Associations Between Risk Perception and HPV Knowledge and Vaccine Uptake: Highlighting the LGBTQ+ Population.

INTRODUCTION: Gay and bisexual males and other LGBTQ+ communities are more frequently exposed to factors associated with an increased risk of human papillomavirus (HPV) acquisition. Vaccination is critical to protect against HPV+ head and neck cancer (HNC). We characterized the association of perceived level of risk of contraction with HPV knowledge, and vaccine decision-making. STUDY DESIGN: Cross-sectional cohort. SETTING: LGBTQ and general survey Reddit forums (control). METHODS: A survey was shared amongst the online forums. Descriptive statistics characterized the data. Multivariable logistic regression was used to understand factors associated with vaccination, self-perceived high risk, and knowledge of HPV + HNC. RESULTS: Of 718 respondents, most were female (41.09%), Caucasian (59.89%), college-educated (33.01%), and insured (77.15%) with a mean age of 30.75 years. Half were vaccinated (49.16%), with most unvaccinated endorsing interest (60.58%). Few dependents were vaccinated (25.91%), with interest in vaccination among parents of unvaccinated children (38.58%). Knowledge of HIV's association with HPV (62.95%), HPV causing HNC (55.57%), and the vaccine's efficacy against HNC (55.57%) was also moderate. Identifying female (P = .042), a self-perceived high-risk (P < .001), and having vaccinated children (P < .001) increased vaccination likelihood; transgender (P = .021), or lesbian or gay sexual identity (P < .001) decreased likelihood. Personal HNC diagnosis (P < .001), self-vaccination (P < .001), having vaccinated children (P < .001), having anal sex (P = .001) or no knowledge of past HPV status (P < .001) increased likelihood of high self-perceived risk. CONCLUSION: Efforts to improve public education regarding the association between HPV and HNC and vaccination efficacy are required to better inform vaccine decision-making among individuals at risk for HPV infection.

Assessing Laryngectomy Patient Education on YouTube: Investigating Quality and Reliability.

Objective: This study aimed to characterize the quality of laryngectomy-related patient education on YouTube and understand factors impacting video content quality. Study Design: Cross-sectional cohort analysis. Setting: Laryngectomy-related videos on YouTube. Methods: YouTube was anonymously queried for various laryngectomy procedure search terms. Video quality was evaluated using the validated DISCERN instrument which assesses treatment-related information quality. Descriptive statistics were used to characterize our cohort. Univariate and multivariable linear regression were used to assess factors associated with increased DISCERN score. Significance was set at P < .05. Results: Our 78-video cohort exhibited moderate levels of engagement, averaging 13,028.40 views (SD = 24,246.93), 69.79 likes (SD = 163.75), and 5.27 comments (SD = 18.81). Videos were most frequently uploaded to accounts belonging to physicians (43.59%) or health care groups (41.03%) and showcased operations (52.56%) or physician-led education (20.51%). Otolaryngologists were featured in most videos (85.90%), and most videos originated outside the United States (67.95%). Laryngectomy videos demonstrated poor reliability (mean = 2.35, SD = 0.77), quality of treatment information (mean = 1.92, SD = 0.86), and overall video quality (mean = 1.97, SD = 1.12). In multivariable linear regression, operative videos were associated with lower video quality relative to nonoperative videos (ß = -1.63, 95% confidence interval [CI] = [-2.03 to -1.24], P < .001); the opposite was true for videos from accounts with higher subscriber counts (ß = 0.02, 95% CI = [0.01-0.03], P = .005). Conclusion: The quality and quantity of YouTube's laryngectomy educational content is limited. There is an acute need to increase the quantity and quality of online laryngectomy-related content to better support patients and caregivers as they cope with their diagnosis, prepare for, and recover from surgery.

Cost-Effectiveness Analysis of PET-CT Surveillance After Treatment of Human Papillomavirus-Positive Oropharyngeal Cancer.

