cases were analyzed in a pairwise fashion to maximize available data. 113 total patients with DS were identified: 84 (74.3%) in the control group and 29 (25.7%) in the T&A group. Height, weight, BMI, and Z-score data were compared between the control and T&A groups at 6-month intervals over a 24-month period. RESULTS: Children with DS who underwent T&A were comparable by demographics to children with DS who did not undergo T&A. Mean weight gain at 24 months for the T&A group was 8.07 ± 5.66 kg compared with 5.76 ± 13.20 kg in controls. The median Z-score at 24 months for the T&A group was 1.11 (0.10-1.88) compared with 1.17 (0.80-1.75) in controls. Children undergoing T&A had a stable median Z-score change of 0.09 at 24 months (p = 0.861, compared to baseline) while children who did not undergo T&A had a significantly increased median Z-score of 0.52 (p = 0.035, compared to baseline). Despite this, there were no significant intergroup differences between weight change, BMI, nor Z-score at any interval (p > 0.05). CONCLUSIONS AND RELEVANCE: Children with DS did not have an increased rate of weight gain or increased BMI after T&A. BMI Z-scores were shown to stabilize over 24 months in the T&A group and increase in the control group. While this suggests that T&A provides an added benefit of weight control in patients with DS, the results should be interpreted with caution due to the small sample size and the fact that not all patients had complete follow up across a 24-month period.

Tonsillectomy in Children with Down Syndrome: A National Cohort of Inpatients.

Objective To describe the cost, length of stay, and incidence of postoperative hemorrhage associated with Down syndrome (DS) patients undergoing tonsillectomy in a national sample of inpatient children. Study Design This study uses a national cross-sectional cohort to analyze children with and without DS undergoing tonsillectomy with or without adenoidectomy. Setting 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database. Subjects and Methods The database was analyzed for postoperative hemorrhage and respiratory compromise, length of stay, and total charges of hospital stay. These outcomes were compared between patients with DS vs patients without DS. Results In total, 7512 patients were identified who underwent tonsillectomy: 7159 patients without DS and 353 patients with DS. The non-DS group was younger with a median age of 3 years (range, 0-18) compared with a DS median age of 4 years (range, 0-20), P = .004. The DS group had a significant increase in postoperative hemorrhage compared with non-DS (10 [2.8%] vs 87 [1.2%], respectively), P = .024. However, the DS and non-DS groups were comparable for respiratory complications (5 [1.4%] vs 106 [1.5%], respectively), P = .922. Median length of stay was significantly increased in the DS group (1 [interquartile range (IQR), 1-3]) compared with the non-DS group (1 [IQR, 1-2]), P < .001. Median charges for hospital stay totaled $17,451 (IQR, $11,901-$24,949) for the DS group compared with $14,395 (IQR, $9739-$21,890) for the non-DS group, P < .001. Conclusion Across the United States, children with DS hospitalized for tonsillectomy have an increased length of stay and cost of care. These data also suggest an increased risk of postoperative hemorrhage during the initial admission without an increased risk of respiratory complications.

Impact of resident involvement in outpatient otolaryngology procedures: An analysis of 17,647 cases.

OBJECTIVE: This study examines the impact of resident physician participation on postoperative outcomes in outpatient otolaryngologic surgery. STUDY DESIGN: Retrospective cohort. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for outpatient otolaryngologic procedures performed on adult patients. Cases were analyzed with the following cohorts: attending with resident or attending without resident. Outcomes included complications, readmission, reoperation, and operative time. RESULTS: A total of 17,647 cases were analyzed, with 13,123 patients in the attending without resident cohort and 4,524 patients in the attending with resident cohort. The majority of patients were female (58.7%) and white (88.0%). The average age was 44 (range 16-89) years, and average body mass index was 29.0 ± 7.3 kg/m2 . Total relative value units were higher in the attending with resident group 14.6 ± 12.0 compared with 10.2 ± 8.3 in the attending without resident group (P < 0.01). Univariate analysis revealed that resident participation increased complication rate (2.0% vs. 1.4%, P < 0.01) and operative time (108 ± 98 minutes vs. 60 ± 55 minutes, P < 0.01). There were no differences in readmissions (P = 0.35), reoperations (P > 0.05), or death rates (P = 0.32) between groups. Multivariate regression analysis, however, revealed that resident participation did not increase the rate of any complication, and that operative time was the only significantly impacted variable (P < 0.01). CONCLUSION: Resident surgical training remains a vital component of the current health care system. Previous research has shown that, despite increased operative time, resident participation does not significantly impact complication rates for otolaryngology procedures. This study confirms these findings in the outpatient setting, thus reassuring both the surgeon and patients that resident participation does not impact procedural safety. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2026-2032, 2017.

