Female Surgical Ergonomics in Otolaryngology: A National Survey Study.

OBJECTIVE: To assess the nature and impact surgical ergonomic challenges experienced by female otolaryngologists. STUDY DESIGN: National survey study. SETTING: Female otolaryngology residents, fellows and attendings recruited via social media posting and email distribution. METHODS: We distributed a survey study to female otolaryngologists throughout the United States. The height and glove size of participants reporting difficulties with equipment and instruments were compared to those not reporting difficulties. RESULTS: Ninety-six female otolaryngologists participated in our study, comprised of 43% residents, 10% fellows, and 47% attendings. Ninety percent of participants reported difficulties using equipment and 77% of participants reported difficulty with instruments, the most common being nasal endoscopic instruments (28%). The vast majority of participants reported pain during and (or) after the operation (92%). Head and neck (53%) and rhinology (44%) were identified as particularly challenging specialities, but only 25% of participants reported that ergonomics affected their career plans. Participants felt that adjustable equipment (60%), a variety of sizes of instruments (43%), and more discussion around ergonomics (47%) would help. Respondents reported adjusting the operating room to accommodate their size took extra time (44%) and was a mental burden (39%). Participants reporting difficulties with operating room equipment were significantly shorter than those without difficulties (64 inches vs 67 inches, P = .037), and those reporting difficulties with instruments had a smaller median glove size (6 vs 6.5, P = .018). CONCLUSION: Surgical ergonomics represent a challenge for female otolaryngologists, particularly those with smaller hands and shorter height. Partnering with industry, we must address the needs of an increasingly diverse workforce to ensure that all surgeons can operate effectively and comfortably.

The Readability of Patient-Facing Social Media Posts on Common Otolaryngologic Diagnoses.

OBJECTIVE: To assess the readability of patient-facing educational information about the most common otolaryngology diagnoses on popular social media platforms. STUDY DESIGN: Cross-sectional study. SETTING: Social media platforms. METHODS: The top 5 otolaryngologic diagnoses were identified from the National Ambulatory Medical Care Survey Database. Facebook, Twitter, TikTok, and Instagram were searched using these terms, and the top 25 patient-facing posts from unique accounts for each search term and poster type (otolaryngologist, other medical professional, layperson) were identified. Captions, text, and audio from images and video, and linked articles were extracted. The readability of each post element was calculated with multiple readability formulae. Readability was summarized and was compared between poster types, platforms, and search terms via Kruskal-Wallis testing. RESULTS: Median readability, by grade level, by grade level, was greater than 10 for captions, 5 for image-associated text, and 9 for linked articles. Captions and images in posts by laypeople were significantly more readable than captions by otolaryngologists or other medical professionals, but there was no difference for linked articles. All post components were more readable in posts about cerumen than those about other search terms. CONCLUSIONS: When examining the readability of posts on social media regarding the most common otolaryngology diagnoses, we found that many posts are less readable than recommended for patients, and found that posts by laypeople were significantly more readable than those by medical professionals. Medical professionals should work to make educational social media posts more readable to facilitate patient comprehension.

Management and outcomes of obstructive sleep apnea in infants.

OBJECTIVE: To characterize the clinical characteristics of infants with obstructive sleep apnea (OSA), define the resolution rate of infant OSA, and identify factors associated with OSA resolution. METHODS: We identified infants diagnosed with OSA via retrospective chart review at less than one year of age at a tertiary care center. We identified patient comorbidities, flexible or rigid airway evaluations, surgical procedures, and oxygen/other respiratory support administration. We identified infants as having resolved OSA based on clinical or polysomnogram resolution. We compared the frequency of comorbid diagnoses and receipt of interventions in infants with resolved versus non-resolved OSA by χ2 analysis. RESULTS: 83 patients were included. Prematurity was found in 35/83 (42%), hypotonia-related diagnoses in 31/83 (37%), and craniofacial abnormalities in 34/83 (41%). Resolution was observed in 61/83 (74%), either clinically or by polysomnogram, during follow up. On χ2 analysis, surgical intervention was not associated with likelihood of resolution (73% versus 74% in those without surgical intervention, p = 0.98). Patients with airway abnormalities on flexible or rigid evaluation were less likely to have OSA resolution than those without (63% versus 100%, p = 0.010), as were patients with hypotonia-related diagnoses (58% versus 83%, p = 0.014). In patients with laryngomalacia, there was no association of supraglottoplasty with increased resolution (88% with supraglottoplasty versus 80% without, p = 1.00). CONCLUSIONS: We identified a group of infants with OSA with diverse comorbidities. There was a high rate of resolution. This data can assist with treatment planning and family counselling for infants with OSA. A prospective clinical trial is needed to better assess consequences of OSA in this age.

