Functional nasal surgery in the office-based setting.

Objective: Nasal obstruction is a very common problem often addressed by functional nasal surgery. Increasingly, these procedures are being performed in the office setting secondary to decreased down time, cost, and obviation of general anesthesia. Our goal with this review is to discuss how to appropriately select patients for office-based procedures, what procedures may be considered, and current outcomes with in-office functional nasal surgery. Data Sources: PubMed, Scopus, Google Scholar. Methods: Research databases were searched for articles discussing techniques for performing functional nasal surgery in an office setting, and outcomes of various in-office functional nasal procedures. Results: Studies found and included in this review discuss many aspects of office-based functional nasal surgery, including practical points on patient selection and office set-up, what procedures can safely be performed, and outcomes of different techniques to address specific problems. Broadly, procedures amenable to performance in the office address the internal and external nasal valves, the nasal septum, and the inferior turbinates. Conclusion: A wide range of techniques to aaddress the nasal valves, septum, and inferior turbinates can be performed in a safe and effective manner without the need for an operative suite.

An update on rib grafting in rhinoplasty: which rib is right?

PURPOSE OF REVIEW: In revision or posttraumatic rhinoplasty, the quantity and quality of septal cartilage available for grafting is often deficient and auricular cartilage often provides insufficient strength for structural nasal reconstruction. Accordingly, rib cartilage serves as a reliable, abundant source of cartilage for grafting. However, the various sources of rib cartilage carry respective benefits and weaknesses. This review examines recent studies, novel applications and a comparison of the primary sources of rib cartilage, including autologous cartilage, irradiated cadaveric rib and fresh frozen cadaveric cartilage. RECENT FINDINGS: Options for rib cartilage include autologous, irradiated cadaveric rib, and more recently, reports on fresh frozen cadaveric cartilage. Studies continue to conclude that autologous and irradiated donor cartilage carry equivalent results, have similar rates of complication and have a comparable cost profile. SUMMARY: Regardless of the source, rib cartilage plays an important role in structural rhinoplasty, especially in revision cases. Although the risks, benefits and long-term results of autologous and radiated homologous cartilage have been evaluated in observational studies, fresh frozen rib cartilage will need further follow up before widespread use, although preliminary literature shows promise.

Degree of Self-Reported Facial Impairment Correlates with Social Impairment in Individuals with Facial Paralysis and Synkinesis.

Importance: Facial paralysis leads to both aesthetic and functional deficits placing patients at risk for sociopsychological sequelae and social impairment. Objective: To examine the effect of facial paralysis and synkinesis on social impairment and quality of life (QOL). Design, Setting, and Participants: This is a cross-sectional study at a tertiary care medical center. Adults with a history of facial palsy were broadly categorized by self-reported degree of facial paralysis and synkinesis. Main Outcomes and Measures: Clinical demographic information, self-reported degrees of facial paralysis and synkinesis, and facial palsy-specific QOL as measured by the Facial Clinimetric Evaluation (FaCE) Scale and the Synkinesis Assessment Questionnaire (SAQ) were collected. FaCE and SAQ scales were evaluated as predictors of social impairment outcomes, as measured by the Brief Fear of Negative Evaluation-II (BFNE-II), the Social Anxiety Questionnaire (SAQ-A30), and Social Avoidance and Distress (SAD) scales, in addition to health utility scores from the Short-Form 6D (SF-6D). Results: Fifty-six participants with facial palsy were included (30% male; average age: 56.4 [standard deviation (SD): 15] years). Sixty-three percent of participants reported history of Bell's palsy; 37% reported other etiologies. Forty-seven percent of participants reported moderate or severe facial impairment and 46% of participants reported involuntary facial movement. Participants with moderate or severe facial impairment exhibited increased BFNE-II (p = 0.03), SAQ-A30 (p = 0.04), and SAD (p < 0.01) scores and lower health valuation on SF-6D (p = 0.04). FaCE scores moderately correlated with lower health valuation (r = 0.39, p < 0.01), and moderately and inversely correlated with SAD (r = -0.33, p = 0.01) and BFNE-II (r = -0.35, p < 0.01) scores. Furthermore, worsening FaCE scores predicted worsening SAQ (p < 0.01), SAD (p = 0.01), BFNE-II (p < 0.01), and SF-6D (p < 0.01) scores. Worse degrees of synkinesis correlated with higher BFNE-II scores (r = 0.38, p < 0.01) and worsening SAQ scores predicted worsening FaCE (p < 0.01) and BFNE-II (p < 0.01) scores. Females demonstrated significantly worse BFNE-II scores (p = 0.04) when compared with men, and female gender significantly predicted worse FaCE scores (p < 0.01). Seventy-one percent of women with self-reported moderate or severe facial impairment met criteria for social anxiety, as did 67% of women with self-reported moderate or severe synkinesis. Conclusions and Relevance: Individuals with self-reported moderate or severe facial impairment exhibit a higher degree of social impairment and poorer health valuation than those with no or mild facial impairment. Facial palsy-specific QOL moderately and inversely correlated with social impairment and moderately correlated with health valuation. Our results indicate that FaCE scores may be used as a predictor of SAD, BFNE-II, and SF-6D scores and that facial palsy QOL and its relationship with social impairment should be considered when treating patients with a history of facial palsy.