Titanium Ossicular Chain Reconstruction Revision Success and Preoperative Factors Predicting Success.

Objective Determine rates of success after revision titanium ossicular chain reconstruction with either partial or total ossicular replacement prosthesis and assess preoperative factors predicting positive outcomes. Study Design Case series with planned data collection. Setting Tertiary hospital. Subjects and Methods The charts of 76 surgical patients who underwent revision titanium ossicular chain reconstruction from 2003 to 2014 were abstracted from a prospectively maintained database at the Medical University of South Carolina. Postoperative air-bone gap (ABG) after revision surgery at short-term (<6 months) and intermediate to long-term (>1 year) follow-up and preoperative factors associated with postoperative ABG ≤20 dB were recorded. A paired t test or Wilcoxon signed-rank sum test was utilized to compare preoperative, short-term, or intermediate to long-term results. Results Seventy-six patients underwent revision ossiculoplasty and met inclusion criteria. Mean postoperative ABG was 22.5 at short-term follow-up ( P < .0001) and 24.4 at intermediate to long-term follow-up ( P = .003). Postoperative ABG ≤20 dB was achieved in 51.5% of patients. The only preoperative factor associated with postoperative ABG ≤20 dB was location of original primary ossiculoplasty ( P = .01). Conclusions This is one of the larger studies involving revision titanium ossiculoplasty. Revision surgery showed a significant improvement in postoperative ABG. The location of the original ossiculoplasty correlated with success of revision surgery (defined as postoperative ABG ≤20 dB). Patients who had the primary ossiculoplasty at an outside hospital may have better audiometric outcomes than patients who had it at a tertiary hospital.

Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery.

BACKGROUND: In patients undergoing transnasal endoscopic sellar surgery, an analysis of risk factors and predictors of intraoperative and postoperative cerebrospinal fluid leak (CSF) would provide important prognostic information. METHODS: A retrospective review of patients undergoing endoscopic sellar surgery for pituitary adenomas or craniopharyngiomas between 2002 and 2014 at 7 international centers was performed. Demographic, comorbidity, and tumor characteristics were evaluated to determine the associations between intraoperative and postoperative CSF leaks. Correlations between reconstructive and CSF diversion techniques were associated with postoperative CSF leak rates. Odds ratios (OR) were identified using a multivariate logistic regression model. RESULTS: Data were collected on 1108 pituitary adenomas and 53 craniopharyngiomas. Overall, 30.1% of patients had an intraoperative leak and 5.9% had a postoperative leak. Preoperative factors associated with increased intraoperative leaks were mild liver disease, craniopharyngioma, and extension into the anterior cranial fossa. In patients with intraoperative CSF leaks, postoperative leaks occurred in 10.3%, with a higher postoperative leak rate in craniopharyngiomas (20.8% vs 5.1% in pituitary adenomas). Once an intraoperative leak occurred, craniopharyngioma (OR = 4.255, p = 0.010) and higher body mass index (BMI) predicted postoperative leak (OR = 1.055, p = 0.010). In patients with an intraoperative leak, the use of septal flaps reduced the occurrence of postoperative leak (OR = 0.431, p = 0.027). Rigid reconstruction and CSF diversion techniques did not impact postoperative leak rates. CONCLUSION: Intraoperative CSF leaks can occur during endoscopic sellar surgery, especially in larger tumors or craniopharyngiomas. Once an intraoperative leak occurs, risk factors for postoperative leaks include craniopharyngiomas and higher BMI. Use of septal flaps decreases this risk.