Female Surgical Ergonomics in Otolaryngology: A Qualitative Study.

OBJECTIVE: To explore the surgical ergonomic challenges experienced by women in otolaryngology, identify specific equipment that is ergonomically challenging, and assess the impact of suboptimal ergonomics on female otolaryngologists. METHODS: We performed a qualitative study using an interpretive framework rooted in grounded theory. We performed semi-structured qualitative interviews of 14 female otolaryngologists from nine institutions at various stages in training and across subspecialties. Interviews were independently analyzed by thematic content analysis by two researchers and inter-rater reliability was assessed via Cohen's kappa. Differing opinions were reconciled via discussion. RESULTS: Participants noted difficulties with equipment including microscopes, chairs, step stools, and tables as well as difficulty using larger surgical instruments, preference for smaller instruments, frustration with lack of smaller instruments, and a desire for a larger spectrum of instrument sizes. Participants reported neck, hand, and back pain associated with operating. Participants suggested modifications to the operative environment, including a wider variety of instrument sizes, adjustable instruments, and more focus and attention on ergonomic issues and the range of surgeon physiques. Participants felt that optimizing their operating room set-up was an additional burden on them, and that lack of inclusive instrumentation affected their sense of belonging. Participants emphasized positive stories of mentorship and empowerment from peers and superiors of all genders. CONCLUSION: Female otolaryngologists face unique ergonomic challenges. As the otolaryngology workforce becomes increasingly diverse, it is important to address the needs of a diverse set of physiques to avoid inadvertently disadvantaging certain individuals. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:3034-3041, 2023.

Upper Airway Stimulation in Female Patients: Safety and Efficacy of a Novel Lateral Approach.

OBJECTIVE: To describe a novel lateral approach for hypoglossal nerve stimulator (HNS) implantation in women and provide evidence for its safety and efficacy. STUDY DESIGN: Retrospective case series. SETTING: Single academic medical center. METHODS: We identified patients implanted with HNS by a single surgeon from January 2017 to December 2021. Patient characteristics, postoperative complications, surgical duration, response to therapy, and need for revision surgery were recorded. RESULTS: One hundred four patients were included, including 93 males and 11 females. The lateral approach for HNS implantation involves placing the chest incision for the implantable pulse generator and respiratory sensor lead vertically in the anterior axillary line instead of horizontally in the infraclavicular area. No changes are made to the stimulator lead placement. All female patients were implanted using a lateral approach and all male patients were implanted via the standard anterior approach. Half of the patients were implanted via a 2-incision technique. The median surgical time duration was equivalent in male and female patients (119 [interquartile range (IQR): 105-138] vs 126 [IQR: 115-141], respectively). Revision was required in 2 (18%) females versus 6 (6%) males (p = .17). There were equivalent rates of therapy response as well as postoperative complications. CONCLUSION: A more cosmetic lateral approach is feasible for HNS in female patients and has a similar rate of adverse events and therapy responsiveness. Additional considerations in female patients include the ability to tolerate mammography as well as HNS implantation in the setting of existing breast implants.

Hypoglossal nerve stimulator patient usage: Patterns and trends over time.