OBJECTIVE: To determine the cost-effectiveness of surveillance imaging with PET/CT scan among patients with human papillomavirus-positive oropharyngeal squamous cell carcinoma. STUDY DESIGN: Cost-effectiveness analysis. SETTING: Oncologic care centers in the United States with head and neck oncologic surgeons and physicians. METHODS: We compared the cost-effectiveness of 2 posttreatment surveillance strategies: clinical surveillance with the addition of PET/CT scan versus clinical surveillance alone in human papillomavirus-positive oropharyngeal squamous cell carcinoma patients. We constructed a Markov decision model which was analyzed from a third-party payer's perspective using 1-year Markov cycles and a 30-year time horizon. Values for transition probabilities, costs, health care utilities, and their studied ranges were derived from the literature. RESULTS: The incremental cost-effectiveness ratio for PET/CT with clinical surveillance versus clinical surveillance alone was $89,850 per quality-adjusted life year gained. Flexible fiberoptic scope exams during clinical surveillance would have to be over 51% sensitive or PET/CT scan cost would have to exceed $1678 for clinical surveillance alone to be more cost-effective. The willingness-to-pay threshold at which imaging surveillance was equally cost-effective to clinical surveillance was approximately $80,000/QALY. CONCLUSION: Despite lower recurrence rates of human papillomavirus-positive oropharyngeal cancer, a single PET/CT scan within 6 months after primary treatment remains a cost-effective tool for routine surveillance when its cost does not exceed $1678. The cost-effectiveness of this strategy is also dependent on the clinical surveillance sensitivity (flexible fiberoptic pharyngoscopy), and willingness-to-pay thresholds which vary by country.

Evaluation of Oropharyngeal Cancer Information from Revolutionary Artificial Intelligence Chatbot.

OBJECTIVE: With burgeoning popularity of artificial intelligence-based chatbots, oropharyngeal cancer patients now have access to a novel source of medical information. Because chatbot information is not reviewed by experts, we sought to evaluate an artificial intelligence-based chatbot's oropharyngeal cancer-related information for accuracy. METHODS: Fifteen oropharyngeal cancer-related questions were developed and input into ChatGPT version 3.5. Four physician-graders independently assessed accuracy, comprehensiveness, and similarity to a physician response using 5-point Likert scales. Responses graded lower than three were then critiqued by physician-graders. Critiques were analyzed using inductive thematic analysis. Readability of responses was assessed using Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Grade Level (FKRGL) scales. RESULTS: Average accuracy, comprehensiveness, and similarity to a physician response scores were 3.88 (SD = 0.99), 3.80 (SD = 1.14), and 3.67 (SD = 1.08), respectively. Posttreatment-related questions were most accurate, comprehensive, and similar to a physician response, followed by treatment-related, then diagnosis-related questions. Posttreatment-related questions scored significantly higher than diagnosis-related questions in all three domains (p < 0.01). Two themes of the physician critiques were identified: suboptimal education value and potential to misinform patients. The mean FRE and FKRGL scores both indicated greater than an 11th grade readability level-higher than the 6th grade level recommended for patients. CONCLUSION: ChatGPT responses may not educate patients to an appropriate degree, could outright misinform them, and read at a more difficult grade level than is recommended for patient material. As oropharyngeal cancer patients represent a vulnerable population facing complex, life-altering diagnoses, and treatments, they should be cautious when consuming chatbot-generated medical information. LEVEL OF EVIDENCE: NA Laryngoscope, 134:2252-2257, 2024.

Differences in presentation, treatment, and outcomes among minority head and neck cancer patient groups in Los Angeles County.

IMPORTANCE: While minorities represent around 20 % of all HNC patients, these demographics are largely understudied. Furthermore, trends in national studies may not always be fully replicated in locoregional populations, indicating a need for more nuanced study. OBJECTIVE: To better understand our patient population, we sought to understand differences in presentation, management, and outcome between Caucasians and minority groups with HNC. DESIGN: Retrospective cohort analysis of the Los Angeles County Surveillance Epidemiology and End Results (SEER) database. SETTING: Los Angeles County. PARTICIPANTS: All patients in Los Angeles County diagnosed with cancer of the head and neck from January 1, 1988 to December 31, 2018. MAIN OUTCOMES AND MEASURES: The primary outcome in our study was significant differences between racial and ethnic groups in age of diagnosis, sex, socioeconomic quintile, insurance status, stage at diagnosis, treatment modality, time to first treatment, and cancer-specific cause of death. RESULTS: Our 18,510-patient cohort was largely male (64.35 %), white (69.57 %), and were on average 62.84 years old (SD = 20.07). When stratifying patients by race and ethnicity, significant differences were found in average age at diagnosis, sex, socioeconomic quintile, insurance status, and stage at diagnosis, treatment modalities utilized, and time to first treatment (all p < 0.001). Relative to all other head and neck patients, minority groups were significantly younger, had lower proportions of male patients, were less likely to pursue surgery, were more likely to pursue chemotherapy or radiation, and endorsed longer time to first treatment (all p < 0.001). The distribution of socioeconomic quintile (all p < 0.001), insurance status (all p < 0.001), and stage at diagnosis (all p < 0.05) also significantly varied between minority and reference groups. Only African Americans exhibited significantly higher rates of cancer-specific cause of death relative to non-African Americans (p < 0.001). CONCLUSIONS AND RELEVANCE: Pervasive socioeconomic disparities between Caucasian HNC patients and those of other minority racial and ethnic groups in Los Angeles County that likely and significantly impact the diagnosis and management of HNC and its resultant outcomes. We encourage others to similarly examine their local populations to tailor the quality of care provided to patients.

