Intraoperative Pathology Consultation in Patients With p16-Positive Unknown Primary Squamous Cell Carcinoma.

Importance: Current guidelines recommend intraoperative frozen section(s) during diagnostic surgery for squamous cell carcinoma for unknown primary tumors (SCCUP). Objective: To determine the utility of intraoperative pathology consultation during transoral robotic surgery (TORS) in localizing primary tumors and influencing need for adjuvant therapy. Design, Setting, and Participants: A retrospective case series including 47 adult patients with human papillomavirus (HPV)-associated SCCUP who underwent TORS/oropharyngectomy between January 2016 and February 2023 was carried out at a single tertiary care hospital. The analysis took place on May 13, 2024. Exposures: Nodal stage, tonsillectomy history, extranodal extension (ENE). Main Outcomes and Measures: Intraoperative pathology consultation and final pathology results were compared with surgical outcomes, including margin revision, need for second procedure and/or radiation with or without chemotherapy. Results: This study included 47 adult patients. Mean (range) age was 61 (41-79) years; patients were mostly men (37 [79%]). Overall, primary tumors were identified in 37 patients (79%), including all cases with positive nodes involving more than 1 neck level. Patients whose primary tumor was not found tended to have tobacco use history (8/10 vs 13/37 [35%]; difference, 45%; 95% CI, 16%-74%) and absence of ENE (8/10 vs 15/37 [41%]; difference, 39%; 95% CI, 10%-68%). Primary tumor was identified intraoperatively in 18 of 37 patients (49%). SCCs identified intraoperatively were significantly larger than SCCs found on permanent sections only: mean (SE), 1.2 (0.13) cm vs 0.5 (0.1) cm (difference, 0.7 cm; 95% CI, 0.53-1.94). The sensitivity, specificity, positive predictive value, and negative predictive value of intraoperative consultation was 49% (95% CI, 33%-64%), 100% (95% CI, 100%-100%), 100%, and 34% (95% CI, 19%-53%), respectively. Margins were revised in 11 of 18 patients (61%) whose primary tumor was identified intraoperatively (during original procedure) and in 3 of 19 patients (16%) whose primary tumor was identified on permanent pathologic findings only (during a second procedure) (11/18 [61%] vs 3/19 [16%]; difference, 45%; 95% CI, 17%-73%). However, there was no significant difference in the use of adjuvant radiotherapy with or without chemotherapy or need for a second procedure based on intraoperative primary tumor localization. Conclusion and Relevance: In this case series study, the sensitivity and negative predictive value of intraoperative pathology consultation among 47 patients was less than 50%. Given the lack of influence on the need for radiotherapy with or without chemotherapy or second procedure, the practical utility of routine intraoperative frozen section requires further scrutiny.

Impact of puberty on procedure frequency for treatment of simple head and neck lymphatic and venous malformations.

OBJECTIVE: Puberty has been shown to accelerate growth of vascular malformations, including lymphatic (LM) and venous malformations (VM). This study aims to compare the number of procedures performed before and after puberty in patients with LM and VM to assess whether the onset of puberty results in higher treatment frequency. METHODS: A retrospective review of head and neck LM and VM patients who were evaluated between January 2009 and December 2019 was performed. Patient demographics, lesion characteristics, and procedural details were recorded. For the purposes of this study, 11 years or older in females and 12 years or older in males were the established cut-offs for the onset of puberty. RESULTS: After initial screening of 357 patients, 83 patients were included in the study based on inclusion criteria. There were 34 patients with LM (41 %) and 49 with VM (59 %). The mean age at diagnosis was 6.1 ± 10.9 years (LM: 4.2 ± 7.0, VM: 7.4 ± 12.9, p = 0.489). 68 patients underwent treatments, which included sclerotherapy, surgical excision, and/or laser. For all patients, the average number of lifetime treatments when initiated before puberty was 3.78 ± 2.81 and when initiated after puberty was 2.17 ± 1.37 (p = 0.022). Patients diagnosed pre-puberty were more likely to undergo treatments vs. those diagnosed after puberty (OR 10.00, 95 % CI: 2.61-38.28, p < 0.001). CONCLUSION: We found that the number of treatments was fewer in those who started treatment after puberty. This finding suggests that providers may elect to proceed with observation in asymptomatic patients, given that waiting until after the onset of puberty has not shown an increase in the procedural load on patients.

Adherence to Tympanostomy Tube Clinical Practice Guidelines in an Advanced Practice Provider Clinic.

