The total amount of fluid administered is associated with postoperative complications in head and neck cancer surgery.

Objective: Patients with head and neck cancer often undergo extensive ablative and reconstructive surgery. Many risk factors are unalterable, but some operative variables are possible to adjust. The goal of this study was to estimate the association between operative variables and the incidence of perioperative complications in a contemporary tertiary care university-based head and neck patient population and a Veteran Administration hospital head and neck patient population from an earlier time period. Methods: We retrospectively reviewed all patients who underwent major head and neck surgery. Results: Two-hundred-two university patients and 122 veteran patients were reviewed. On multivariable analysis, the total amount of intravenous (IV) fluid received during the procedure was associated with postoperative complications as were patients' weight, American Society of Anesthesiologists (ASA) score, and adult comorbidity evaluation-27 (ACE-27) score. These associations did not depend on whether the patient was treated at the university or veteran hospital. Conclusion: Our study suggests that the odds of a postoperative complication increase as the total amount of IV fluid increases.

Implementing an Interprofessional Difficult Airway Response Team to Identify and Manage High-Risk Airways.

OBJECTIVE: To describe a multidisciplinary approach to and results from the creation of a difficult airway response team (DART) to address the management of inpatient loss of airway events. METHODS: Description of an interprofessional process to establish and sustain a DART program at a tertiary care hospital. An Institutional Review Board-approved retrospective review of the quantitative results was conducted from November 2019 through March 2021. RESULTS: After establishing the existing processes for difficult airway management, a focus on "work as imagined" identified 4 pillars to address the goal for the project of bringing the right providers with the right equipment to the right patients at the right time through DART equipment carts, an expanded DART code team, a screening tool to identify patients with at-risk airways and unique messaging for DART code alerts. "Work as done" was assessed through simulations. Educational efforts included further simulations and group teaching. Sustainability was achieved through ongoing e-learning and bidirectional feedback. During the period of study, there were 40,752 patients admitted and 28,013 (69%) screens completed. At-risk airways were identified in 4282 admissions (11%), most commonly due to a history of a difficult airway (19%) and elevated body mass index (16%). The DART responded to 126 codes. There were no airway-related deaths or serious adverse events. DISCUSSION: A successful DART program was created, optimized, and sustained using components of interprofessional meetings, simulation, bidirectional feedback, and quantitative analysis. IMPLICATIONS FOR PRACTICE: The techniques described can serve to guide groups who identify a quality improvement project that involves interactions between multiple stakeholders.

Head and neck cancer readmission reduction (HANCARRE) project: Reducing 30-day readmissions.

Objective: Unplanned 30-day readmissions result in increased costs and decreased patient satisfaction. The objective of this study was to compare readmission rates before and after a multidisciplinary quality improvement initiative that focuses on patient and staff education, use of targeted skilled nursing facilities, and appropriate use of patient observation status. Methods: This was a quality improvement study of all unplanned admissions to the Head and Neck Oncology service at a tertiary care facility during a 3-year period between October 2015 and September 2018. In October 2016, when the Head and Neck Oncology service revised its discharge practices for patients undergoing extirpative and/or reconstructive surgery. These changes included enhancing patient education, increasing the use of a skilled nursing facility with directed staff education and patient handoffs by advanced practice nurses, and appropriate utilization of 23-h observation status for returning patients. The readmission rate from the pre-intervention era (October 2015 through September 2016) was compared to the readmission rate from the post-intervention era (October 2016 through September 2018). Secondary outcomes were the rates of 23-h observation within 30 days of the discharge as well as emergency room visits within 30 days of discharge. Results: In this sample of 449 patients, 161 (35.9%) were observed before the change-in-practice (before October 2016), and 288 (64.1%) were observed following the change-in-practice (after September 2016). On univariable analysis, the risk of readmission declined by approximately 41.4% from the pre-intervention era, though this conclusion was not statistically significant (P = 0.06). On multivariable analysis, patients at moderate or high risk of death were 2.31 times more likely than those at minor risk of death to readmit within 30 days (P = 0.03). Similarly, those with recurrent or persistent cancer were 3.33 times more likely than those undergoing initial curative surgical management of cancer to readmit within 30 days (P = 0.001). No patient characteristics were associated with a 23-h observation following discharge (all P > 0.05). Conclusions were similar for emergency room visits following discharge. Conclusions: A three-part quality improvement strategy resulted in a clinically important decrease in 30-day readmissions, though the decline was not statistically significant. There were no significant changes in 23-h observation within 30 days of discharge or emergency room visits within 30 days of discharge.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Survival, Outcomes, and Use of Acuity Scoring Systems Following Tracheotomy in Veteran Patients.

