Improving Outpatient Follow-Up Rates for New In-Hospital Consults.

OBJECTIVE(S): This investigation aimed to define the rate of outpatient follow-up after in-hospital consultation, identify factors associated with establishing care, and evaluate an alternative scheduling process to improve outpatient adherence. METHODS: Two-phase, prospective study at an academic, tertiary-care institution from March 2020 to August 2022. First, all patients not previously known to our practice encountered via inpatient consult who warranted outpatient follow-up were prospectively captured. Logistic regression analysis was used to identify demographic, disease, and practice factors predictive of follow-up. Second, a randomized control trial was performed to validate the effects of pre-assigning appointments prior to discharge. RESULTS: Six hundred subjects were included in the final study cohort; 500 in phase-one, and 100 randomized during phase-two. In the phase-one cohort, 54% (n = 272) were lost to follow-up. Multivariate analysis showed increased odds of outpatient follow-up when appointments were pre-assigned before discharge (odds ratio [OR]: 3.69 [95% confidence interval [CI]: 2.29-5.96], p < 0.001), the primary reason for hospitalization was ENT and consult-related (OR: 3.29 [1.92-5.64], p < 0.001), and the diagnosis was one of Oncology (OR: 1.93 [1.02-3.69], p = 0.045) or Pediatrics (OR: 3.36 [1.41-7.98], p = 0.006) subspecialties. During phase-two, subjects randomized for pre-assigned appointments had higher outpatient follow-up (82%) compared to the control group (20%) (p < 0.001). CONCLUSION: Hospital-based consultations represent an important referral pathway for new patients. Disease characteristics may identify patients less likely to follow-up upon discharge. Appointment scheduling protocols, including pre-assigning appointments, are modifiable targets for improving adherence to care. Laryngoscope, 133:2540-2545, 2023.

Outcomes Associated With Fibrin Sealant Use in Lateral Neck Dissections.

OBJECTIVE: To determine whether the use of fibrin sealant tissue adhesives during lateral neck dissections is associated with a change in postoperative outcomes. STUDY DESIGN: Retrospective cohort. SETTING: Institutionally affiliated tertiary care center. METHODS: Various demographic, disease, and surgical data were collected for patients who underwent lateral neck dissections. Univariate regression analysis was performed with the following outcomes: total drain output and duration of drain placement, as well as incidence of postoperative infection, hematoma, seroma, chyle leak, and salivary leak. RESULTS: A total of 133 patients underwent lateral neck dissections. Fibrin sealant was used in 35% of cases (n = 46). Its use was not associated with differences in total drain output (P = .77) or the number of days that the drains were in place (P = .83). On secondary analysis, the use of fibrin sealant was not associated with a difference in postoperative incidence of hematoma (P = .65), seroma (P = .68), chyle leak (P = .42), or salivary leak (P = .73). These results were consistent when stratified by the presence of intraoperative complications. Its use accompanied an average cost of $674 per case. CONCLUSIONS: Fibrin sealant use during lateral neck dissections was not associated with a reduction in drain output or days that the drains remained in situ. Although the current study was limited by sample size, fibrin sealant use was not associated with a decreased risk of postoperative adverse events. The evidence in this report suggests that the routine use of these products adds cost without clear benefit.

Incidence and Significance of Hypermetabolic PET-CT Findings in Unilateral TVF Motion Impairment.

OBJECTIVE: To determine the incidence and significance of asymmetric hypermetabolic laryngeal findings on positron emission tomography-computed tomography (PET-CT) in patients with unilateral true vocal fold (TVF) motion abnormalities. STUDY DESIGN: Retrospective cohort. SETTING: Single-center tertiary care institution. SUBJECTS AND METHODS: The medical records of patients with unilateral TVF motion abnormalities were reviewed. The incidence of normal and asymmetric hypermetabolic laryngeal findings was calculated in patients who underwent PET-CT and laryngeal examination, operative laryngoscopy with biopsy, or injection medialization laryngoplasty. RESULTS: A total of 135 patients with unilateral TVF motion abnormalities underwent PET-CT. After exclusion of patients who completed new or surveillance imaging for a laryngeal neoplasm (n = 27), asymmetric hypermetabolic findings in the larynx were noted in 21 (19%) cases: 13 (12%) on the contralateral side of the impaired TVF, 8 (7%) on the ipsilateral side. Two (25%) patients with ipsilateral hypermetabolism had concerning subsequent fiberoptic laryngeal examinations prompting operative biopsy. There was no evidence of inflammatory or neoplastic disease in all patients with contralateral hypermetabolic findings. Fifteen patients completed PET-CT scans after injection medialization procedures; 6 (40%) displayed avidity ipsilateral to the side of the injection. The median time from injection to scan was 27 days, as opposed to 193 days in the unremarkable scans (P = .011). CONCLUSION: Contralateral hypermetabolism in patients with unilateral TVF motion abnormalities may represent a false-positive finding. Ipsilateral hypermetabolic uptake without recent fold instrumentation warrants prompt diagnostic evaluation.