Objective: Hypoglossal nerve stimulation (HNS) is an effective treatment for obstructive sleep apnea (OSA) patients intolerant of continuous positive airway pressure but is only effective if used regularly. Usage patterns have not been studied in detail. In this study, we aimed to characterize granular HNS usage patterns. Methods: Patients implanted by a single surgeon at an academic medical center from August 2016 to January 2021 were identified from a prospective database, which was merged with the Inspire Cloud usage database. Patient, OSA, and usage characteristics were summarized, and patient- and OSA-related characteristics were associated with usage characteristics by Wilcoxon rank-sum analyses. Usage trends over time were summarized in the overall cohort and stratified by initial usage. Results: Fifty patients were included. Median usage was 94% of nights (interquartile range [IQR]: 82%-98%) for 5.8 h per night (IQR: 4.9-6.4). Higher post-operative apnea-hypopnea index predicted fewer nights used (92% [IQR: 82%-97%] vs. 96% [IQR: 91%-99%]). No other characteristics examined were significantly associated with usage. Median hours used per night decreased from 6.80 h (IQR: 5.32-7.94) on Day 1 to 5.76 (IQR: 1.81-7.13) on Day 361. This decrease was most pronounced in the quartile with the lowest initial usage. Conclusion: This study found that most patient and OSA characteristics were not associated with HNS usage, and that usage generally decreased over time. This decrease in usage over time was most pronounced in patients with the lowest initial usage. Further work should identify interventions to improve usage patterns to optimize clinical outcomes. Level of Evidence: 4.

The impact of a double vein anastomoses on doppler's loss of signal rates.

BACKGROUND: Impact on blood flow by double vein anastomosis in head and neck free flaps is unclear. We aimed to assess venous doppler loss of signal (LOS) rates of double vein system compared with a single vein system. METHODS: Consecutive free flaps with implanted venous flow couplers between 2015-2017 were included. LOS rates were compared between groups and with regard to flap type, defect site and recipient vein within double vein group. RESULTS: 92 double-vein (184 veins) and 48 single-vein flaps were included. LOS was similar in single- and double-vein flaps (11/48 (25%) versus 46/184 (25%), p = 0.765). Double veins had fewer flap takebacks compared with single vein (4.3% vs. 12.5%, p = 0.075). Common facial vein (CFV) anastomosis showed superior LOS rates compared with external jugular and CFV branches (p = 0.026). CONCLUSIONS: Double vein anastomosis does not impact LOS rates, results in fewer flap takebacks, yet LOS rates depend on selected recipient vein.

Hypoglossal Nerve Stimulator Implantation in an Ambulatory Surgery Center Versus Hospital.

OBJECTIVES/HYPOTHESIS: Hypoglossal nerve stimulator (HGNS) implantation is highly effective in treating obstructive sleep apnea (OSA) in select patient populations that are intolerant of continuous positive airway pressure. Implantation surgery is traditionally performed in hospital outpatient departments (HOPD) due to concern about anesthetic effects and airway manipulation in an OSA population. In this study, we examined complications and efficiency of HGNS implantation in an ambulatory surgery center (ASC) versus HOPD. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with HGNS implantation performed between May 2015-January 2021 at our HOPD or ACS were included. Patient-related characteristics, surgical times, and postoperative complications were obtained via chart review. Reimbursement data on a national level for Medicare patients were calculated based on publicly available data from the Center for Medicare Services. Patient characteristics, surgical times, and complications were summarized as medians with interquartile ranges (IQRs) and proportions in each surgical setting group as appropriate. These were compared between surgical setting groups via Wilcoxon rank-sum testing and χ2 testing. RESULTS: A total of 122 patients were included. Patients in the HOPD group had significantly higher median apnea-hypopnea index (AHI) (42.0 [IQR 27.9-51.0]) compared to the ASC group (31.0 [IQR 21.0-44.2], P = .005). The intervals between in-room and case start, case finish and out-of-room, and time in the postoperative area were significantly shorter in the ASC group compared to the HOPD group. Reimbursement on a national level was estimated at 18% lower for patients with surgery performed at the ASC. There was no significant difference in postoperative complications. CONCLUSIONS: HGNS implantation in an ASC is safe and more efficient than in a HOPD, and may also be more cost-effective. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:706-710, 2022.

Travel distance is associated with stage at presentation and laryngectomy rates among patients with laryngeal cancer.