OBJECTIVE: We compared adherence rates by attending otolaryngologists (OTOs) and advanced practice providers (APPs) to the 2013 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline (CPG) for children with recurrent acute otitis media (RAOM) undergoing bilateral myringotomy and tympanostomy tube placement (BMT). METHODS: Patients aged 6 months to 12 years old undergoing BMT for RAOM who had a pre-operative visit with an independent APP or OTO were reviewed. Patients satisfied CPG criteria if middle ear effusion was identified at the pre-operative visit (pre-op) or if they did not have effusion but met exception criteria based on their risk for developmental difficulties and contraindications to medical therapy. Adherence rates between APPs and OTOs were compared. Agreement between pre-op and time-of-surgery middle ear effusion identification was assessed. RESULTS: Nine hundred twenty-three patients were included. Six hundred one patients were seen by OTOs and 322 by APPs. Middle ear effusion was identified at pre-op in 84% of APP patients and in 76% of OTO patients (P = .005). Eight percent of APP patients and 11% of OTO patients met exception criteria (P = .138). Overall, 87% of OTO patients and 92% of APP patients met either CPG or exception criteria for BMT (P = .037). A logistic regression model demonstrated that pre-op provider type did not significantly impact rates of agreement between pre-op visit and time-of-surgery middle ear effusion identification. CONCLUSIONS: Independent APP-led clinics can reliably and effectively deliver evidence-based care for prevalent conditions such as RAOM at similar rates of adherence to CPGs as OTOs.

Operative Surveillance of Airway Hemangiomas in PHACE Syndrome.

OBJECTIVE: PHACE is a rare syndrome that can present with airway hemangiomas. Management for these patients is variable and the utilization of operative endoscopic airway evaluation has not been described. The objectives of this study were to identify the incidence of airway symptoms in patients being evaluated for PHACE syndrome and determine the utility of operative endoscopy. METHODS: An IRB-approved retrospective cohort study was conducted on consecutive pediatric patients with head and neck infantile hemangioma (IH) evaluated in a multi-disciplinary vascular anomalies center between 2013 and 2019. Patients were included if they were being worked up for PHACE syndrome and had an otolaryngology evaluation. Demographics, clinical, and surgical variables were collected. RESULTS: There were 317 patients with head and neck IH. Thirty-six patients met inclusion criteria. The majority of patients were female (31/36; 86.1%) and less than half of the patients (15/36; 41.7%) were eventually diagnosed with PHACE syndrome. Median age at presentation was 2 months (range 0-82 months). A total of 28/36 (77.8%) of patients were managed with propranolol. The majority of the patients presented without aerodigestive symptoms; however, 16/36 (44.4%) of patients presented with symptoms such as stridor, hoarseness, and dysphagia. A total of 20/36 (55.6%) of patients underwent operative endoscopy. A total of 8/20 (40.0%) of patients who underwent operative endoscopy had operative intervention. Of the entire cohort, only 2/15 (13.3%) patients diagnosed with PHACE were found to have a subglottic hemangioma. Both patients presented with stridor. CONCLUSION: Operative endoscopy remains useful in the workup of PHACE syndrome to identify subglottic hemangiomas, however there may be relatively low yield in asymptomatic patients. In office flexible laryngoscopy may be a less invasive means to examine the subglottic region. A multi-center prospective study would be necessary to evaluate incidence of subglottic hemangiomas in asymptomatic patients evaluated for PHACE.

Non-involuting congenital hemangioma with delayed hypertrophy: A case series.

BACKGROUND: Noninvoluting congenital hemangiomas (NICH) are rare and poorly understood vascular tumors that are present at birth, characterized by lack of growth after birth and lack of involution. We report uncharacteristic cases of NICH hypertrophy occurring later in life. METHODS: This is a case series describing the clinical presentation, management, and histologic characteristics of two cases of NICH hypertrophy. RESULTS: Two patients with a NICH of the scalp experienced lesion hypertrophy in teenage or early adult life. Case 1 is a 14-year-old female who presented with a flat left parietal scalp lesion that at first grew slowly with the patient; however, over the span of months grew substantially resulting in an exophytic lesion. The patient had the lesion surgically excised. Case 2 is a 26-year-old female with NICH of left occipital scalp and posterior neck who noted new nodules on the inferior border of the lesion. MRA/MRI showed extension into the occipital calvarium, level V of the neck, and paraspinal musculature. The patient elected to observe given the extent of the lesion and her minimal symptoms. CONCLUSION: Although postnatal growth of NICH have been described, cases usually occur during the pre-adolescent period where growth is usually proportional to overall growth of the patient. This study describes two cases of rapid onset NICH hypertrophy occurring later in life. Knowledge of the potential for delayed hypertrophy may lead families to seek earlier intervention or opt for more definitive interventions. Additionally, recognition of these variable distinctions will contribute to a better understanding of CH and its various subtypes.