OBJECTIVES: To determine whether established prognosis tools used in the general population of critically ill patients will accurately predict tracheotomy-related outcomes and survival outcomes in critically ill patients undergoing tracheotomy. METHODS: Retrospective chart review of 94 consecutive critically ill patients undergoing isolated tracheotomy. RESULTS: Logistic Organ Dysfunction System (LODS) and sepsis-related organ failure assessment (SOFA) scores, 2 validated measures of acuity in critically ill patients, were calculated for all patients. The only tracheotomy-related outcome of significance was the finding that patients with an LODS score ≤6 were more likely to become ventilator independent (P < .015). Higher LODS or SOFA scores were associated with in-house death (LODS, P = .001, SOFA, P = .008) and death within 90 days (LODS, P = .009, SOFA, P = .031), while death within 180 days was associated only with a higher LODS score (LODS, P = .018). When controlling for age, there was an association between both LODS (P = .015) and SOFA (P = .019) scores and death within 90 days of tracheotomy. CONCLUSIONS: The survival outcome for critically ill patients undergoing tracheotomy seems accurately predicted based on scoring systems designed for use in the general population of critically ill patients. Logistic Organ Dysfunction System may also be useful to predict the likelihood of the tracheotomy-related outcome of ventilator independence. This suggests that LODS scores may be helpful to palliative care clinicians as part of a shared decision-making aid in critically ill, ventilated patients for whom tracheotomy is being considered.

Candidate Biomarkers for HPV-Negative Head and Neck Cancer Identified via Gene Expression Barcode Analysis.

OBJECTIVES: (1) Reanalyze publicly available genomic data for HPV-negative oral cavity squamous cell carcinoma to look for candidate biomarkers. (2) Evaluate the association of the identified biomarkers with survival. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care. SUBJECTS AND METHODS: Gene expression barcode analysis was applied to an existing publicly available data set of 54 HPV-negative oral cavity squamous cell carcinoma tumor samples to identify candidate genes associated with poor prognosis. Genes identified were evaluated for their association with survival on the basis of univariable and multivariable Cox proportional hazards models. RESULTS: Three genes were found to be associated with poor prognosis. The most significant association was seen with spectrin expression. Subjects whose tumors expressed spectrin were 4.60 times more likely (hazard ratio; 95% confidence interval: 1.88-11.25) to die at any given time when compared with those without spectrin (P = .001). On univariable analysis, subjects with late-stage cancer were 6.34 times more likely (hazard ratio; 95% confidence interval: 1.41-28.53; P = .02) to die at any given time, but interestingly, after controlling for spectrin, this effect was attenuated (P = .07). Despite controlling for several possible confounding effects, the effect of spectrin remained hazardous throughout all multivariable models. This was true even after controlling for cancer stage and extracapsular extension (P = .004). CONCLUSION: Our analysis of public genomic data shows promise in identifying biomarkers that may allow clinicians to make more accurate survival predictions. Spectrin is a strong candidate for further biomarker testing.

11q21.1-11q23.3 Is a site of intrinsic genomic instability triggered by irradiation.

The chromosome location, 11q21-23, is linked to loss of heterozygosity (LOH) in multiple tumors including those of breast, lung, and head and neck. To examine the process of LOH induction, the H292 cell line (human muco-epidermoid carcinoma) was irradiated or treated with anti-CD95 antibody, and individual clones isolated through two rounds of cloning. Regions of LOH were determined by screening a suite of eight polymorphic microsatellite markers covering 11p15-11q24 using fluorescent primers and genetic analyzer peak discrimination. LOH induction was observed extending through 11q21.1-11q23.3 in 6/49 of clones surviving 4 Gy and 8/50 after 8 Gy. Analysis of selected clones by Affymetrix 6.0 single nucleotide polymorphism (SNP) arrays confirmed the initial assessment indicating a consistent 27.3-27.7 Mbp deletion in multiple clones. The telomeric border of LOH mapped to a 1 Mbp region of elevated recombination. Whole genome analysis of SNP data indicated that site-restricted LOH also occurred across multiple additional genomic locations. These data indicate that 11q21.1-11q23.3, and potentially other regions of this cell line are sites of intrinsic cell-specific instability leading to LOH after irradiation. Such deletions may subsequently be propagated by genetic selection and clonal expansion.

A 25-year analysis of veterans treated for tonsillar squamous cell carcinoma.