Reconstructing Forearm Free Flap Donor Sites Using Full-Thickness Skin Grafts Harvested from the Ipsilateral Arm.

OBJECTIVE: To compare morbidity and aesthetic outcomes of full-thickness skin grafts (FTSGs) and split-thickness skin grafts (STSGs) in the reconstruction of the forearm free flap donor site. STUDY DESIGN: Case series, retrospective chart review. SETTING: Institutional microvascular database. SUBJECTS AND METHODS: Subjects who underwent forearm free flaps and FTSGs for donor site reconstruction from April 2016 to November 2017 were included. FTSGs were obtained from the donor forearm with a proximal S-shaped incision, thereby avoiding additional wound creation. Morbidity outcomes were compared to 68 consecutive patients with STSG reconstruction from January 2009 to May 2010. Complications, including tendon exposure, subjective functional impairment, complete graft loss, partial graft loss, infection, paresthesias, and hematoma/seroma, were evaluated, as were aesthetic outcomes. RESULTS: Sixty-eight patients underwent FTSG reconstruction. No significant differences between FTSGs and STSGs were demonstrated in terms of graft loss ≥40% (4% vs 4%, P = 1.000), partial graft loss (<40%) (29% vs 40%, P = .207), tendon exposure (9% vs 12%, P = .573), infection (15% vs 13%, P = .805), paresthesias (12% vs 7%, P = .382), subjective functional impairment (0% vs 2%, P = .316), or hematoma/seroma (2% vs 0%, P = .316). Aesthetic outcomes were better in the FTSG group compared to the STSG group, as determined by both patients (P = .004) and surgeon (P < .001). CONCLUSIONS: Our results advocate for the consideration of FTSGs in the reconstruction of the forearm free flap donor site given superior aesthetic results without additional donor site morbidity or additional wound creation when compared to STSGs.

Increased risk of head and neck cancer in Agent Orange exposed Vietnam Era veterans.