Uvulopalatopharyngoplasty: Does Multilevel Surgery Increase Risk?

OBJECTIVES: (1) Determine the rate of postoperative complications, reoperation, readmission, and death after uvulopalatopharyngoplasty (UPPP) for sleep apnea through multi-institutional clinical data. (2) Compare outcomes of UPPP between multilevel and single-level procedures for the treatment of sleep apnea. STUDY DESIGN: Retrospective database analysis. METHODS: The American College of Surgeons National Surgical Quality Improvement Program-a nationally validated, prospective, multi-institutional database from 2005 to 2013-was analyzed for patients who underwent UPPP, per corresponding Current Procedural Terminology codes. Patients were categorized into 3 groups: UPPP alone, UPPP + nasal cavity (NC), and UPPP + base of tongue (BOT). Perioperative outcome measures of interest include surgical/medical complications, reoperation, readmission, and death. Comparisons were made among surgical groups through univariate cross-sectional analysis. RESULTS: A total of 1079 patients underwent UPPP; 413 patients had UPPP + NC; and 200 patients had UPPP + BOT procedures. One death was reported for the entire cohort of patients. Among all 3 groups (UPPP, UPPP + NC, and UPPP + BOT), no differences were noted in the rates of medical complications (P = .445), surgical complications (P = .396), reoperation (P = .332), and readmission (P = .447). However, the length of hospital stay in days was greatest for the UPPP + BOT group (UPPP, 0.81 ± 0.69; UPPP + NC, 0.87 ± 0.90; UPPP + BOT, 1.50 ± 2.70; P < .001). CONCLUSION: These national data demonstrate no significant increase in risk when UPPP is performed as a single- or multilevel procedure. When indicated, UPPP with multilevel procedures may be safely performed for treatment of sleep apnea. These data set a benchmark for perioperative risk in UPPP surgery and will prove useful for counseling patients.

Prognostic Factors in Myoepithelial Carcinoma of the Major Salivary Glands.

OBJECTIVES: (1) Identify all cases of myoepithelial carcinoma of the major salivary glands from the National Cancer Data Base (NCDB). (2) Analyze the effect of grade, stage, and regional nodal metastasis on survival in myoepithelial carcinoma of the major salivary glands. STUDY DESIGN: Retrospective review of NCDB. SETTING: Multicenter data pooled from 1998 to 2012 in the NCDB. METHODS: We identified all reported cases of myoepithelial carcinomas of the major salivary glands from the United States from 1998 to 2012 in the NCDB. Clinical parameters were then examined and analyzed for predictors of survival. RESULTS: A total of 473 cases of myoepithelial carcinoma were identified. Of the reported cases, 38.1% were low grade; 26.7%, intermediate grade; and 35.2%, high grade. When presenting stage was examined, 24.4% were stage I; 30.6%, stage II; 22.5%, stage III; 12.2%, stage IVa; 3.0%, stage IVb; and 4.1%, stage IVc. At presentation, 18.7% of patients had regional nodal disease, and 4.5% had distant metastases. The 3- and 5-year survival rates were 73% and 64%, respectively. The presence of nodal disease significantly reduced mean survival time versus those without (64 vs 108 months, P < .001), as did high-grade disease compared with low grade (67 vs 114 months, P < .001) and stage III/IV compared with stage I/II disease (61 vs 118 months, P < .001). CONCLUSIONS: The presence of regional nodal disease, high-grade disease, and advanced stage are predictors of lower survival in myoepithelial carcinoma. Further studies based on types of treatment are warranted.

Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery.

