Functional Outcomes of Swallowing Following Surgery for Obstructive Sleep Apnea.

OBJECTIVE: Identification and evaluation of swallowing dysfunction in patients undergoing upper airway surgery for obstructive sleep apnea (OSA) is limited. This study evaluated subjective swallowing function pre and postoperatively in patients undergoing multi-level reconstructive pharyngeal sleep surgery. METHODS: A retrospective analysis of prospectively-administered Eating Assessment Tool (EAT-10) scores was conducted among adult patients undergoing surgery for OSA at a tertiary sleep surgery center. Preoperative and 1, 3, and 6-month postoperative time points were assessed. Patients were subdivided into two groups based on the degree of upper airway reconstruction performed. All patients underwent uvulopalatopharyngoplasty +/-tonsillectomy and tongue-base reduction. Patients undergoing Phase 1 reconstructive surgery additionally underwent tongue-base advancement procedures. RESULTS: A total 100 patients underwent airway reconstructive surgery. Forty-one patients underwent Phase 1 surgery; 59 patients underwent Mini-Phase 1 surgery. Neither group demonstrated preoperative dysphagia. Both groups experienced significant subjective dysphagia at 1-month postoperatively, which was greater among Phase 1 patients (mean EAT-10 14.8; SD 10.4) versus Mini-Phase 1 patients (mean EAT-10 6.7; SD 7.5) (p < 0.001). Swallowing function among both groups normalized by 3 and 6 months postoperatively. Phase 1 patients with pre-operative dysphagia (mean EAT-10 9.6; SD 5) demonstrated initial worsening of their swallowing postoperatively; however, reported improved swallowing versus pre-operative levels by 6 months postoperatively (mean EAT-10 3.6; SD 4.3) (p = 0.03). CONCLUSION: Pharyngeal surgery resulted in no significant, persistent adverse change in swallowing function. Among both groups, significant subjective dysphagia was reported at 1 month postoperatively, yet returned to preoperative levels by 6 months postoperatively. OSA patients with pre-existing dysphagia undergoing Phase 1 surgery trended towards improved swallowing function postoperatively. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:199-204, 2023.

Patient Perspectives on Switching from Infliximab to Infliximab-dyyb in Patients with Rheumatologic Diseases in the United States.

OBJECTIVE: The introduction of biosimilars for rheumatologic diseases (RDs) has provided a potentially lower-cost therapy compared with their bio-originator products; however, adoption of biosimilars may be challenged by patient perceptions. The objective of this study was to describe patients' perspectives of switching from infliximab to infliximab-dyyb. METHODS: This was a survey of adult patients with RDs who qualified for switching from infliximab to infliximab-dyyb therapy between September 1 2017 and January 31 2018. Verbal consent was obtained prior to administration of a telephone survey. Survey questions were focused on the safety, efficacy, and knowledge of biosimilar therapy. RESULTS: A total of 108 patients were identified with 52 (48%) patients consenting to study participation. Forty (77%) and 12 (23%) patients reported switching and not switching, respectively, to infliximab-dyyb. Regarding disease control, most respondents (80%) were satisfied to very satisfied with the switch to infliximab-dyyb. Major concerns reported for switching included not knowing enough about the medication (38%), potential side effects (35%), and loss of disease activity control (35%). CONCLUSION: Overall, patients reported satisfaction with switching from infliximab to infliximab-dyyb, but concerns regarding safety and efficacy were expressed. Patient involvement in the switching decision-making process may allay concerns and enhance biosimilar uptake.

The effect of second hand smoke in patients with squamous cell carcinoma of the head and neck.