Jehovah's witness head and neck free flap reconstruction patient outcomes.

BACKGROUND: Jehovah's Witnesses are members of a Christian religious denomination that rejects the transfusion of whole blood and component blood products. Given new transfusion-free strategies, Jehovah's Witness patients are undergoing free flap reconstructions with increased regularity. However, outcome data remains limited. With this study, we sought to examine post-operative outcomes in Jehovah's Witness patients undergoing free flap reconstruction of the head and neck, compare their outcomes to non-Jehovah's Witness patients, and enumerate strategies to enhance the safety of transfusion-free surgery. METHODS: A retrospective chart review was carried out on 10 patients who identified as Jehovah's Witness and 63 patients who did not. Demographic information, pre-operative laboratory values, peri-operative resuscitative interventions, and peri-operative outcome measures were compiled. Descriptive data analysis, Mann-Whitney, Chi-square tests, and multivariate analysis were used. RESULTS: Jehovah's Witness patients were significantly older than non-Jehovah's Witness patients (p = 0.03) and had significantly higher ASA scores (p = 0.009). Head and neck cancer was the primary surgical indication in both groups (p = 0.71). Jehovah's witness patients have significantly less intraoperative blood loss (p = 0.011) and lower post-operative hemoglobin (p = 0.002) compared to non-Jehovah's Witness patients. While Jehovah's Witness patients had significantly higher rates of severe anemia (p = 0.014), there was no significant difference between the two groups in other post-operative complications and readmission rates even in a multivariate analysis accounting for age and ASA score. CONCLUSIONS: Free flap microvascular reconstruction can be reliably performed on Jehovah's Witness head and neck patients without an increased risk of complication. Policies such as the use of non-blood volume expanders, albumin, Epogen, perioperative iron supplementation, cell saver and acute normovolemic hemodilution are key to ensuring good outcomes.

Association of patient characteristics, ultrasound features, and molecular testing with malignancy risk in Bethesda III-V thyroid nodules.

Objective: To evaluate the role of patient characteristics, ultrasound findings, and molecular testing in predicting risk of malignancy in Bethesda III, IV, and V thyroid nodules. Design: Single institution retrospective review of 230 patients with Bethesda III, IV, and V cytopathology undergoing thyroidectomy between 2009 and 2018. Setting: Private and public tertiary urban university hospitals at the same academic institution. Subjects and methods: Patients who underwent thyroidectomy with Bethesda III, IV, and V nodules were included. Patient demographics, presence of underlying thyroid disease, nodule size, sonographic features, gene expression results, and surgical procedure were documented. Correlation between these variables and final histopathologic diagnosis of malignancy was analyzed. Results: The 230 patients (103 Bethesda III, 64 Bethesda IV, and 63 Bethesda V) were included for analysis. Bethesda III nodules harbored malignancy in 26.2% of cases compared with 26.6% of Bethesda IV nodules and 82.5% of Bethesda V nodules. On multivariate analysis, age was inversely correlated with a diagnosis of malignancy (OR: 0.98, 95% confidence interval [CI]: 0.96-0.99, p = .03) Although the presence of microcalcifications was positively associated with cancer (OR: 2.31, CI: 1.24-4.29, p = .008) The co-occurrence of microcalcifications and irregular margins was associated with a higher odds of malignancy (OR: 4.42, 95% CI: 1.32-14.93, p = .016), whereas the combination of microcalcifications, irregular margins, and hypoechogenicity was associated with the greatest cancer risk (OR: 5.52, 95% CI: 1.12-27.78, p = .036). Conclusions: The presence of microcalcifications in thyroid nodules categorized as Bethesda III-V is an independent risk factor for malignancy. The combination of microcalcifications, irregular margins, and hypoechogenicity is associated with a greater malignancy risk in nodules indeterminate for thyroid cancer on cytopathology.

