Analysis of trends in radiofrequency ablation in a tertiary care center practice.

BACKGROUND: Radiofrequency ablation (RFA) for thyroid nodules has recently been introduced into the United States healthcare system landscape. Little is known about the process of incorporating this procedure into existing clinical practice. METHODS: A retrospective chart review of a single institution was conducted to examine referral patterns and decision-making after the introduction of RFA into an endocrine surgery-focused practice. Patient demographics and thyroid-specific data were recorded. Two reviewers abstracted and coded reasons for the noncompletion of RFA. Two-sample t tests were used to compare groups; linear regression was used to assess trends and practice patterns. RESULTS: Chart review identified 451 patients referred for consideration of RFA from January 2020 to December 2022. Only 255 (56.5%) went on to receive the treatment. There was no significant difference in nodule volume between treated and nontreated groups (18.5 vs. 14.9 cm3, p = 0.07). Concern for malignancy on genetic testing, size (too large/too small), recommendation for Ethanol ablation, and multinodular disease without target nodules were the most common reasons for physician deferral. Of patients who declined to proceed, 46% opted to undergo surgical excision. Linear regression showed that referral numbers significantly increased with time; however, the proportion of patients receiving treatment decreased yearly, primarily because of higher rates of physician deferral. CONCLUSIONS: This study reflects the complex decision-making in offering minimally invasive thyroid nodule ablation. Despite a greater number of referrals over time, physician criteria became increasingly selective. Optimal candidacy in RFA is an evolving determination requiring patient and physician input to guide ideal practice patterns.

Foreign Body Reaction Requiring Re-Exploration After Tympanoplasty With Porcine Small Intestinal Submucosa Reconstruction.

OBJECTIVE: We present the first published case of large foreign body reaction to Biodesign (Cook Medical, Bloomington, IN), an acellular otologic graft matrix derived from porcine small intestinal submucosa, after use in tympanoplasty surgery in a patient without previous exposure to meat products. METHODS: A single case report of a 39-year-old female who developed tinnitus, ear drainage, and large fibrotic mass in external auditory canal and extending into middle ear after Type I medial graft tympanoplasty with Biodesign Graft. Left endoscopic microdissection and resection of the tympanic membrane and middle ear fibrotic mass were performed. MAIN FINDINGS: Surgical excision of the fibrous mass required extensive microdissection to ensure preservation of the ossicles and chorda tympani. Postoperatively, hearing improved and otalgia and otorrhea resolved. CONCLUSIONS: We report the first case of post-tympanoplasty reaction with the use of Biodesign acellular porcine graft in a patient with no previous known exposure to meat products. Although this presentation appears to be rare, it reinforces the need for careful patient selection and counseling around the use of porcine or other foreign grafts.

Difference in Perception of Nasal Aesthetic Appearance Between Surgeons and Rhinoplasty Patients: A Single-Center Perspective.

BACKGROUND: Patient satisfaction is an essential outcome measure after a rhinoplasty. Yet it is not known whether the opinions of rhinoplasty patients and surgeons on nasal aesthetic appearance differ. OBJECTIVES: The aim of this study was to determine the differences between patients and surgeons in their perception of nasal aesthetic appearance. METHODS: A retrospective cohort of 300 patients seen in consultation for cosmetic, functional, or combined cosmetic and functional rhinoplasty at a single tertiary care center from June 2017 to June 2020 was studied. Based on preoperative patient images, 6 surgeons with varying levels of expertise assessed nasal aesthetics utilizing a modified Standardized Cosmesis and Health Nasal Outcomes Survey for nasal cosmesis (SCHNOS-C). These scores were then compared to the patient-reported SCHNOS-C scores. RESULTS: The cosmetic, functional, and combined subgroups consisted of 100 patients each. The mean [standard deviation] age was 35.4 [13.7] years and 64% were women. The modified SCHNOS-C scores were well-correlated among the 6 surgeons but showed only weak correlations of 0.07 to 0.20 between patient-reported scores and scores assessed by the surgeons. Compared with the surgeon's scores, patients in the cosmetic subgroup perceived their nasal aesthetic problems to be more severe whereas the those in the functional subgroup perceived their nasal aesthetic problems to be milder compared with the surgeons' assessment. CONCLUSIONS: Our findings suggest that patients and surgeons perceive nasal cosmesis differently. This difference should be considered carefully when planning rhinoplasty or assessing its outcome.

Perioperative Pain Management After Primary Palate Repair: A 3-Surgeon Retrospective Study.