BACKGROUND: Active tobacco smoking is a well-known risk factor for head and neck malignancy, and strong evidence has associated tobacco as the main carcinogenic factor in squamous cell cancers of this region. Evidence supporting a carcinogenic effect of second-hand smoke (SHS) on head and neck organs in non-smokers was also demonstrated with results consistent with those for active smokers. There is little data on the effects of SHS in patients previously treated for squamous cell carcinomas of the head and neck. OBJECTIVE: The purpose of this study was to prospectively evaluate the role of SHS on recurrence and survival in treated head and neck cancer patients. METHODS: We conducted a prospective cohort study to examine the association between self-reported SHS exposure and the risk of recurrence and mortality in patients treated for squamous cell cancers of the head and neck in a longitudinal fashion. Patients filled out an exhaustive smoking questionnaire on presentation and abbreviated questionnaires at each follow-up visit, which occurred every 6 months. Primary outcome measures were recurrence, development of a second primary malignancy, and recurrence-free survival. Chi square analysis was used to assess the association between SHS and the primary outcomes. A multivariate binary logistic regression analysis was applied to determine the independent predictors of recurrence. Cox proportional hazards and Kaplan Meier modeling were employed to assess the possible relationships between SHS exposure and time to develop the primary outcomes. RESULTS: Untreated new patients with a histologically confirmed diagnosis of first primary SCC of the UADT (defined as cancer of the oral cavity, the oropharynx, the hypopharynx, and the larynx) were recruited. Patients seen at The University of Texas Medical Branch (UTMB) Head and Neck oncology clinic from 1988 to 1996 were considered as cases in this study. One hundred and thirty-five patients were enrolled in the study. The median follow-up time for the sample was 54 months (3.92 years). Complete records were achieved for 92% of patients, thus 124 patients were included in the final analysis. SHS significantly correlated with recurrence and recurrence-free survival. The rate of recurrence was 46% in the group exposed to SHS and 22% in the non-exposed group. Based on multivariate binary logistic regression analysis, SHS exposure was detected as a significant independent predictor for recurrence (HR = 3.00 [95% CI 1.18-7.63]). Kaplan-Meier analysis demonstrated that patients who were not exposed to SHS had a statistically significant longer recurrence-free survival (log-rank P = 0.029). The mean survival for non SHS-exposed patients was 76 [63-89] months versus 54 [45-63] months for those exposed to SHS. CONCLUSIONS: SHS exposure is an independent predictor of recurrence and survival after head and neck cancer treatment. These results support the importance and efforts of reducing smoking at home in in the work-place.

Association between health literacy and 30-day healthcare use after hospital discharge in the heart failure population.

BACKGROUND: Low health literacy increases the risk for hospital readmissions. Despite this, the measurement and use of health literacy to guide discharge counseling and planning in heart failure patients is not commonly performed. A short 3-Question Brief Health Literacy Screen (BHLS) is available and takes less than three minutes to complete, but has never been evaluated to help determine whether health literacy affects healthcare use after discharge in patients with heart failure. OBJECTIVE: The purpose of this study was to assess 30-day readmissions and emergency department visits based on health literacy evaluated by the BHLS in an acute care heart failure population. METHODS: This was a prospective observational cohort study conducted at a large quaternary health system. Hospitalized patients with a diagnosis of heart failure were assessed for health literacy using the BHLS. Unplanned healthcare use after discharge including 30-day, all-cause ED visits and hospital readmissions was assessed using univariate and logistic regression models. RESULTS: Two hundred and sixty four patients aged 66.6 ± 14.3 (mean ± SD) years met inclusion/exclusion criteria of whom 175 (66.3%) had a BHLS score >9 (adequate health literacy) and 89 (33.7%) had a BHLS score ≤9 (low health literacy). Predictors of low health literacy included older age (p = 0.019), lower education level (p < 0.001) and unemployed (p = 0.048). After controlling for potential confounders, low health literacy was independently associated with 30-day healthcare use after hospital discharge (OR:1.80; 95% CI: 1.04-3.11; p = 0.035). CONCLUSION: Using a short, 3-question validated survey instrument, it was demonstrated that low health literacy was associated with increased 30-day unplanned healthcare use after discharge in this heart failure population. These results provide a clinically useful, easily incorporated tool that could identify high-risk patients at need for clinical interventions.

Pyrroloquinoline quinone increases the expression and activity of Sirt1 and -3 genes in HepG2 cells.