BACKGROUND: The impact of travel distance on stage at presentation and management strategies of laryngeal squamous cell carcinoma (SCC) is unknown. We investigated this relationship. METHODS: Retrospective review of patients with laryngeal SCC in the National Cancer Data Base from 2004 to 2016. Multivariate analysis determined relationships between travel distance, sociodemographic, geographic, and hospital factors. Logistic regression determined the influence of travel distance on T-stage and overall stage at presentation, and receipt of total laryngectomy. RESULTS: Sixty thousand four hundred and thirty-nine patients were divided into groups based on distance to treatment: short (<12.5 miles); intermediate (12.5-49.9 miles); and long (>50 miles). Increased travel was associated with T4-stage (intermediate vs. short OR 1.11, CI 1.04-1.18, p = 0.001; long vs. short OR 1.5, CI 1.36-1.65, p < 0.001), and total laryngectomy (intermediate vs. short OR 1.40, CI 1.3-1.5, p ≤ 0.001; long vs. short OR 2.52, CI 2.28-2.79, p ≤ 0.001). In T4 disease, total laryngectomy was associated with improved survival compared to nonsurgical treatment (HR 0.75, CI 0.70-0.80, p < 0.001) regardless of travel distance. CONCLUSION: Longer travel distance to care is associated with increased stage at presentation, rate of laryngectomy, and improved survival in advanced laryngeal SCC. Health policy efforts should be directed towards improving early access to diagnosis and care.

Preoperative biopsy in parotid malignancies: Variation in use and impact on surgical margins.

OBJECTIVES: Determine rate of preoperative biopsy in parotid malignancies, identify factors associated with its use, and its association with surgical margins. STUDY DESIGN: Retrospective cohort. SETTING: Commission on Cancer-Accredited Institutions. SUBJECTS AND METHODS: We included 5533 patients treated surgically for a parotid malignancy 2004-2014 in the National Cancer Database. Chi-squared tests, univariable, and multivariable logistic regressions were used to evaluate predictors of preoperative biopsy (defined as needle, aspiration, or incisional), and associate biopsy with surgical margins. RESULTS: Preoperative biopsy was utilized in 26.0% of patients. Biopsy was more likely in patients >60 years (odds ratio [OR]: 1.19, P = .035), advanced clinical T stage (vs. T1,T2 OR: 1.23, P = .009; T3 OR: 1.26, P = .026; T4A OR: 2.05, P < .001), advanced clinical N stage (vs. N0, N1: OR: 1.39, P = .013; N2/3: OR: 1.63, P < .001), in academic centers (OR: 1.18, P < .024), and in higher volume centers (vs. low, medium OR: 1.28, P = .002; high OR: 2.16, P < .001). Biopsy use increased over time (vs. 2004-2006, 2007-2010 OR: 1.20, P = .047; 2011-2014 OR: 1.39, P < .001). Biopsy was associated with a reduced risk of positive margins in patients with clinical T1 stage (OR: 0.70, P = .012), and younger than 61 (OR: 0.79, P = .036). CONCLUSION: The national rate of preoperative biopsy in parotid malignancy is low at 26.0%, but has increased over time. Preoperative biopsy is associated with a reduced risk of positive margins in younger patients and those with early clinical stage, suggesting its increased use may improve surgical outcomes and decrease reoperation or adjuvant therapy in these subgroups of patients. LEVEL OF EVIDENCE: 3 Laryngoscope, 130:1450-1458, 2020.

Industry Payments for Otolaryngology Research: A Four-Year Analysis of the Open Payments Database.

OBJECTIVE: To characterize industry research payments to otolaryngologists. STUDY DESIGN: Cross-sectional retrospective analysis. METHODS: We examined research payments made to otolaryngologists 2014 through 2017 included in the Open Payments Database. Trends in payment values over time were characterized and compared to other surgical specialties. Geographical and temporal trends in payments to specific principal investigators, along with the ties to specific companies, were analyzed. RESULTS: Among surgical specialties, otolaryngology was the second lowest paid in terms of total compensation from industry for research per active U.S. physician. The median (mean) payment to otolaryngologists was $819 ($5,514), $548 ($3,083), $771 ($3,484), and $1,000 ($5,768) in 2014, 2015, 2016, and 2017, respectively. There was typically a higher mean and median payment per otolaryngologists in the Northeast, although significant differences between each region varied by year. The 40 most highly funded recipients had total compensation that was on average spread over 3.35 years of the database, 2.975 different companies, and 7.35 distinct scientific studies-all significantly higher compared to otolaryngologists with less funding. CONCLUSION: Research payments to otolaryngologists are concentrated in a small number of otolaryngologists; however, many of the most highly funded principal investigators worked on numerous studies with a variety of different companies over many years. Our characterization of the Open Payments Database over 4 years illustrates the depth of relationship between otolaryngology research and industry as well as raises awareness regarding the ease of connecting otolaryngologists to research payments. LEVEL OF EVIDENCE: NA Laryngoscope, 130:314-320, 2020.