OBJECTIVE: Pain management strategies following palatoplasty vary substantially. Despite efforts to reduce narcotic utilization, specific analgesic regimens are typically guided by surgeon preference. Our aim was to define analgesic variables that affect postoperative narcotic use and time to resumption of oral intake. DESIGN: This is a retrospective review from 2015 to 2018. PATIENTS: Nonsyndromic patients undergoing primary palate repair. MAIN OUTCOMES MEASURES: Analgesic variables included: local anesthetic, pterygopalatine ganglion nerve block, palatal pack, and postoperative use of ketorolac, dexamethasone, and nursing-controlled analgesia (NCA) opioid dosing. Proxy measures for pain included time to resumption of oral intake and morphine equivalence (mg/kg/h) administered. RESULTS: Veau phenotypes for the 111 patients included were: I (28%), II (19%), III (33%), IV (16%), and submucous (4%). Age, weight, local anesthetic, and postoperative use of ketorolac, dexamethasone, and palatal pack had no effect on either proxy measure (P > .05). Postoperative narcotic usage was significantly lower in patients who had an intraoperative suprazygomatic peripheral nerve block and significantly higher when NCA was utilized (P < .05). Neither variable had a significant impact on time to resumption of oral intake (P > .05). CONCLUSION: Several perioperative analgesic strategies lead to comparable postoperative consumption of narcotic and time to resume oral intake. The authors advise careful consideration of NCA due to the potential for increased narcotic utilization that we found in our institution. Based on our promising findings, further studies are warranted to assess risks, benefits, and costs of performing peripheral nerve blocks at the time of palatoplasty.

The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?

Introduction: During a two-stage free gracilis muscle transfer (FGMT) to restore smile to patients with facial paralysis, some surgeons assess nerve regeneration through the cross-face nerve graft (CFNG) with the Tinel sign and a nerve biopsy. Objective: To test whether ultimate smile reanimation outcomes are correlated with (1) the Tinel sign or (2) myelinated axons of the biopsied CFNG at the time of FGMT. Methods: Retrospective case series was performed at a tertiary care facial nerve center. Dynamic smile outcomes were quantified with Emotrics analysis of pre- and postoperative photographs. Results: Of the 113 FGMT surgeries by CFNG performed since 2002, 92 patients had pre- and postoperative photo-documentation. Most patients (89%, N = 82) had a positive Tinel sign at the time of FGMT; however, 14 patients with positive Tinel signs were deemed failures. Interestingly, 4 patients with a negative Tinel sign went on to have successful dynamic outcomes and 16 patients lacking myelinated axons in their CFNG biopsy ultimately achieved successful smile outcomes. Conclusion: Although the majority of patients had a positive Tinel sign and myelinated axons in the CFNG at the time of FGMT, the presence or absence of either factor did not predict ultimate smile outcome in this series.

Patient-reported outcomes measures used in facial vascularized composite allotransplantation: A systematic literature review.

BACKGROUND: Facial vascularized composite allotransplantation (fVCA) is a life-enhancing procedure performed to improve quality of life (QOL). Patient-reported outcome measures (PROMs) are tools used to assess QOL from the patients' perspective, and are increasingly recognized as an important clinical metric to assess outcomes of treatment. A systematic literature review was performed to identify and appraise the content of PROMs used in fVCA. METHODS: We searched PUBMED/Medline, CINAHL, Embase, PsychInfo, and Web of Science from their inception through to June 2020. Included studies used a PROM in candidates and recipients of fVCA of any gender or age. We excluded abstracts, reviews, editorials, and dissertations. Items from each PROM were extracted and coded, using top-level codes and subcodes, to develop a preliminary conceptual framework of QOL concerns in fVCA, and to guide future PROM selection. RESULTS: Title and abstract screening of 6089 publications resulted in 16 studies that met inclusion criteria. Review of the 16 studies identified 38 PROMs, none of which were developed for fVCA. Review of the coded content for each PROM identified six top-level codes (appearance, facial function, physical, psychological and social health, and experience of care) and 16 subcodes, making up the preliminary conceptual framework. CONCLUSION: There are currently no PROMs designed to measure QOL concerns of fVCA candidates and recipients. Findings from this systematic review will be used to inform an interview guide for use in qualitative interviews to elicit and refine important concepts related to QOL in fVCA.

Reliability Between In-Person and Still Photograph Assessment of Facial Function in Facial Paralysis Using the eFACE Facial Grading System.