Human papillomavirus detection in oral rinses and history of tonsillectomy in U.S. adults.

PURPOSE: This study aims to elucidate any relationship between prior tonsillectomy and the presence of oropharyngeal HPV DNA found in screening mouth rinses. MATERIALS AND METHODS: A cross sectional study was conducted using the 2011-2014 National Health and Nutrition Examination Survey (NHANES). Participants between 40 and 69 were included in the study and medical, surgical, and sexual health history were recorded. Multivariable analyses were conducted to examine factors associated with HPV prevalence in oral rinse samples. RESULTS: A total of 4825 participants were recorded with 21.1 % having a history of tonsillectomy. In the no tonsillectomy group, 8.6 % of respondents had a positive oral rinse for HPV, while 7.2 % of those with a tonsillectomy had a positive rinse sample. There was no association between age and HPV prevalence (OR = 1.04, 95 % CI: [1.00-1.07]). When controlling for demographics, medical history, and sexual behaviors, tonsillectomy history was not shown to have an association with HPV (OR = 0.86, 95 % CI: [0.53-1.40]). However, men, Hispanics, smokers, and those with higher lifetime sexual partners had increased odds of having a positive HPV oral rinse sample which was statistically significant. CONCLUSION: Our data showed that a history of tonsillectomy was not significantly associated with the presence of HPV in an oral rinse. However, a significant relationship was seen between the presence of HPV in oral rinses and certain demographic factors such as male gender, Hispanic race, smoking history, and increased sexual partners.

Use of ICG Angiography in Head and Neck Reconstruction With the Supraclavicular Artery Island Flap.

PURPOSE: Adequate distal skin paddle perfusion is essential to preventing postoperative flap necrosis in head and neck reconstruction. To describe the use of indocyanine green angiography (ICGA), to assess skin paddle perfusion in the setting of head and neck reconstruction with the supraclavicular artery island flap at a single institution and assess the effect of ICGA use on the rate of postoperative skin paddle necrosis. METHODS: A retrospective cohort study consistently of patients who underwent head and neck reconstruction with a supraclavicular artery island flap for any indication at a tertiary medical center from 2010 to 2018. The predictor variable was ICGA use. The primary outcome was rate of skin paddle necrosis. Secondary outcomes included rates of post-operative overall complications, dehiscence, fistula, and reoperation. Covariates included demographic, operative, flap perfusion assessment, and postoperative variables. Retrospective assessment of distal flap perfusion was performed on available ICGA video recordings. Descriptive and bivariate statistics were computed. Statistical significance was set at P ≤ .05. RESULTS: A total of 104 patients were included and ICGA was used in 23 cases. In 10 of these cases, flap trimming was performed due to concern of flap hypoperfusion on ICGA. The median relative distal flap perfusion was 16.7 ± 2.6% in trimmed flaps, compared to 35 ± 13.2% in untrimmed flaps. ICGA use was not associated with rate of skin paddle necrosis (P = .76). CONCLUSIONS: ICGA is a viable method of assessing intraoperative supraclavicular artery island skin paddle perfusion and can help determine the need for distal flap trimming when tissue viability based on clinical findings alone is uncertain. ICGA use for skin paddles with uncertain perfusion on intraoperative clinical findings prevented a potential increase in postoperative necrosis compared to that of skin paddles with adequate perfusion on intraoperative clinical findings. Future studies are required to determine the minimum distal perfusion value that indicates hypoperfusion and the need for flap modification.

Cost-effectiveness Analysis of Submandibular Gland Preservation With Sialendoscopy for the Management of Sialolithiasis.