Is robotic surgery an option for early T-stage laryngeal cancer? Early nationwide results.

OBJECTIVES/HYPOTHESIS: To characterize patients undergoing laryngeal transoral robotic surgery (TORS) and compare to open partial surgery and transoral laser microsurgery (TLM) in achieving negative margins, requiring adjuvant radiation, and overall survival. STUDY DESIGN: Retrospective database analysis. METHODS: Early-stage (T1/2) laryngeal squamous cell carcinoma patients from the National Cancer Database. Univariable and multivariable logistic and Cox regressions were used to identify predictors. RESULTS: There were 1,780 patients included in the study (186 [10.4%] = TORS; 523 [29.4%] = open surgery; 1,071 [60.2%] = TLM). TORS was more commonly treated at academic centers (68.8% = open surgery, 53.9% = TLM, 71.0% = TORS; P < .001) and had more T2 (52.7% = TORS, 46.7% = open surgery, 20.5% = TLM; P < .001) and N-positive disease (26.9% = TORS, 19.5% = open surgery, 5.5% = TLM; P < .001). Surgical approach was significantly associated with margin status (positive margin rates: TORS = 17.4%, TLM = 20.0%, open surgery = 13.8%) between open surgery and TLM in multivariable analysis (compared to open surgery, TLM: 1.63 [1.12-2.38], TORS: 1.18 [0.72-1.94]; P = .04). Surgical approach was not associated with receipt of adjuvant radiation (compared to open surgery, TLM: 1.52 [1.04-2.24], TORS: 1.56 [0.97-2.49]; P = .05). It was not associated with margins or adjuvant radiation in supraglottic patients. TORS had the highest 5-year overall survival, although the survival for TLM was similar (68.7% and 64.8%, respectively), and both were higher than that of open surgery (59.1%; P = .01). In multivariable Cox regression for supraglottic patients, there was no observed difference between TORS and open surgery (compared to TORS, open surgery: 1.44 [0.93-2.24]; P = .25). CONCLUSIONS: On multivariable analysis, there was no observed difference in margin status in TORS patients compared to TLM and open surgery (in both the total cohort and supraglottic subgroup). Similarly there was no observed difference in necessitating adjuvant radiation. In Cox regression, there was no observed difference between TORS and open surgery in overall survival for supraglottic patients. This study suggests that TORS may be a viable treatment option for early-stage laryngeal cancer. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1195-1201, 2020.

Margins in Sinonasal Squamous Cell Carcinoma: Predictors, Outcomes, and the Endoscopic Approach.

OBJECTIVES: To identify factors associated with positive margins following surgical management of sinonasal squamous cell carcinoma (SNSCC), especially with regard to endoscopic treatment. METHODS: In a retrospective analysis of adult patients with clinically staged tumor (T)1 to T4a SNSCC within the National Cancer Database (NCDB) from 2004 to 2014, factors were associated with positive margins using multivariable binary logistic regression. Cases from 2010 to 2014 had surgical approach (open vs. endoscopic) available and were analyzed in a subgroup to assess the association of surgical approach with margin status. The association of margin status with overall survival (OS) and additional therapy administration was also assessed. RESULTS: We identified 2,968 cases, of which 807 (27.2%) had positive margins. On multivariable analysis, factors associated with positive margins included higher T stage (T4a vs. T1: odds ratio [OR] 2.768 [95% CI 2.143-3.577]), less differentiated tumors (poorly differentiated vs. well differentiated: OR 1.403 [95% CI 1.060-1.856]), and tumors in the ethmoid sinus (vs. nasal cavity; OR 1.889 [95% CI 1.305-2.734]). Cases treated at higher volume facilities (HVFs) were associated with a lower likelihood of positive margins (OR 0.716 [95% CI 0.582-0.881]). Positive margins were associated with decreased OS (hazard ratio 1.672 [95% CI 1.464-1.908]) and an increased rate of additional therapy (OR 1.966 [95% confidence interval 1.597-2.421]). An endoscopic approach was not associated with an increased likelihood of obtaining positive margins (vs. open; OR 1.151 [0.903-1.651]). CONCLUSION: Positive margins were less likely when performed at HVFs and more likely in the ethmoid sinus than other subsites. Importantly, there was no association between positive margins and surgical approach. Endoscopic surgery may offer a safe, less invasive alternative to open surgery for select patients. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E388-E396, 2020.