IMPORTANCE: United States military personnel during the Vietnam Era were potentially exposed to Agent Orange, a known carcinogen. The link between Agent Orange and head and neck cancers is largely unknown; laryngeal cancer is currently the only subsite with sufficient evidence of an Agent Orange association. OBJECTIVE: We aim to determine the relationship between Agent Orange exposure and the incidence of head and neck cancers in Vietnam Era veterans as well as any relationship with head and neck cancer survival. MATERIALS AND METHODS: The present study utilizes the Veterans Affairs Corporate Data Warehouse (VA CDW) to identify Vietnam Era veterans, their Agent Orange exposure status, limited demographic data, presence of head and neck cancer, and survival data. RESULTS: Of 8,877,971 Vietnam Era veterans, 22% self-reported exposure to Agent Orange, and 54,717 had a diagnosis of head and neck cancer. Agent Orange exposure significantly predicted upper aerodigestive tract carcinoma, with a relative risk (RR) of 1.10. On subsite analysis, Agent Orange exposure (as well as race, gender, and substance use) was significantly associated with oropharyngeal (RR 1.16), nasopharyngeal (RR 1.22), laryngeal (1.11), and thyroid (1.24) cancers. Agent Orange exposure was associated with improved 10-year overall survival in upper aerodigestive tract cancer patients. CONCLUSIONS AND RELEVANCE: Self-reported Agent Orange exposure correlated with increased risks of oropharyngeal, nasopharyngeal, laryngeal, and thyroid cancers, and predicted improved survival in upper aerodigestive tract cancer patients. These findings broaden our understanding of the risks of Agent Orange exposure.

Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy.

OBJECTIVES/HYPOTHESIS: Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS. STUDY DESIGN: Retrospective outcomes research. METHODS: Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed. RESULTS: Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P < .001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P = .031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P = .005). CONCLUSIONS: AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS. LEVEL OF EVIDENCE: 2c Laryngoscope, 2019.

Head and neck free flap survival when requiring interposition vein grafting: A multi-instiutional review.

OBJECTIVE: Interposition vein grafting in free flap reconstruction is often viewed as a risky procedure, but is necessary in cases of inadequate pedicle length. MATERIALS AND METHODS: Two tertiary care centers retrospectively.reviewed 3008 head and neck free flap reconstructions from 2008 to 2017 91 patients were identified requiring interposition vein grafting during reconstruction. Pre and perioperative characteristics were recorded Univariate and multivariate analyses were conducted with a p value <0.05 indicating statistical significance. RESULTS: Of the 91 patients 75% had undergone reconstruction for cancer, 66% of these cases were in the setting of recurrence or complication, 33% had a previous free flap, and 52% had prior radiation therapy. Surgical site was primarily craniofacial (36%) or oral cavity (26%). The majority of vein grafts were saphenous (64%), average graft length 18 cm (SD 11 cm). Half were used for both artery and vein anastomosis. Flap survival was 85% overall and only prior free flap was predictive of failure on multivariate analysis. No other peri-operative or graft variable assessed in this study were predictive of flap failure. CONCLUSION: In a multi-institutional study of head and neck free flap reconstructions using interposition vein grafts, we identified an overall 85% success rate with no significant difference between soft tissue and osteocutaneous flaps despite the complicated nature of these cases.

Elevated incidence of head and neck cancer in solid organ transplant recipients.

BACKGROUND: Solid organ transplant recipients are known to be at an increased risk of cancer development, but research on head and neck cancer in transplant recipients has been limited and prior risk assessments may not be accurate. METHODS: A retrospective review using a national Veterans Administration database to query outpatient problem lists for ICD codes indicating solid organ transplant and subsequent diagnosis of head and neck cancer. RESULTS: In a study of 30 939 656 patients (37 969 solid organ transplants and 113 995 head and neck cancers), history of transplant significantly predicted head and neck cancer, with relative risks ranging from 1.85 (thyroid) to 2.91 (salivary gland). Worse overall survival (OS) was seen for head and neck cancer patients with prior transplants. CONCLUSIONS: In a large case-control study, prior transplant was a risk factor for head and neck cancer development and worse OS for head and neck cancer patients.

Malignant peripheral nerve sheath tumors: Analysis of the national cancer database.