Importance: Assessing facial function using high-quality photographs would improve long-term and objective outcomes tracking in facial palsy, facilitate automated facial grading using artificial intelligence algorithms, and allow for remote follow up. Objective: To determine agreement between in-person and photographic electronic facial function scale (eFACE) assessments, and evaluate inter-rater reliability of photographic eFACE evaluation. Design, Setting, and Participants: Retrospective review of eFACE scores from in-person interviews and standardized photographs using the Massachusetts Eye and Ear (MEE) Standard Facial Palsy Dataset. Main Outcomes and Measures: eFACE total scores and subset scores determined by two experienced facial reanimation surgeons in person and from photographs. Results: Intraclass correlation coefficients for eFACE scores were 0.96 (95% CI 0.94 to 0.97) for total scores, 0.99 (95% CI 0.989 to 0.995) for static scores, 0.82 (95% CI 0.74 to 0.88) for dynamic scores, and 0.98 (95% CI 0.97 to 0.99) for synkinesis scores. Photographic and in-person scores had a mean difference of -0.64 (95% CI -2.05 to 0.77; p = 0.37) for total score, -1.58 (95% CI -4.22 to 1.05; p = 0.24) for the static subset, 0.14 (95% CI -1.70 to 1.97; p = 0.88) for the dynamic subset, and -1.11 (95% CI -3.09 to 0.86; p = 0.26) for the synkinetic subset. Bland-Altman analysis showed no trend for increasing differences in total score or subset scores. Conclusions: eFACE assessment obtained via photographs exhibits excellent inter-rater reliability and strong agreement with in-person assessment, demonstrating facial symmetry in facial palsy patients can be monitored using standardized frontal photographs.

Short-term mortality risks among patients with oropharynx cancer by human papillomavirus status.

BACKGROUND: There is substantial variation in head and neck cancer (HNC) mortality and competing mortality among patients with HNC. In this study, the authors characterize the causes and risks of short-term mortality among patients with oropharynx cancer (OPC) and how these risks differ by human papillomavirus (HPV) status. METHODS: A custom Surveillance, Epidemiology, and End Results (SEER) data set with HPV status was used to identify 4930 patients with OPC who were diagnosed with nonmetastatic (M0) disease from 2013 to 2014, including 3560 (72.2%) HPV-positive patients and 1370 HPV-negative patients. Causes of death and cumulative incidence estimates for HNC-specific mortality, competing mortality, second-cancer mortality, and noncancer mortality were analyzed by HPV status. Risk factors for mortality events were determined using multivariable competing risk regression models. RESULTS: Compared with HPV-negative patients, HPV-positive patients had a lower risk of 2-year cumulative incidence of all-cause mortality (10.4% vs 33.3%; P < .0001) and a lower risk of both HNC-specific mortality (4.8% vs 16.2%; P < .0001) and competing-cause mortality (5.6% vs 16.8%; P < .0001). Second-cancer mortality was the most common cause of non-HNC mortality among HPV-negative patients. Both second-cancer mortality and noncancer mortality were significantly higher among patients who had HPV-negative OPC (10.8% and 6.1%, respectively) compared with those who had HPV-positive OPC (2.4% and 3.2%, respectively; both P < .0001). The median follow-up was 11 months (range 1-23 months) in this cohort with known HPV-status. CONCLUSIONS: Patients with HPV-positive and HPV-negative OPC have significantly different rates of both HNC mortality and competing mortality. HPV-negative patients are at substantial risk of competing mortality, even within 2 years of cancer diagnosis. These differences can inform power calculations for clinical trials and patient management in the acute and survivorship settings.

The role of routine nasolacrimal sac biopsy during endoscopic dacryocystorhinostomy.

OBJECTIVES/HYPOTHESIS: Most patients who undergo endoscopic dacryocystorhinostomy (DCR) have a diagnosis of idiopathic nasolacrimal duct obstruction. The purpose of this study was to examine the impact of routine biopsy of the lacrimal sac performed at time of DCR on subsequent patient diagnosis and treatment. STUDY DESIGN: Retrospective review. METHODS: The histopathology of nasolacrimal specimens (n = 769), obtained from 654 consecutive patients undergoing endoscopic DCR by a single surgeon over a 30-year period, were reviewed. Specific focus included the identification of unanticipated pathologic findings as they related to pertinent patient demographics, clinical presentation, radiologic findings, and intraoperative observations. RESULTS: The study population was 69.6% female, with an average age of 56.1 ± 18.2 years. Pathological findings of tissue from the nasolacrimal sac, which was routinely sampled in all cases, showed inflammation (n = 566 [73.6%]), normal histology (n = 147 [19.1%]), granulomas (n = 8 [1.0%]), and neoplastic process (n = 7 [0.9%]). Patient history, preoperative CT scan, and/or intraoperative findings alerted the surgeon to the possibility of an unusual diagnosis in 12 of the 15 patients. An unsuspected neoplastic or granulomatous cause of lacrimal obstruction was identified on intraoperative biopsy in three patients (0.46%). CONCLUSIONS: Although neoplastic and granulomatous diseases are relatively rare causes of lacrimal obstruction necessitating DCR surgery, they may be identified by through patient evaluation in most cases and by routine intraoperative biopsy of the lacrimal sac in all cases. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:584-589, 2020.