OBJECTIVE: To determine the recurrence and survival outcome based on treatment date, type of treatment, stage of disease, and comorbidity and the recurrence and survival differences based on smoking status as a surrogate for human papillomavirus status in veterans treated for tonsillar squamous cell carcinoma (SCC). DESIGN: Outcome cohort study. SETTING: Tertiary care Department of Veterans Affairs hospital. PATIENTS: A consecutive sample from 1981 through 2006 of 683 patients treated for oropharyngeal SCC was screened, and 141 patients with tonsillar SCC without distant metastatic spread and a minimum of 2 years of follow-up were included. MAIN OUTCOME MEASURES: Disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). RESULTS: Disease-free survival was significantly better in cohort II (treated during or after 1997) compared with cohort I (treated before 1997) (2- and 5-year DFS, 82% vs 64% and 67% vs 48%; P = .02). Disease-specific survival was better in the surgical vs nonsurgical group (2- and 5-year DSS, 77% vs 46% and 67% vs 30%; P < .001), as was the OS (2- and 5-year OS, 66% vs 41% and 45% vs 23%; P = .005). In subjects with early-stage disease, OS and DSS were not different regardless of treatment type. In subjects with late-stage disease treated most recently (time cohort II), there was significantly better DSS in those receiving surgical vs nonsurgical treatment (2-year DSS, 70% vs 43%; P = .045). Nonsmokers had better OS (94 months vs 41 months; P = .001) and lower incidence of recurrence (8% vs 44%; P = .02). CONCLUSION: In veterans treated for tonsillar SCC, we advocate the consideration of a treatment plan that includes surgery for patients presenting with advanced-stage SCC of the tonsil, even in patients with notable comorbidities.

Primary tumor thickness as a risk factor for contralateral cervical metastases in T1/T2 oral tongue squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Contralateral cervical metastases represent an avoidable source of failure in squamous cell carcinoma (SCCa) of the oral tongue. We sought to identify risk factors for the development of contralateral cervical metastases in T1/T2 oral tongue SCCa. STUDY DESIGN: Retrospective review. METHODS: We reviewed the medical records of 50 sequential cases of Stage I/II SCCa of the oral tongue treated with surgery between 1983 and 2003 at Loyola University Medical Center and Hines VA Hospital. Clinical staging, primary tumor thickness, results of neck dissection, adjuvant treatment, site and date of recurrence, and final outcome were recorded. Follow-up ranged from 0.2 to 17 years, with a mean of 5 years. Data were analyzed using multivariate logistic, Cox regression analysis, and a classification and logistic regression tree analysis. RESULTS: The odds ratio for risk of developing contralateral neck metastasis was 5% for each 1 mm increase in tumor thickness (P = .68). The risk did not change when controlling for the presence of ipsilateral metastasis. There was a significant relationship between contralateral cervical metastases and the development of recurrent disease at any site (P = .005). Classification tree analysis determined the risk for contralateral metastases and was greatest for patients with tumors > 3.75 mm thick and < or = 9.5 mm thick. CONCLUSIONS: This report is the first to our knowledge that evaluates thickness as a risk factor for contralateral cervical metastasis in oral tongue SCCa. We recommend consideration be given to treating the contralateral neck in cases where the primary tumor is > 3.75 mm thick.

Sebaceous lymphadenoma identified by fine needle aspiration biopsy: a case report.

BACKGROUND: Sebaceous lymphadenoma of the parotid gland is a rare benign neoplasm. This is the first reported case of fine needle aspiration biopsy (FNAB) findings for sebaceous lymphadenoma of the parotid gland. CASE: A 60-year-old male presented with painless, bilateral parotid swelling noted for 5 months. The swelling was more pronounced on the right. Examination revealed bilaterally prominent parotid glands with diffuse firmness but no discrete masses. There was no evidence of facial nerve dysfunction. Laboratory evaluation was negative for infectious and autoimmune etiologies. Magnetic resonance imaging revealed bilateral cystic parotid masses. FNAB of the right parotid was obtained to assist with preoperative counseling. It revealed lymphoid and salivary gland parenchymal cells. The patient underwent a right superficial parotidectomy. The surgical specimen of the parotid mass confirmed the diagnosis of sebaceous lymphadenoma on the tissue section. The contralateral parotid mass had not been excised at this writing. CONCLUSION: This report is the first to describe the FNAB findings of the unusual benign parotid neoplasm sebaceous lymphadenoma. Though the definitive diagnosis of any parotid mass requires tissue, generally obtained via parotidectomy, an FNAB diagnosis can be useful in counseling a patient prior to definitive biopsy.