Sirtuin (Sirt) 1 and Sirt 3 are nicotinamide adenine dinucleotide ((+))-dependent protein deacetylases that are important to a number of mitochondrial-related functions; thus, identification of sirtuin activators is important. Herein, we hypothesize that pyrroloquinoline quinone (PQQ) can act as a Sirt1/Sirt3 activator. In HepG2 cell cultures, PQQ increased the expression of Sirt1 and Sirt3 gene, protein, and activity levels (P < .05). We also observed a significant increase in nicotinamide phosphoribosyltransferase gene expression (as early as 18 hours) and increased NAD(+) activity at 24 hours. In addition, targets of Sirt1 and Sirt3 (peroxisome proliferator-activated receptor γ coactivator 1α, nuclear respiratory factor 1 and 2, and mitochondrial transcription factor A) were increased at 48 hours. This is the first report that demonstrates PQQ as an activator of Sirt1 and Sirt3 expression and activity, making it an attractive therapeutic agent for the treatment of metabolic diseases and for healthy aging. Based on our study and the available data in vivo, PQQ has the potential to serve as a therapeutic nutraceutical, when enhancing mitochondrial function.

Corticosteroids in peritonsillar abscess treatment: a blinded placebo-controlled clinical trial.

OBJECTIVES/HYPOTHESIS: Sore throat is a common, benign emergency department (ED) presentation; however, peritonsillar abscess (PTA) is a complication that requires aggressive management. Use of systemic corticosteroids (SCSs) in PTA is occurring without clear evidence of benefit. This study examined the efficacy and safety of SCS treatment for patients with PTA. STUDY DESIGN: Randomized, double-blind, placebo-controlled trial. METHODS: A controlled trial with concealed allocation and double-blinding was conducted at two Canadian EDs. Following written informed consent, eligible patients received 48 hours of intravenous clindamycin and a single dose of the study drug (dexamethasone [DEX] or placebo [PLAC], intravenously [IV]). Follow-up occurred at 24 hours, 48 hours, and 7 days. The primary outcome was pain; other outcomes were side effects and return to normal activities/diet. RESULTS: A total of 182 patients were screened for eligibility; 41 patients were enrolled (21 DEX; 20 PLAC). At 24 hours, those receiving DEX reported lower pain scores (1.4 vs. 5.1; P = .009); however, these differences disappeared by 48 hours (P = .22) and 7 days (P = .4). At 24 hours, more patients receiving DEX returned to normal activities (33% vs. 11%) and dietary intake (38% vs 25%); however, these differences were not significant and disappeared by 48 hours and 7 days. Side effects were rare and did not differ between groups (P > .05). CONCLUSIONS: Combined with PTA drainage and IV antibiotics, 10 mg IV DEX resulted in less pain at 24 hours when compared to PLAC, without any serious side effects. This effect is short-lived, and further research is required on factors associated with PTA treatment success.

Fourth branchial cleft cyst with no identifiable tract: case report and treatment approach.

We describe a rare case of a fourth branchial cleft cyst that had no identifiable tract. The patient was a 23-year-old man who presented with recurring neck abscesses. After six similar episodes, computed tomography finally demonstrated that the most recent abscess had extended into the thyroid gland, a finding that led to the correct diagnosis. Extensive surgical extirpation of the cyst with an adjacent neck dissection was performed, and the patient remained symptom-free at 25 months of follow-up. The occurrence of a fourth branchial cleft cyst with no clear tract presents a surgical dilemma, as complete dissection cannot be guaranteed. Consequently, such patients are predisposed to recurrence. We propose that definitive management of a fourth branchial cleft cyst with no identifiable tract focus on eliminating the likely embryologically based path of bacterial seeding. This includes a hemithyroidectomy in conjunction with a selective neck dissection to cover all areas where a fourth branchial tract may lie within the neck.

Lingual thyroid in adults: management algorithm based on swallowing outcomes.