Giant Cell Tumor of the Carotid Body: A Rare Tumor in a Novel Location.

Primary giant cell tumor of soft tissue (GCT-ST) is a rare entity that is considered the soft tissue equivalent of giant cell tumor of bone. It most commonly arises in soft tissues of the trunk and extremities, with occurrence in the head and neck being extremely rare. We report a case of GCT-ST of the carotid body, the first report of a tumor of this kind arising from this site in the neck. Giant cell tumor of soft tissue is generally considered a benign tumor with low malignant potential; thus, surgical excision is usually curative. However, due to the location and invasive nature of this patient's tumor, complete excision was not possible. We discuss the implication of this for long-term management of this patient, as well as similarities and differences in clinical presentation, histology, and biological behavior between this case and previously reported cases of GCT-ST.

The Impact of RVU-Based Compensation on Patient Safety Outcomes in Outpatient Otolaryngology Procedures.

OBJECTIVE: To determine the effects an incentive-based physician compensation model has on safety outcomes related to outpatient otolaryngology surgical procedures. STUDY DESIGN: A retrospective analysis of a prospectively maintained database assessing the difference in outpatient surgical volume and postoperative adverse outcomes before and after the implementation of a relative value unit (RVU)-based payment structure. SETTING: Single-center academic otolaryngology practice operating at a hospital-owned ambulatory surgery center. SUBJECTS AND METHODS: Data prospectively collected from outpatient otolaryngology surgical cases performed at the surgery center from April 2013 to April 2018 were retrospectively reviewed. Equal pre-RVU and post-RVU study periods were calculated for 4 surgeons based on their chronological transition in payment structure (range, 46-56 months). Case volume and incidence rates of adverse outcomes, including postoperative infections, emergency department visits, unplanned hospital admissions, and returns to the operating room, were compared between the pre-RVU and post-RVU study periods at both the surgeon and group levels. RESULTS: At the group level, the post-RVU period was associated with a higher volume of surgical cases ( P = .001). No significant differences were observed in the overall incidence of adverse outcomes ( P = .21) or among the specific rates of postoperative hospitalizations ( P = .39), infections ( P = .45), unplanned returns to the operating room ( P = 1.00), or emergency department visits ( P = .39). Comparable results were observed at the individual surgeon level. CONCLUSION: The implementation of an incentive-based salary was not associated with a change in the incidence of adverse safety outcomes in the setting of increased outpatient otolaryngology procedures.

Case report: mediastinal hematoma secondary to hypertension, presenting as a retropharyngeal space abscess.

The majority of retropharyngeal hematomas described in the literature have been associated with anticoagulation therapy, tumors, aneurysm, infection or cervical spine injury. We present a case of a 55-year-old African American female with acute chest pain, sore throat, and dysphagia. Her past medical history was significant for uncontrolled hypertension and cervical spine arthritis. Physical exam was significant for posterior pharyngeal edema and her labs indicated mild leukocytosis. Contrast-enhanced CT scan of the neck demonstrated an extensive retropharyngeal fluid collection with mediastinal extension, concerning for an abscess. A trans-oral and trans-cervical incision and drainage of the presumed abscess revealed clotted blood and venous ooze. Penrose drains were placed in the retropharyngeal space to allow for spontaneous drainage over the next two days. The patient was kept intubated for 8 days to ensure a secure airway while venous ooze was allowed to self-tamponade. Antihypertensive medications were utilized to control her labile blood pressures. To our knowledge this is the first case report of uncontrolled chronic hypertension as the etiology of a spontaneous mediastinal venous hematoma with presentation as a retropharyngeal space fluid collection. When evaluating retropharyngeal space occupying lesion with mediastinal extension, consideration should be given to mediastinal venous plexus bleeding. Treatment involves securing the airway, drainage, and control of blood pressure.