BACKGROUND: The goal of this study was to identify preoperative risk factors associated with increased perioperative morbidity after endoscopic pituitary surgery. METHODS: A retrospective review of patients undergoing endoscopic pituitary adenoma surgery between 2002 and 2014 at 6 international centers was performed. Standard demographic and comorbidity data, as well as information regarding tumor extent and treatment were collected. Logistic regression was used to examine risk factors for the following 30-day outcomes: systemic complications, intracranial complications, postoperative cerebrospinal fluid (CSF) leaks, length of hospital stay, readmission, and reoperation. RESULTS: Data was collected on 982 patients with a mean age of 52 years. The median body mass index (BMI) for all patients was 30.9 kg/m(2) with 56% female. The median hospital stay was 5 days and 23.8% of patients suffered a postoperative adverse event. Systemic complications occurred in 3.2% of patients and intraventricular extension was a risk factor (odds ratio [OR] 8.9). Intracranial complications occurred in 7.3% of patients and risk factors included previous radiation (OR 8.6) and intraventricular extension (OR 7.9). Reoperation occurred in 6.5% of patients and intraventricular extension (OR 7.3) and age (<40 years, OR 3.5; 40 to 64 years, OR 3.2) were risk factors. Postoperative CSF leaks occurred in 5.5% of patients and risk factors included female gender (OR 2.4), BMI ≥ 30 (OR 2.1), age (<40 years, OR 5.3; 40 to 64 years, OR, 7.9), and intraventricular extension (OR, 9.5). CONCLUSION: Postoperative endoscopic pituitary adenoma surgery complications are associated with tumors with intraventricular extension, preoperative radiation, as well as common patient comorbidities. Identification of these factors may permit implementation of strategies to reduce postoperative complications.

Predictors of 30-day morbidity and mortality in transnasal microscopic pituitary tumor excision.

BACKGROUND: There is a lack of population-based, multi-institutional analyses of factors associated with morbidity and mortality following pituitary tumor excision. METHODS: The American College of Surgeons National Surgical Quality Improvement Project files were used to compile information on patients that had undergone transnasal microscopic pituitary tumor resection from 2006 to 2012. Patient demographics, comorbidities, operative characteristics, and morbidity and mortality in the 30 days following surgery were included. Multivariate logistic regression was used for categorical variables and multivariate linear regression was used for continuous variables to evaluate factors leading to adverse events. RESULTS: A total of 658 patients were included, of which 58 (8.81%) experienced a complication, reoperation or death in the 30 days following surgery. The most common complications were reoperation (3.37%), followed by unplanned reintubation (1.99%), urinary tract infection (1.68%), and transfusion (1.68%). Predictors of any complication, reoperation, or death include preoperative sepsis (odds ratio [OR] = 7.596) and lower preoperative serum albumin (OR = 6.667). Younger age predicted surgical complications (OR = 1.105). Predictors of medical complications include higher body mass index (OR = 1.112), chronic steroid use (OR = 6.568), preoperative sepsis (OR = 15.297), and lower preoperative serum hematocrit (OR = 1.225). Predictors of increased total length of hospital stay were older age (ß = 0.146), higher body mass index (ß = 0.188), chronic steroid use (ß = 0.142), preoperative sepsis (ß = 0.489), and lower preoperative serum albumin (ß = -0.213). CONCLUSION: Although adverse events following pituitary tumor excision are low, awareness of factors associated with morbidity and mortality in the early postoperative period may allow for improved patient monitoring and outcomes.

Upper airway stimulation for obstructive sleep apnea: The surgical learning curve.

OBJECTIVES/HYPOTHESIS: To determine the effect of surgeon experience with an upper airway stimulation (UAS) system on surgical time and complication rates. STUDY DESIGN: Retrospective review. METHODS: Surgical procedure times and complication rates observed in patients implanted at 22 study centers as part of a phase III, multicenter surgical trial of upper airway nerve stimulation therapy for obstructive sleep apnea were reviewed. RESULTS: The study included 126 subjects who were predominantly male (83%), with a mean age of 54.5 years (range = 31-80 years), and the mean body mass index was 28.4 ± 2.6. There were an average of 5.7 (range = 1-22) surgical implants per site, with an average surgical time of 2.52 ± 0.98 hours (range = 1.08-6.0 hours). The surgical implant time decreased significantly with surgeon experience, from 2.98 ± 1.18 hours for a surgeon's first implant (n = 22) to 2.08 ± 0.55 hours for the fifth implant (n = 10, P = .025). Surgical time was inversely correlated with the site implant number (rho = -0.334, P < .001). Procedure-specific complications were uncommon and self-limited and did not decrease appreciably with increasing experience. CONCLUSIONS: Surgical time for implantation of the UAS system decreased significantly after the first five implants and then stabilized. The rate of surgical complications did not decrease with surgeon experience, although this may be attributable to the low overall rate of serious surgical complications and low number of implants at some centers. LEVEL OF EVIDENCE: 4.