OBJECTIVES: Malignant peripheral nerve sheath tumor (MPNST) is a rare type of soft tissue sarcoma (STS) that carries significant mortality. Given the rarity of MPNST, current knowledge on the disease is limited. We aim to characterize patient, tumor, and treatment factors, and determine variables associated with 5-year overall survival (OS) in individuals with MPNST. MATERIALS AND METHODS: We utilized the National Cancer Database (NCDB) to identify adult patients diagnosed with MPNST from 2004 to 2015, and analyze patient, tumor, treatment, and survival data. American Joint Committee on Cancer (AJCC 8) staging criteria for STS was utilized. RESULTS: In our cohort of 2,858 patients with MPNST, median age at diagnosis was 47. The 5-year OS rate was 52%. Age, race, tumor size, and treatment regimen significantly predicted 5-year OS on univariate analysis. AJCC 8 stage appeared to predict 5-year OS in head and neck tumors (though not significantly), but not trunk and extremity tumors. CONCLUSION: While our cohort of patients with MPNST are typically relatively young and healthy, 5-year OS is only 52%. Notably, age extremes, large tumor size, and certain treatment regimens are associated with worse outcomes. While AJCC 8 staging guidelines may have some value in predicting OS in head and neck tumors, they do not reliably risk stratify patients with trunk and extremity MPNST. Ultimately, MPNST is associated with high mortality with few modifiable risk factors, and survival may not be adequately predicted by current staging systems.

Frontal sinus "mega-trephination" in a tertiary rhinology practice.

BACKGROUND: Frontal sinus trephination is traditionally performed through a small cutaneous incision and osteotomy, allowing irrigation of the frontal sinus. Utilizing the trephination osteotomy for endoscopic visualization and surgical manipulation requires a larger opening. This "mega-trephination" is thought to carry an increased risk of cosmetic deformity given the increased bony removal at the anterior table. The purpose of our study was to clarify the risks of frontal sinus mega-trephination and examine how this technique is incorporated into a modern, tertiary care rhinology practice. METHODS: Patients were identified through billing records and confirmed by retrospective chart review. All patients underwent frontal sinus mega-trephination, which is defined as an osteotomy large enough for insertion of a 4-mm endoscope and an operative instrument simultaneously. All patients had at least 2 years of follow-up. The primary outcome was complication rate, including cosmetic deformity. RESULTS: Sixty-four patients underwent frontal sinus mega-trephination from 2006 to 2016. The most common surgical indications were chronic sinusitis (34%), mucocele (19%), osteoma (17%), acute sinusitis (11%), and inverting papilloma (9%). Ten patients (16%) underwent mega-trephination alone, whereas the others had mega-trephination with endoscopic sinus surgery. Twenty-one patients (33%) had minor complications. The most common complications were self-limited paresthesia (11%), infection (8%), and epistaxis (3%). No patient complained of permanent cosmetic deformity or required revision surgery for cosmesis. CONCLUSION: Frontal sinus mega-trephination is a useful tool to augment the rhinologist's armamentarium in complex frontal sinus anatomy and pathology. This procedure is well tolerated, safe, and not associated with long-term cosmetic deformity.

Association Between Sarcopenia and Mortality in Patients Undergoing Surgical Excision of Head and Neck Cancer.

Importance: Sarcopenia, or the loss of muscle mass, is associated with poor treatment outcomes in a variety of surgical fields. However, the association between sarcopenia and long-term survival in a broad cohort of patients with head and neck cancer (HNC) is unknown. Objective: To determine whether sarcopenia is associated with long-term survival in patients undergoing major head and neck surgery for HNC. Design, Setting, and Participants: A retrospective medical records review was conducted at a tertiary care academic hospital. Two hundred sixty patients undergoing major head and neck ablative procedures with cross-sectional abdominal imaging performed within 45 days prior to surgery were included in the analysis. The study was conducted from January 1, 2005, to December 31, 2016. Data analysis was performed from June 1, 2018, to February 28, 2019. Interventions: Measurement of cross-sectional muscle area at the L3 vertebra level. Main Outcomes and Measures: Two- and 5-year overall survival were the primary outcomes. Results: Of the 260 patients included in the study, 193 were men (74.2%); mean (SD) age was 61.1 (11) years. Sarcopenia was present in 144 patients (55.4%). Two-year overall survival was 71.9% of the patients (n = 82) in the sarcopenia group compared with 88.5% of the patients (n = 85) in the nonsarcopenia group (odds ratio [OR], 0.33; 95% CI, 0.16-0.70). At 5 years, overall survival was 36.5% in patients (n = 23) with sarcopenia and 60.5% in patients (n = 26) without sarcopenia (OR, 0.38; 95% CI, 0.17-0.84). On multivariate analysis, sarcopenia was a significant negative predictor of both 2-year (OR, 0.33; 95% CI, 0.14-0.77) and 5-year (OR, 0.38; 95% CI, 0.17-0.84) overall survival. Conclusions and Relevance: Sarcopenia appears to be a significant negative predictor of long-term overall survival in patients with HNC undergoing major head and neck surgery. Sarcopenia may be accurately assessed on cross-sectional imaging and may be useful clinically as a prognostic variable and as an area for intervention to improve treatment outcomes.