OBJECTIVE: To compare the cost-effectiveness of sialendoscopy with gland excision for the management of submandibular gland sialolithiasis. STUDY DESIGN: Cost-effectiveness analysis. SETTING: Outpatient surgery centers. METHODS: A Markov decision model compared the cost-effectiveness of sialendoscopy versus gland excision for managing submandibular gland sialolithiasis. Surgical outcome probabilities were found in the primary literature. The quality of life of patients was represented by health utilities, and costs were estimated from a third-party payer's perspective. The effectiveness of each intervention was measured in quality-adjusted life-years (QALYs). The incremental costs and effectiveness of each intervention were compared, and a willingness-to-pay ratio of $150,000 per QALY was considered cost-effective. One-way, multivariate, and probabilistic sensitivity analyses were performed to challenge model conclusions. RESULTS: Over 10 years, sialendoscopy yielded 9.00 QALYs at an average cost of $8306, while gland excision produced 8.94 QALYs at an average cost of $6103. The ICER for sialendoscopy was $36,717 per QALY gained, making sialendoscopy cost-effective by our best estimates. The model was sensitive to the probability of success and the cost of sialendoscopy. Sialendoscopy must meet a probability-of-success threshold of 0.61 (61%) and cost ≤$11,996 to remain cost-effective. A Monte Carlo simulation revealed sialendoscopy to be cost-effective 60% of the time. CONCLUSION: Sialendoscopy appears to be a cost-effective management strategy for sialolithiasis of the submandibular gland when certain thresholds are maintained. Further studies elucidating the clinical factors that determine successful sialendoscopy may be aided by these thresholds as well as future comparisons of novel technology.

Targeted Wellness Initiatives Are Most Effective for Reducing Otolaryngology Resident Burnout.

OBJECTIVE: Investigate the effect of a targeted wellness program on burnout in Otolaryngology residents. METHODS: Residents and faculty collaboratively developed a program aimed at improving resident wellness. Program implementation began in July of 2018 and after 1 year, residents evaluated the program's effects on burnout. We used the Maslach Burnout Inventory (MBI) and a Likert scale to evaluate the effects of the program. RESULTS: After 1 year of the resident wellness program, the MBI results showed an increase in the number of residents in the "engaged" category and a decrease in those rated as "burnout." Residents rated favorably initiatives grouped into the following themes: time away from work, faculty engaging with residents outside of the hospital environment, efforts to enhance residents' self-efficacy, fostering a positive culture among residents, and providing easy access to physical activity. The majority of initiatives were targeted to the "culture of wellness" domain, as defined by the Stanford Well MD framework. Our program targeted to a lesser extent the other 2 domains, "efficiency of practice" and "personal resilience." CONCLUSION: After 1 year, the wellness program resulted in a trend toward improving burnout. Future efforts should be focused on targeting the multidimensional drivers of burnout as defined by established wellness frameworks. Realizing new stressors brought on by the COVID-19 pandemic will also be an area of active effort and research.

Risk Factors for Plate Extrusion After Mandibular Reconstruction With Vascularized Free Flap.

PURPOSE: Plate extrusion after mandibular reconstruction is a complication that imposes significant morbidity on the patient. The goal of this study is to estimate the incidence of plate extrusion after mandible reconstruction with a vascularized free flap and to identify the factors associated with plate extrusion. METHODS: This was a retrospective cohort study involving patients who underwent mandibular reconstruction from October 2008 to July 2019 at LAC + USC or Keck Hospital of USC. Inclusion criteria were age ≥ 18 years, single-stage mandibular reconstruction with vascularized free flap, and follow-up of at least 12 months. Relevant demographic, intraoperative, and postoperative data were collected. The primary outcome was postoperative plate extrusion within the 12-month follow-up. Descriptive, univariate, and multivariate analyses were performed. Statistical significance was set at P ≤ .05. RESULTS: A total of 102 patients were included in this study. The majority received a fibula free flap (90%) for a malignant neoplasm (76%). All patients had at least 12 months of follow-up. The rate of plate extrusion was 16%, with the majority of those patients undergoing plate removal (69%). After adjusting for postoperative fistula, soft tissue, and length of hospitalization, we found that any history of smoking (odds ratio = 12.8; confidence interval, 1.57 to 104.2), number of osteotomies (odds ratio 3.07; confidence interval, 1.09 to 8.6), flap nonviability (odds ratio = 18.2; confidence interval, 2.22 to 148.8) were associated with plate extrusion on multivariate analysis. Postoperative soft tissue infection approached significance. CONCLUSIONS: This study demonstrates that smoking history, number of osteotomies, and flap nonviability are associated with plate extrusion after mandible reconstruction. Performing fewer osteotomies when possible to avoid excessively small flap bone segments and minimizing postoperative complications may improve long-term outcomes after mandibular reconstruction.

Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis.

OBJECTIVE: To determine the most cost-effective reconstruction method after salvage total laryngectomy. STUDY DESIGN: Cost-effectiveness analysis. SETTING: Tertiary care hospitals with head and neck oncologic and reconstructive surgeons. SUBJECTS AND METHODS: We constructed a Markov-based decision model to compare reconstruction by primary closure to pectoralis flap and free flap after salvage total laryngectomy. The model simulated disease with transition probabilities and health utilities found in primary literature and estimated the average overall cost of each reconstructive method using Medicare billing codes. Effectiveness was compared using quality-adjusted life years (QALYs). One-way and probabilistic sensitivity analyses were performed to scrutinize the conclusions of our model. Reconstruction methods were compared using incremental cost-effectiveness ratios (ICERs). In the United States, less than $150,000 per QALY gained is considered cost-effective (2019 US dollars). RESULTS: Our base case analysis revealed that primary closure was less expensive ($44,370) and yielded more QALYs (0.91) than both pectoralis ($45,163, 0.81 QALYs) and free flap ($46,244, 0.85 QALYs), making it the most cost-effective option. Between flaps, free flap was cost-effective over pectoralis flap (ICER = $27,025/QALY gained). Sensitivity analyses showed primary closure as cost-effective 69% of the time over either flap. These conclusions were sensitive to the health utilities (quality of life) of each method of reconstruction. CONCLUSION: Tissue flaps to augment closure after salvage total laryngectomy are not always the most cost-effective reconstructive option. The long-term morbidity of flap surgery oftentimes outweighs the benefit of lowering fistula rates after surgery. Careful consideration must be taken when advising patients of their reconstructive options.

Complete response with talimogene laherparepvec in recurrent melanoma of the ear: A case report.

The current standard of care for cutaneous melanoma of the ear is surgical excision. This approach may result in unfavorable functional and cosmetic outcomes. We report here a case of recurrent melanoma of the ear that achieved complete response with talimogene laherparepvec treatment after the patient declined surgical resection.

Prevalence of oral human papillomavirus infections by race in the United States: An association with sexual behavior.

OBJECTIVES: To investigate the differences in oral HPV infection and sexual behaviors by race in the US. MATERIALS AND METHODS: We analyzed data from the 2011-2014 US National Health and Nutrition Examination Survey during which participants aged 18-69 years completed oral rinse exam for HPV detection (n = 8,229). Logistic regression was used to examine the associations of race with various types of oral HPV infection and sexual behaviors. RESULTS: The prevalence of overall oral HPV infection and HPV type16 infection was 7.5% [95% CI: 6.6-8.4] and 1.1% [95% CI: 0.7-1.3], respectively. Blacks were more likely to have any oral HPV infection [OR: 1.22, 95% CI: 1.01-1.47] and Asian Americans were less likely to have any oral HPV infection [OR: 0.33, 95% CI: 0.24-0.49] than Whites. In a multivariate model, Whites were less likely to have any oral HPV infections than Blacks while having higher order of impact by the number of lifetime sex partners. Overall, Asian Americans were less likely to have type16 infection [OR: 0.21, 95% CI: 0.06-0.67] than Whites; however, that difference disappears when adjusting for sexual behaviors. CONCLUSIONS: In this nationally representative sample of US adults, the prevalence of overall oral HPV infections was higher among Blacks and lower among Asians in comparison to Whites. Further analysis with sexual behavior data suggested that the racial differences in prevalence are likely due to different sexual behaviors.

Association of Race/Ethnicity, Stage, and Survival in Oral Cavity Squamous Cell Carcinoma: A SEER Study.