Ossiculoplasty With Titanium Prostheses in Patients With Intact Stapes: Comparison of TORP Versus PORP.

OBJECTIVES: Inferior rotation of the stapes or a small middle ear cleft can make placement of partial ossicular replacement prostheses (PORP) challenging. This study examines outcomes of total titanium prosthesis (TORP) ossiculoplasty in such patients and compares the results to PORPs. STUDY DESIGN: Review of prospective database. SETTING: Tertiary hospital. PATIENTS: Patients with an intact/mobile stapes undergoing titanium ossicular chain reconstruction from 2002 to 2014. INTERVENTION: Ossicular chain reconstruction. OUTCOMES: Hearing outcomes included ABG, closure of ABG(ΔABG), SRT, improvement in SRT(ΔSRT), achievement of ABG ≤20 dB, and stability over time. RESULTS: Eighty-three patients were included; 56 were PORPs and 27 were TORPs. At initial follow-up (<6 mo), mean ABG and ΔABG in the TORP group were 20.6 and 11.7 dB, respectively. Postoperative ABG≤20 dB was achieved in 60.0% of TORPs. At longer-term follow-up (mean 54.0 mo), hearing remained stable in TORPs. Specifically, the mean ABG and ΔABG were 17.7 and 13.3 dB, respectively. Sixty-three percent of TORPs achieved ABG ≤20 dB at later follow-up. When compared PORPs at both short and longer-term follow-ups, no differences in hearing outcomes were noted. A small, but statistically significant, deterioration in both ABG and SRT was observed within the PORP group (p = 0.02 and <0.01, respectively). CONCLUSION: TORP reconstruction in patients with an intact stapes is associated with good short and longer-term hearing results. Furthermore, hearing outcomes within TORPs remain stable at follow-up >12 months postoperatively. Results did not differ when compared with traditional PORP reconstruction, suggesting that TORP through an intact stapes arch is an acceptable alternative to PORP reconstruction in patients with challenging anatomy.

Malignant Otitis Externa: A Novel Stratification Protocol for Predicting Treatment Outcomes.

OBJECTIVES: 1) Stratify malignant otitis externa into severe and nonsevere disease categories. 2) Predict treatment courses and outcomes based on this stratification. SETTING: Tertiary center. PATIENTS: Retrospective review 2004 to 2014; 28 patients. Inclusion criteria are a diagnosis by senior authors, radiographic evidence of disease, admission for intravenous antibiotics/debridement, minimum 1 year of follow-up. INTERVENTIONS: Severe group stratification if two or more of the following: cranial nerve VII palsy, fungal positive culture, relapse, surgery performed, major radiographic findings. All other patients stratified to nonsevere group. MAIN OUTCOME MEASURES: Cure, alive/refractory disease, death by disease, death by other cause. Secondary measures are antibiotic duration and number of disease-related admissions. RESULTS: Forty-three percent (12 of 28) and 57% (16 of 28) of patients stratified into the severe and nonsevere groups. The severe group had significantly more adverse disease-specific outcomes than the nonsevere group (7 of 12 versus 0 of 16; p = 0.002). Disease-specific mortality was 42% and 0% in the severe and nonsevere groups, respectively. The severe group had longer antibiotic courses (12.8 versus 6.9 wk; p = 0.01) and more disease-related admissions/relapses (1.6 versus 1, p < 0.001). Only four of 12 severe group patients achieved cure. All but two nonsevere patients achieved cure, with those two dying of other causes. CONCLUSION: A subgroup of malignant otitis externa may exist that is not as susceptible to parenteral antibiotics and local debridement. A combination of clinical and radiographic findings may be useful for stratifying patients into severe/nonsevere categories. Patients with severe disease may be more likely to die of their disease and have worse treatment courses such that additional surgical intervention may be indicated.