Risk of Head and Neck Cancer in Patients With Prior Hematologic Malignant Tumors.

Importance: More than 1.3 million people in the United States have a hematologic malignant tumor currently or in remission. Previous studies have demonstrated an increased risk of secondary neoplasms in patients with hematologic malignant tumors, but research specifically on the risk of head and neck solid tumors in patients with prior hematologic malignant tumors is limited. Objectives: To examine a possible association between prior hematologic malignant tumors and risk of head and neck cancer and to assess the overall survival (OS) among these patients. Design, Setting, and Participants: This retrospective analysis used the Veterans Affairs (VA) Corporate Data Warehouse (CDW) to identify patients with diagnoses of hematologic malignant tumors and head and neck cancers. All patients in the VA CDW with a birthdate between January 1, 1910, and December 31, 1969, were included, for a cohort of 30 939 656 veterans. Data analysis was performed from August 15, 2018, to January 31, 2019. Exposures: Outpatient problem lists were queried for diagnoses of hematologic malignant tumor and associated malignant tumors using International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes to categorize patients by history of hematologic malignant tumors. Main Outcomes and Measures: Presence of head and neck cancer was determined from ICD-9 and ICD-10 codes of outpatient problem lists, and cancers were grouped by subsite. The OS was determined from date of death or last outpatient visit date. Results: Of 30 939 656 patients (27 636 683 [89.3%] male; 13 971 259 [45.2%] white), 207 322 patients had a hematologic malignant tumor, of whom 1353 were later diagnosed with head and neck cancer. A history of hematologic malignant tumors was significantly associated with overall aerodigestive tract cancer, with a relative risk (RR) of 1.6 (95% CI, 1.5-1.7), as well as oral cavity (RR, 1.7; 95% CI, 1.5-1.9), oropharynx (RR, 1.7; 95% CI, 1.5-1.9), larynx (RR, 1.3; 95% CI, 1.2-1.5), nasopharynx (RR, 2.8; 95% CI, 2.1-3.9), sinonasal (RR, 3.0; 95% CI, 2.2-4.1), salivary gland (RR, 2.8; 95% CI, 2.4-3.3), and thyroid (RR, 2.1; 95% CI, 1.9-2.4) tumors on subsite analysis. A prior hematologic malignant tumor was also negatively associated with 2-year and 5-year OS for multiple subsites. Conclusions and Relevance: A prior diagnosis of hematologic or associated malignant tumors was associated with an increased risk of solid head and neck cancers in a range of subsites. In addition, for several head and neck cancer subsites, patients with prior hematologic malignant tumors had worse 2-year and 5-year OS. These results indicate that a prior hematologic malignant tumor may be an adverse risk factor in the development and progression of head and neck cancer.

Long-term Trends in Head and Neck Surgery Outcomes.