OBJECTIVE: To review the presentation, workup, and functional outcomes of adult patients diagnosed with lingual thyroid treated by transoral subtotal excision. These results were then used to formulate a management algorithm. DESIGN: Retrospective chart review (2001-2008). SETTING: Tertiary care academic hospital. PATIENTS: All patients diagnosed with a lingual thyroid as an adult were identified in the University of Alberta's head and neck mass database. Charts were reviewed for initial presentation, diagnostic methods, radiographic findings, and treatment and follow-up results. INTERVENTION: Transoral subtotal excision of lingual thyroid tissue. MAIN OUTCOME MEASURE: Postoperative swallowing function as measured by pharyngeal residue and aspiration on videofluoroscopic swallowing studies. RESULTS: Five patients with lingual thyroids meeting the study criteria were identified. All were females aged 29 to 58 years (mean 44 years). Presentations ranged from asymptomatic to acute airway obstruction. Diagnosis was made with flexible nasopharyngoscopy, thyroid scintigraphy, and computed tomography. All patients underwent transoral subtotal excision of their thyroids with either a CO2 laser or electrocautery. Two patients complained of residual symptoms and received adjunctive 131I, which led to symptom resolution. Pathologic evaluation revealed benign thyroid tissue. Swallowing function remained efficacious and safe in all patients, as shown by a lack of aspiration and low pharyngeal residue scores. These results were used to propose a management algorithm for the spectrum of adult-diagnosed lingual thyroid presentations. CONCLUSIONS: Transoral subtotal excision of lingual thyroid glands provides adequate resection of the lesion with good postoperative swallowing function. When appropriate, this is advocated as the treatment modality of choice.

Transfusion as a predictor of recurrence and survival in head and neck cancer surgery patients.

OBJECTIVE: There is mixed evidence regarding the association of perioperative blood transfusion to disease recurrence and mortality in head and neck cancer patients. Moreover, few investigations have examined the effects of leukocyte-depleted (leukodepleted) red cell transfusion. The presented study was undertaken to ascertain whether perioperative transfusion of leukodepleted blood is associated with recurrence and survival in head and neck cancer surgery patients. METHODS: The records of all patients having undergone head and neck surgery for malignant disease between October 1996 and October 2002 were reviewed. Hospital, blood bank, and cancer registry database records were reviewed and data were recorded onto a standardized computer spreadsheet. The primary outcome variable was the number of perioperatively transfused units of allogeneic leukodepleted blood. Multivariate analysis and Cox regression methods were employed. RESULTS: Five hundred twenty patients met the criteria for inclusion in the study. Recurrence and mortality rates were significantly different between transfusion and no-transfusion groups, in favour of the no-transfusion group. In addition to age, T stage, and N stage, multivariate analysis revealed leukodepleted blood transfusion to be an independent predictor of both recurrence (odds ratio 1.6) and survival (hazard ratio 1.5). CONCLUSION: Perioperative transfusion of leukodepleted blood is associated with higher recurrence rates and decreased survival in head and neck cancer surgery.

Free tissue transfer flap reconstruction of parotidectomy defects: outcomes analysis and the utility of three-dimensional laser surface scans.

BACKGROUND: Tumours of the parotid gland are generally managed surgically without reconstruction. The usual long-term outcomes of these techniques are facial scars, asymmetry, and permanent contour deficits. These cosmetic deformities can significantly affect patients' self-image and negatively impact their quality of life. Free tissue transfers have been used increasingly over the past years to improve patients' cosmetic and satisfaction outcomes. OBJECTIVE: The purpose of this study was to evaluate the cosmetic and symmetry outcomes of patients undergoing free flap reconstruction after parotid surgery. METHODS: The study was approved by the ethics review board at the University of Alberta. All patients undergoing total parotid surgery were offered a free flap tissue transfer reconstructive procedure. Seven consecutive patients undergoing the reconstruction option were included in the study. The control group was composed of seven patients who had undergone total parotid surgery without reconstruction. Data regarding demographics, surgical procedure, pathology, and postoperative complications were collected. Facial symmetry was evaluated with questionnaires and laser surface scanning. RESULTS: There were no statistically significant differences between the two groups with regard to age, sex, timing of surgery, or pathology. The reconstructed patients tended to perceive a better symmetry when compared to the nonreconstructed patients (p = .0014). The reconstructed patients had all experienced a slight volume increase on the operative side compared to the contralateral side, with a mean difference of 4.99% increase in volume. Conversely, the nonreconstructed patients all experienced a notable volume deficit on the operative side compared to the nonoperative side-an average 12.15% volume loss was seen postoperatively. This difference was statistically significant (p ≤ .0001). CONCLUSIONS: Free tissue transfer reconstruction is an effective means of reconstructing postparotidectomy defects in patients for whom facial volume asymmetry is a concern.

Minimally invasive parathyroidectomy under local anesthesia: patient satisfaction and overall outcome.