The Association between Industry Payments and Brand-Name Prescriptions in Otolaryngologists.

OBJECTIVE: To associate pharmaceutical industry payments to brand-name prescriptions by otolaryngologists. STUDY DESIGN: Retrospective cross-sectional analysis. SETTING: Open Payments Database and the Medicare Part D Participant User File 2013-2016. SUBJECTS AND METHODS: We identified otolaryngologists receiving nonresearch industry payments and prescribing to Medicare Part D recipients. Records were linked by physician name and state. The value of industry payments and the percentage of brand-name drugs prescribed per hospital referral region (HRR) were characterized as medians. Industry payments were correlated to the rate of brand-name prescription by Kendall's τ correlation. This was repeated at the individual physician level and stratified by payment type. RESULTS: In total, 8167 otolaryngologists received a median of $434 (interquartile range, $138-$1278) in industry compensation over 11 (3-26) payments. Brand-name drugs made up a median of 12.9% (8.6%-18-4%) of each physician's drug claims. The number (τ = 0.05, P < .001) and dollar amount (τ = 0.04, P < .001) of industry payments were correlated with the rate of brand-name drug prescription at the individual physician level. The number of industry payments was also associated with the rate of brand-name prescription by HRR (τ = 0.14, P < .001), but the dollar amount was not. By HRR, food and beverage payments received by physicians were associated with the rate of brand-name drug prescription (τ = 0.04, P < .001), but travel and lodging payments were not. CONCLUSIONS: Industry financial transactions are associated with brand-name drug prescriptions in otolaryngologists, and these associations are stronger at the regional level than at the individual physician level. These correlations are of modest strength and should be interpreted cautiously by readers.

Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study.

OBJECTIVES: To determine national positive margin rates in transoral laser microsurgery, to compare patients with positive and negative margins, and to identify factors associated with positive margins. STUDY DESIGN: Retrospective review of the National Cancer Database. SETTING: Population based. SUBJECTS/METHODS: Patients included those with TIS-T3 laryngeal squamous cell carcinoma (2004-2014). Univariable and multivariable logistic regression were used to identify predictors. RESULTS: A total of 1959 patients met inclusion criteria. The national positive margin rate was 22.3%. Sixty-five percent of patients had T1 disease; 94.3% were N-negative; and 74.0% had glottic tumors. Fifty-eight percent of patients were treated at academic centers, and 60.6% were treated at facilities performing <2 cases per year. On multivariable analysis, factors associated with margin status included facility volume (odds ratio [95% CI]; in cases per year: 0.93 [0.89-0.97], P = .001), academic status (vs nonacademic; academic: 0.70 [0.54-0.90], P = .008), T-stage (vs T1; T2: 2.74 [2.05-3.65], T3: 5.53 [3.55-8.63], TIS: 0.59 [0.38-0.92], P < .001), and N-stage (vs N0; N1: 3.42 [1.79-6.54], N2: 2.01 [1.09-3.69], P < .001). Tumor subsite was not associated with margin status. CONCLUSION: The national positive margin rate for laryngeal laser surgery is 22%, which is concerning given the equivalent survival benefit offered by surgery and primary radiation and the increased likelihood of bimodal therapy in the situation of positive margins. Cases treated at nonacademic centers and those with lower caseloads had a higher likelihood of positive margins. There was a linear association between T-stage and likelihood of positive margins, with T3 tumors being 5 times as likely as T1 to yield positive margins. This study highlights the importance of proper patient selection for transoral laser microsurgery resections.

Epidemiological analysis of croup in the emergency department using two national datasets.