OBJECTIVE: The aim of the present study is to address the paucity of data on long-term trends in postoperative complication rates in head and neck surgery. Specifically, this study assesses trends in morbidity and mortality following head and neck surgery over a 20-year period from 1995 to 2015 and identifies risk factors for the development of complications. STUDY DESIGN: Retrospective cross-sectional analysis of Veterans Affairs Surgical Quality Improvement Program database from 1995 to 2015. SETTING: Veterans Affairs medical centers across the United States. SUBJECTS AND METHODS: Using the Veterans Affairs Surgical Quality Improvement Program database, we selected 44,161 patients undergoing head and neck procedures from 1995 to 2015. Trends in 30-day morbidity and mortality were assessed, and univariate and multivariate analyses of risk factors for complications were performed. RESULTS: From 1995-2000 to 2011-2015, overall complication rates decreased >45% (from 10.9% to 5.9%), and 30-day postsurgical mortality decreased nearly 70% (from 1.3% to 0.4%). Postoperative hospital stays also significantly declined. Major procedures, such as free flap cases and total laryngectomies, had less change in complication rate as compared with less invasive procedures. CONCLUSION: Substantial improvement in postoperative morbidity and mortality has taken place in head and neck surgery over the past decades. Static complication rates in some procedures may reflect that the improvement of surgical techniques allow for the treatment of sicker patients. The trends seen in this study speak to the importance of probing further why high rates of complications are still seen in certain procedures and ensuring that effective treatment is balanced with limiting morbidity and mortality.

Venous thromboembolism incidence in head and neck surgery patients: Analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database.

OBJECTIVE: Venous thromboembolism (VTE) may cause significant postoperative morbidity and mortality; research in other surgical fields suggests an elevated VTE risk persists up to 30 days after surgery, beyond hospital discharge. We performed a review of the Veteran's Affairs Surgical Quality Improvement Project (VASQIP) database to determine the 30-day incidence of VTE following head and neck surgery and assess the proportion of VTE that occur post-discharge. MATERIALS AND METHODS: A retrospective review was performed of all head and neck ablative procedures captured in the VASQIP database between 1991 and 2015. Post-operative VTE incidence was determined and the relationship of pre-operative data and post-operative mortality to VTE incidence was assessed. RESULTS: 48,986 patients were included in the study; there were 152 VTE events (0.31%) and 39 (25.7%) occurred post-discharge. Lower VTE rates were found in parotidectomies (0.22%) and thyroid/parathyroid cases (0.23%), and higher rates in free flap (1.52%) and laryngectomy cases (0.69%). Age >70, recent weight loss, low serum albumin, and increased surgical time were all associated with increased VTE incidence on multivariate analysis. 90-day mortality in patients without VTE was 2.1% compared to 19.7% in patients who experienced a VTE. CONCLUSION: While the documented rate of VTE in a national dataset is relatively low following head and neck surgeries, it is elevated with certain procedure categories and following long operations, and a significant proportion of VTE occur post-discharge. This study provides baseline data to better inform efforts to risk-stratify and customize thromboprophylaxis for patients undergoing head and neck procedures.

Transoral robotic retropharyngeal node dissection in oropharyngeal squamous cell carcinoma: Patterns of metastasis and functional outcomes.

BACKGROUND: Assessment of the retropharyngeal lymph nodes is essential in the treatment for oropharyngeal squamous cell carcinoma (SCC). Transoral robotic retropharyngeal lymph node dissection (RPLND) may provide valuable staging information and guide selection of adjuvant therapy in a transoral robotic surgery (TORS) treatment paradigm. METHODS: Outcomes were compared between 30 patients with oropharyngeal SCC with tonsillar primaries undergoing RPLND and 37 stage-matched cases without RPLND. RESULTS: Retropharyngeal metastasis was confirmed in 6 patients undergoing RPLND. Compared with 37 stage-matched controls, there were no differences in length of stay, length of feeding tube dependence, net change in perioperative weight, or rates of hemorrhage and postoperative complications. RPLND altered adjuvant treatment recommendations in 1 of 30 patients. CONCLUSION: RPLND is technically feasible by a purely transoral robotic approach. Its performance is not associated with worse swallowing outcomes or rates of complication. In select patients, RPLND may provide valuable staging information and guide the selection of adjuvant therapy.