Effect of Insurance Type on Postoperative Tympanostomy Tube Follow-up.

OBJECTIVE: Bilateral myringotomy with tube insertion (BMT) is a common procedure performed in children. Appropriate follow-up is necessary to ensure management of postoperative sequalae. The objectives are to investigate (1) the relationship between insurance type and postoperative follow-up attendance and (2) the effect of follow-up on need for further care after BMT. STUDY DESIGN: Retrospective cohort study. SETTING: The study included patients <3 years of age undergoing BMT for recurrent acute otitis media at a tertiary care children's hospital within a single year and followed for 3 years. Patients were excluded if they had received a prior BMT; underwent a concurrent otolaryngologic procedure; or had a syndromic diagnosis, craniofacial abnormality, or any significant cardiac or respiratory comorbidity. METHODS: Number of follow-up appointments, demographics, socioeconomic status, and postoperative outcomes were analyzed. RESULTS: A total of 734 patients were included with mean (SD) age of 1.4 years (0.50). The majority of patients had private insurance (520/734, 70.8%). Patients with public insurance attended fewer postoperative appointments (1.5 vs 1.8, P < .001) and had a higher incidence of BMT-related emergency department (ED) visits (10.3% vs 3.8%, P = .001). There was no significance found when different insurance providers were compared. An adjusted multivariate regression analysis showed that patients with private insurance were more likely to attend postoperative appointments (odds ratio, 3.52 [95% CI, 2.12-5.82]; P < .001) and less likely to have a BMT-related ED visit (odds ratio, 0.42 [95% CI, 0.20-0.89]; P = .024). CONCLUSION: Insurance type is related to outcomes after the treatment of recurrent acute otitis media with BMT. Future studies that survey individuals will help identify barriers that contribute to patient absence at follow-ups and need for subsequent ED visits.

Detecting coagulopathy in pediatric patients with post-tonsillectomy hemorrhage.

INTRODUCTION: Post-tonsillectomy hemorrhage (PTH) is a serious complication after a tonsillectomy. Utility of lab work at presentation for PTH was low. This study aims to determine the frequency and type of labs drawn at emergency department (ED) presentation and assess the incidence of uncovering a previously unidentified coagulopathy. METHODS: A retrospective chart review was performed on pediatric patients who were seen in the ED after tonsillectomy at a tertiary care children's hospital from 2017 to 2019. Exclusion criteria were the following: no tonsillar bleed, history of known coagulopathy, treated by outside provider, ≥18 years old. Lab work included complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), and von Willebrand factor (VWF). RESULTS: 364/723 (50.3%) patients met inclusion criteria. 179/364 (49.2%) patients were male and 309/364 (84.9%) patients were Caucasian. Average age at surgery was 8.12 years (SD = 4.0) and average post-operative day at presentation was 6 days (SD = 2.1). Operative control of bleed was performed in 68/364 (18.7%) patients. 334/364 (91.8%) patients had labs drawn in the ED. 64/334 (19.1%) patients were anemic (hemoglobin (Hgb) < 11), 46/334 (13.8%) patients had thrombocytosis (platelets>450,000), 10/334 (3.0%) had elevated PTT and 8/334 (2.4%) had elevated PT. Hematology was consulted in 14/364 (3.8%) patients of whom 6/14 were diagnosed with von Willebrand disease and 1/14 with factor VII deficiency. Aminocaproic acid was used in 8/364 (2.2%) patients due to elevated PTT in 3/8 and multiple episodes of bleeding in 5/8.3/364 (0.8%) patients needed a blood transfusion. No difference was found in incidence of abnormal lab work in patients who did and did not need operative control of bleed (p = .125). Of the 334 patients who had ED labs drawn, 7 (2.1%) had an uncovered coagulopathy. CONCLUSION: Uncovering incidental coagulopathies is rare in patients who present with PTH. Though anemia was the most common abnormality noted, only a small percentage required transfusion, with all having abnormal vital signs. Thrombocytosis was the next common abnormality, and this can be seen in an inflammatory state. Developing algorithms is necessary to better guide appropriate lab work in patients who present with PTH and to provide optimal value of care to patients.

Advanced Practice Provider Clinics: Expediting Care For Children Undergoing Tympanostomy Tube Placement.