OBJECTIVES: To characterize cases of croup presenting to emergency departments (EDs) nationwide, analyze trends, and determine readmission rates. METHODS: Retrospective review of the Nationwide Emergency Department Sample (2007-2014) and the National Hospital Ambulatory Medical Care Survey (2008-2015). RESULTS: Both databases provided similar descriptive statistics. Annual mean of 352,388 (weighted) cases in the National Emergency Department Sample (1.35% of ED cases). Average age and male:female ratio 2.50 years and 1.95:1, respectively. Peak incidence was in autumn (October = 13.7%) with troughs in the summer (July = 3.7%). 21.3% received nebulizers, <1% laryngoscopic or airway procedures, 75.1% steroids, and 13.3% antibiotics. Of the patients receiving antibiotics, 16.0% had isolated croup. 3.0% of cases were admitted to the hospital. No trend was identified in the incidence of croup, mean age, or antibiotic and steroid usage. Hospital admission rates decreased (4.0%-2.3%) and nebulizer usage increased (14.6%-27.5%; p < 0.05). 5% of patients represented repeat admissions (were seen within 72 h prior). CONCLUSIONS: Croup imposes a significant burden on the ED. Although hospital admissions decreased, annual incidence in the ED remained stable. The majority of cases are in males less than three years old, and 5.0% of patients represented readmissions. Only three-quarters received glucocorticoids despite the proven benefits, including reducing readmission rates. Antibiotic usage was high, with a large number representing potential cases of inappropriate antibiotic use.

Positive Surgical Margins in Submandibular Malignancies: Facility and Practice Variation.

OBJECTIVES: Identify positive margin rate in a national cohort of patients with submandibular carcinoma, identify predictors of positive margins, and associate margins with overall survival. STUDY DESIGN: Retrospective cohort. SETTING: Commission on Cancer-accredited hospitals. SUBJECTS AND METHODS: We included patients in the National Cancer Database from 2004 to 2014 who were diagnosed with submandibular carcinoma and underwent primary surgical resection. We determined the rate of positive surgical margins and associated patient, tumor, and treatment factors with positive margins via univariable and multivariable logistic regression analysis. We associated margin status with overall survival by Kaplan-Meier curve and Cox proportional hazards regression. RESULTS: We identified 1150 patients with submandibular malignancy undergoing surgical resection. Positive margin rate was 41.0%. Increased odds of positive margins were seen in patients with advanced T stage (vs T1, T3: odds ratio [OR] = 3.04, P < .001; T4a: OR = 2.89, P < .001), adenoid cystic carcinoma histology (OR = 1.54, P = .020), and those treated at nonacademic facilities (OR = 1.41, P = .008). Patients who underwent a preoperative diagnostic biopsy had decreased odds of positive margins (OR = 0.72, P = .014). Positive margins were associated with reduced overall survival (58% vs 69% 5-year overall survival, P < .001; hazard ratio = 1.49, P = .001) when controlling for patient, tumor, and management factors. CONCLUSIONS: The national positive margin rate of submandibular carcinoma is 41.0%. Preoperative biopsy and treatment at academic institutions independently decreased the risk of positive margins, and positive margins were independently associated with diminished overall survival. Positive margin rate for submandibular carcinoma may be considered a benchmark for quality of care.

Positive margin rates and predictors in transoral robotic surgery after federal approval: A national quality study.

BACKGROUND: Purpose of the study is to assess nationwide margin performance in oropharynx transoral robotic surgery (TORS). METHODS: Retrospective review of the National Cancer Database. RESULTS: Two thousand six hundred sixty-one patients were included. The national positive margin rate (PMR) was 16.9%. High-volume facilities had a lower PMR than low-volume facilities (12.7% vs 21.9%; P < .001). Patients with disease of the tonsil had a lower PMR (15.7%) than base-of-the-tongue (18.2%; P = .14). PMR increased with T classification (T1 = 13.0%, T2 = 17.1%, T3 = 28.2%, T4a = 45.9%, T4b = 58.3%; P < .001). On multivariable regression, factors associated with margin status included only lymph-vascular invasion (1.63[1.13-2.36]; P = .01), high volume (0.57[0.36-0.92]; P = .005), and T classification (as compared to T1, T2: 1.50[1.03-2.18], T3: 3.11[1.77-5.46], T4a: 7.03[2.95-16.75], T4b: 6.72[1.26-35.93]; P < .001). CONCLUSIONS: National PMR is 16.9%, substantially higher than reported in high-volume TORS centers. There is a linear association between positive margins and T classification, with T3 and T4 PMRs exceeding 28%. High-volume facilities are half as likely to yield positive margins compared to low-volume facilities. There was no association between human papilloma virus status, tumor subsite, or academic facility status and positive margins.