OBJECTIVE: To compare minimally invasive parathyroidectomy (MIP) under local anesthesia (MIPULA) to minimally invasive parathyroidectomy performed under general anesthesia (MIPUGA) in terms of postoperative pain, postanesthetic side effects, patient satisfaction, and overall outcome. DESIGN: Prospective comparative cohort study. METHODS: Consecutive consenting patients presenting to a single surgeon's practice were enrolled into MIPULA or MIPUGA groups if inclusion criteria were satisfied. A standard anesthesia and surgical protocol was followed for all included patients. Subjective outcome measurements (pain, overall satisfaction, and other variables) were achieved through questionnaires. Objective outcomes were also measured. RESULTS: Seventy-four patients were enrolled: 58 in the MIPULA group and 16 in the MIPUGA group. Operative time and hospital stay were significantly shorter in the MIPULA group. Subjectively, the MIPULA group was significantly more ready for discharge versus the MIPUGA group. No significant difference in overall satisfaction between groups was noted. Biochemical cure and conversion (MIPULA to general anesthesia open exploration) rates for our cohort were 100% and 4%, respectively. CONCLUSIONS: MIPULA confers significantly shorter operative time and hospital stay with no significant difference in subjective postoperative pain, patient satisfaction, overall outcome, or cure rate when compared to MIPUGA. Provided that appropriate preoperative localization and surgical experience are present, MIPULA can be offered to patients as a safe and reasonable alternative to MIPUGA.

Sleepy driving.

Sleepiness and drowsiness are neurophysiologic states that may cause attenuation of vigilance and slowing of reaction times, and thus increase the risks of driving. This article reviews selected peer-reviewed publications from the past and present body of knowledge regarding sleepiness and drowsiness while driving and related accidents, injuries, and possible death. Comparative studies of driving drunk and driving sleepy are reviewed because both exhibit similarly dangerous driving behaviors. It is hoped that some of the information from this article could provide new interest in the necessity of education for sleepy drivers.

Steel scalpel versus electrocautery blade: comparison of cosmetic and patient satisfaction outcomes of different incision methods.

OBJECTIVE: To determine which method of skin incision has superior cosmetic and patient satisfaction outcomes. METHODS: Consenting patients undergoing bilateral neck dissection who met the inclusion criteria were prospectively enrolled. Each side of the neck was randomly assigned into one of the following two groups: scalpel incision and electrocautery incision. Cosmetic and patient satisfaction outcomes were collected prospectively with patients and outcome assessors blinded to group assignment. Validated self-report questionnaires and objective scar measures were used. RESULTS: Nineteen patients met the criteria for inclusion. Analysis revealed no significant differences between groups in terms of cosmetic or satisfaction outcomes. Use of the steel scalpel was found to result in significantly greater incision-related blood loss compared with use of the electrocautery blade. CONCLUSION: Steel scalpel or electrocautery may be used to incise the skin of patients undergoing bilateral neck dissection with no difference in cosmetic or patient satisfaction outcome. The steel scalpel yields greater incision-related blood loss compared with the electrocautery blade.

Radial forearm donor site: comparison of the functional and cosmetic outcomes of different reconstructive methods.

OBJECTIVE: To determine which method of fascial dissection and skin graft reconstruction of radial forearm free flap defects has superior functional and cosmetic outcomes. METHODS: Consenting patients undergoing major head and neck operative resection and reconstruction with a radial forearm free flap were prospectively enrolled and randomized into one of the following four groups: (1) suprafascial dissection with meshed graft reconstruction; (2) suprafascial dissection with sheet graft reconstruction; (3) subfascial dissection with meshed graft reconstruction; and (4) subfascial dissection with sheet graft reconstruction. Functional, cosmetic, and tendon exposure outcomes were collected prospectively with patients and outcome assessors blinded to treatment group assignment. Validated self-report questionnaires and objective functional measures were used. RESULTS: Sixty-two patients met the criteria for inclusion. Analysis revealed that suprafascial dissection with sheet graft reconstruction yielded superior functional, cosmetic, and tendon exposure outcomes. CONCLUSION: Suprafascial dissection with sheet graft reconstruction should be offered to patients requiring radial forearm free flap reconstruction of major head and neck defects.

Skin lesions and physical deformities of coastal and offshore common bottlenose dolphins (Tursiops truncatus) in Santa Monica Bay and adjacent areas, California.