OBJECTIVE: Survival differences in oral cancer between black and white patients have been reported, but the contributing factors, especially the role of stage, are incompletely understood. Furthermore, the outcomes for Hispanic and Asian patients have been scarcely examined. STUDY DESIGN: Retrospective, population-based national study. SETTING: Surveillance, Epidemiology, and End Results 18 Custom database (January 1, 2010, to December 31, 2014). SUBJECTS AND METHODS: In total, 7630 patients with primary squamous cell carcinoma in the oral cavity were classified as non-Hispanic white (white), non-Hispanic black (black), Hispanic, or Asian. Cox regression was used to obtain unadjusted and adjusted hazard ratios (HRs) of 5-year mortality for race/ethnicity with sequential adjustments for stage and other covariates. Logistic regression was used to examine the relationship between race/ethnicity and stage with adjusted odds ratios (aORs). RESULTS: The cohort consisted of 75.0% whites, 7.6% blacks, 9.1% Hispanics, and 8.3% Asians. Compared to whites, the unadjusted HR for all-cause mortality for blacks was 1.68 (P < .001), which attenuated to 1.15 (P = .039) after adjusting for stage and became insignificant after including insurance. The unadjusted HRs for all-cause mortality were not significant for Hispanics and Asians vs whites. Compared to whites, blacks and Hispanics were more likely to present at later stages (aORs of 2.63 and 1.42, P < .001, respectively). CONCLUSION: The greater mortality for blacks vs whites was largely attributable to the higher prevalence of later stages at presentation and being uninsured among blacks. There was no statistically significant difference in mortality for Hispanics vs whites or Asians vs whites.

Trends in Diagnostic Flexible Laryngoscopy and Videolaryngostroboscopy Utilization in the US Medicare Population.

IMPORTANCE: Diagnostic flexible laryngoscopy (DFL) is the second-most reimbursed procedure by Medicare in otolaryngology. However, the economic trends of this procedure on a population level are unknown. OBJECTIVE: To describe national- and state-level DFL and videolaryngostroboscopy (VLS) utilization and payment trends from 2000 to 2016 in the Medicare population. DESIGN, SETTING, AND PARTICIPANTS: This population-based, cross-sectional study of all Medicare beneficiaries from 2000 through 2016 found that at the national level the total absolute number of DFLs performed in the US Medicare population increased by 87% from 344 183 to 645 172 services, whereas total absolute payments for DFLs made by Medicare concurrently increased by 41% from $38 720 243 to $54 499 071. Rates of DLS and VLS categorized as Current Procedural Terminology (CPT) code 31575 and 31579, respectively. Analysis was carried out between November 18, 2018 and December 18, 2018. EXPOSURES: Diagnostic flexible laryngoscopy and VLS. MAIN OUTCOMES AND MEASURES: The DFL and VLS utilization rates, payments, and reimbursement rate trends were analyzed by year and state. Utilization was assessed for physician characteristics, including specialty and credentials. RESULTS: Nationally from 2000 to 2016 in the Medicare population, DFL utilization per Medicare enrollee increased 30% from 0.0087 to 0.0110 and payment per enrollee decreased 2% from $0.98 to $0.96, whereas VLS utilization and payment per enrollee both increased at least 300% during the same time period, with VLS procedure per enrollee and payment per enrollee increasing by 382% from 0.00028 to 0.0013 and 301% from $0.05 to $0.22, respectively. There was a weak correlation between reimbursement and utilization per enrollee for both DFL (r = 0.23; 95% CI, 0.12-0.34) and VLS (r = 0.26; 95% CI, 0.14-0.37) performed from 2012 to 2016. In 2016, the mean (SD) payment per DFL was $85.14 ($7.95), ranging from $65.45 in Puerto Rico to $104.82 in Washington, DC, a 1.6-fold difference. For VLS, there was a 2-fold difference between the lowest-reimbursing state, Maine ($92.20) and the highest, New York ($182.96). All US dollar values were uniformly adjusted for inflation to 2018 dollar values. Most DFLs in 2016 were performed by otolaryngologists (93.6%). CONCLUSIONS AND RELEVANCE: The DFL utilization rates remained stable compared with VLS in the Medicare population from 2000 to 2016. There was a decrease in both DFL and VLS payments per procedure in the same time period and also weak correlations between reimbursement and utilization. Practice patterns and reimbursement varied geographically across the United States, though VLS exhibited significantly higher variation than DFL at the state level.

EC-IC bypass for cerebral revascularization following skull base tumor resection: Current practices and innovations.

Complex skull base tumors can involve critical vessels of the head and neck. To achieve a gross total resection, vessel sacrifice may be necessary. In cases where vessel sacrifice will cause symptomatic cerebral ischemia, surgical revascularization is required. The purpose of this paper is to review cerebral revascularization for skull base tumors, the indications for these procedures, outcomes, advances, and future directions.