OBJECTIVE/HYPOTHESIS: Advanced practice provider (APP) employment is becoming common in pediatric otolaryngology practices, though few studies have evaluated the consequences that APP-led clinics have on access to care. The objectives of this study were: 1) to investigate whether access to bilateral myringotomy with tympanostomy tube placement (BMT) for recurrent acute otitis media (RAOM) differed between patients seen in otolaryngologist and APP-led clinics 2) to compare clinical characteristics of patients seen by provider type. METHODS: Retrospective cohort study at an academic, tertiary care pediatric otolaryngology practice. All children were <18 years old and underwent evaluation for RAOM followed by BMT. We compared time in days from scheduling pre-operative appointment to appointment date and time from appointment to BMT between patients seen by APPs and otolaryngologists using Mann-Whitney U tests and multivariate linear regression models. We compared clinical characteristics by provider type using Mann-Whitney U tests and Fisher exact tests. RESULTS: A total of 957 children were included. Children seen by APPs had significantly shorter wait times for appointments (median 19 vs. 39 days, P < .001) and shorter times from preoperative appointment to BMT (median 25 vs. 37 days, P < .001). Patients seen by otolaryngologists had increased prevalence of craniofacial abnormalities, Down Syndrome, hearing loss, history of otologic surgery, and higher ASA physical status classification. CONCLUSIONS: Children seen by APPs received care more quickly than those seen by otolaryngologists. Patients seen by otolaryngologists tended to be more medically complex. Implementation of independent APP clinics may expedite and improve access to BMT for children with RAOM. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2133-2140, 2021.

Racial and Ethnic Disparities Among Burn Surgery Leadership.

The underrepresentation of racial and ethnic minority groups has been well-documented in general and plastic surgery but not in burn surgery. The aim of this study is to evaluate current minority group disparities among burn surgery leadership. A cross-sectional analysis was performed. Burn surgeons included directors of American Burn Association-verified burn centers in the United States, past and current presidents of the American Burn Association, and editorial board members of five major burn journals (Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma). Surgeons were compared based on factors including age, gender, training, academic rank, and Hirsch index (h-index). Among 71 burn center directors, 50 societal presidents, and 197 journal editors, minority groups represented 18.3, 2.0, and 34.5%, respectively. Among burn center directors, the group classified collectively as nonwhite was significantly younger (49 vs 56; P < .01), graduated more recently (2003 vs 1996; P < .01), and had a lower h-index (9.5 vs 17.4; P < .05). There were no significant differences in gender, type of residency training, advanced degrees obtained, fellowships, academic rank, and academic leadership positions between white and nonwhite groups. When compared with the 2018 U.S. National Census, burn unit directors had a 5.1% decrease in nonwhite representation. Disparities in representation of ethnic and racial minorities exist in burn surgery despite having similar qualifying factors.

Gender Disparities Among Burn Surgery Leadership.

Gender disparities have been described in the plastic surgery and general surgery literature, but no data have been reported in burn surgery. The aim of this study is to determine gender disparities among burn surgery leadership. A cross-sectional study was performed. Burn surgeons included were directors of American Burn Association (ABA)-verified burn centers, past presidents of the ABA, and International Society for Burn Injuries (ISBI), and editors of the Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma. Training, age, H-index, and academic level and leadership position were compared among surgeons identified. Among the 69 ABA and ISBI past presidents, 203 burn journals' editorial board members, and 71 burn unit directors, females represented only 2.9%, 10.5%, and 17%, respectively. Among burn unit directors, females completed fellowship training more recently than males (female = 2006, male = 1999, P < .02), have lower H-indexes (female = 8.6, male = 17.3, P = .03), and are less represented as full professors (female = 8.3%, male = 42.4%, P = .026). There were no differences in age, residency, research fellowship, or number of fellowships. Gender disparities exist in burn surgery and are highlighted at the leadership level, even though female surgeons have a similar age, residency training, and other background factors. However, gender diversity in burn surgery may improve as females in junior faculty positions advance in their careers.

Factors Affecting Ultrastructural Quality in the Prefrontal Cortex of the Postmortem Human Brain.

Electron microscopy (EM) studies of the postmortem human brain provide a level of resolution essential for understanding brain function in both normal and disease states. However, processes associated with death can impair the cellular and organelle ultrastructural preservation required for quantitative EM studies. Although postmortem interval (PMI), the time between death and preservation of tissue, is thought to be the most influential factor of ultrastructural quality, numerous other factors may also influence tissue preservation. The goal of the present study was to assess the effects of pre- and postmortem factors on multiple components of ultrastructure in the postmortem human prefrontal cortex. Tissue samples from 30 subjects were processed using standard EM histochemistry. The primary dependent measure was number of identifiable neuronal profiles, and secondary measures included presence and/or integrity of synapses, mitochondria, and myelinated axonal fibers. Number of identifiable neuronal profiles was most strongly affected by the interaction of PMI and pH, such that short PMIs and neutral pH values predicted the best preservation. Secondary measures were largely unaffected by pre- and postmortem factors. Together, these data indicate that distinct components of the neuropil are differentially affected by PMI and pH in postmortem human brain.