Skin lesions and physical deformities on coastal and offshore bottlenose dolphins (Tursiops truncatus) were assessed during a photo-identification study conducted between 1997 and 2007 in Santa Monica Bay and adjacent areas in California. During 425 boat surveys, 647 individuals were identified based on marks on their dorsal fins. Of 637 individuals examined for skin lesions and deformities, 79.0% exhibited at least one type of lesion. Offshore animals showed more lesions than coastal animals (offshore: 87.8%, n=209; coastal: 73.4%, n=270). Only one individual showed a physical deformity. Results show that skin lesions affect a large portion of the coastal and offshore dolphin populations in the study area. When considering that lesions and physical deformities can be a sign of disease and may be related to anthropogenic factors, their high presence on dolphins must be a cause of concern.

Methods of functional outcomes assessment following treatment of oral and oropharyngeal cancer: review of the literature.

OBJECTIVE: The purpose of this article is to review and document the differing methods of functional outcome measurements following treatment for oral and oropharyngeal carcinoma. STUDY DESIGN: Literature review. METHODS: Articles were identified using the MEDLINE database search engine. The "Methods" sections of relevant articles were then reviewed, and functional outcomes assessment methods were tabulated. RESULTS: We identified 60 articles published in the last 7 years (2000-2007) that reported on functional outcomes following treatment for oral or oropharyngeal cancer. Twenty-three studies used quality of life questionnaires and 12 used clinical observations to describe function. Swallowing was assessed objectively in 29 studies, with videofluoroscopic swallowing studies as the primary method of assessment. Speech was assessed in only 10 articles, with perceptual analysis used as the primary assessment modality. CONCLUSIONS: Preserving good speech and swallowing function following treatment for oral and oropharyngeal cancer remains an extremely important aspect of cancer care. Nevertheless, there is a clear lack of uniform methods for assessing functional outcomes. We propose that functional outcome studies should include both objective and subjective assessments of swallowing and speech to gain sufficient information on posttreatment function.

Comparison of drain versus no drain thyroidectomy: randomized prospective clinical trial.

OBJECTIVE: To evaluate the use of surgical drains in thyroid surgery. DESIGN: Randomized, prospective, clinical trial. METHODS: Patients were randomized into drain and no drain groups by a blinded observer. Inclusion criteria included all patients presenting for total, hemi-, or completion thyroidectomies. Those with massive goitres or nodules greater than 6 cm were excluded. Fifty-five patients were enrolled in the study. Complications, length of hospital stay, and overall cost were evaluated. RESULTS: In the no drain group, there was a 1.12-day reduction in hospital stay (p < .01), with no increase in postoperative complications. This translated into a cost savings of $2177 per patient. CONCLUSIONS: Thyroid surgery without the use of a drain decreases the length of hospital stay, with no increase in patient morbidity. The overall cost is significantly reduced.

Lansoprazole in globus pharyngeus: double-blind, randomized, placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of once-daily lansoprazole in the typical globus pharyngeus patient, who presents with a normal head and neck examination and without other sinister otolaryngologic complaints. STUDY DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Outpatient otolaryngology office practice. METHODS: After meeting the inclusion criteria, patients were randomized to a 3-month course of either treatment (30 mg lansoprazole daily) or placebo (lactose). All patients were given a medication diary and instructed to take the medication daily on waking. During the office visit, counseling regarding lifestyle modifications for gastroesophageal reflux disease was provided to all patients. MAIN OUTCOME MEASURE: The Glasgow-Edinburgh Throat Scale questionnaire was given prior to treatment and at 1- and 3-month intervals during treatment. RESULTS: Forty patients were enrolled between June 2005 and December 2006. Nineteen patients were randomized to the lansoprazole treatment arm, whereas 21 were enrolled in the placebo arm. Both groups were similar with regard to age, sex, and smoking history. The globus symptom score improved an average of 6.7 of 70 points in the treatment group and 2.9 points in the placebo group. There was no clinically or statistically significant difference between the two groups at any time point. CONCLUSION: The globus pharyngeus patient who presents with a normal head and neck examination and without sinister otolaryngologic complaints does not benefit from once-daily lansoprazole therapy.