Prostate cancer incidence across stage, NCCN risk groups, and age before and after USPSTF Grade D recommendations against prostate-specific antigen screening in 2012.

BACKGROUND: We sought to determine the extent to which US Preventive Services Task Force (USPSTF) 2012 Grade D recommendations against prostate-specific antigen screening may have impacted recent prostate cancer disease incidence patterns in the United States across stage, National Comprehensive Cancer Network (NCCN) risk groups, and age groups. METHODS: SEER*Stat version 8.3.4 was used to calculate annual prostate cancer incidence rates from 2010 to 2015 for men aged ≥50 years according to American Joint Committee on Cancer stage at diagnosis (localized vs metastatic), NCCN risk group (low vs unfavorable [intermediate or high-risk]), and age group (50-74 years vs ≥75 years). Age-adjusted incidences per 100,000 persons with corresponding year-by-year incidence ratios (IRs) were calculated using the 2000 US Census population. RESULTS: From 2010 to 2015, the incidence (per 100,000 persons) of localized prostate cancer decreased from 195.4 to 131.9 (Ptrend  < .001) and from 189.0 to 123.4 (Ptrend  < .001) among men aged 50-74 and ≥75 years, respectively. The largest relative year-by-year decline occurred between 2011 and 2012 in NCCN low-risk disease (IR, 0.77 [0.75-0.79, P < .0001] and IR 0.68 [0.62-0.74, P < .0001] for men aged 50-74 and ≥75 years, respectively). From 2010-2015, the incidence of metastatic disease increased from 6.2 to 7.1 (Ptrend  < .001) and from 16.8 to 22.6 (Ptrend  < .001) among men aged 50-74 and ≥75 years, respectively. CONCLUSIONS: This report illustrates recent prostate cancer "reverse migration" away from indolent disease and toward more aggressive disease beginning in 2012. The incidence of localized disease declined across age groups from 2012 to 2015, with the greatest relative declines occurring in low-risk disease. Additionally, the incidence of distant metastatic disease increased gradually throughout the study period.

Predictors of long-term success and failure in primary and revision endoscopic dacryocystorhinostomy.

BACKGROUND: Although endoscopic dacryocystorhinostomy (endo-DCR) is a common treatment of nasolacrimal duct obstruction, little is known about the determinants of surgical success and failure. The purpose of this study was to identify patient- and technique-specific factors that may influence surgical outcomes of primary and revision endo-DCR. METHODS: A retrospective review was conducted of 596 patients who underwent endo-DCR over a 30-year period (1989-2018). Patients' demographics and surgical techniques were assessed. RESULTS: Among the cohort of patients (n = 478) who underwent primary endo-DCR, 10% (n = 48) required revision surgery. Patients who failed primary DCR tended to be younger (p = 0.015) and were less likely to have chronic sinonasal inflammation on histopathology (p = 0.047) than the successful surgery group. After adjusting for patient demographics and comorbidities, the occurrence of a postoperative complication was significantly associated with primary DCR failure (odds ratio [OR], 2.2; p = 0.032). Among the cohort of patients (n = 118) who underwent revision endo-DCR, 8.5% (n = 10) required additional revision surgery. Patients who failed revision DCR tended to be younger (p = 0.022), more likely to have had intraoperative laser usage (p = 0.031), and more likely to have had an intraoperative complication (p = 0.013) than the successful revision surgery group. Endo-DCR failure was not associated with smoking status, middle turbinate resection, or intraoperative visualization of the internal common punctum (p > 0.05). CONCLUSION: An understanding of factors associated with primary and revision endo-DCR failure can help to inform preoperative counseling, intraoperative surgical technique, and postoperative care in the treatment of patients with nasolacrimal duct obstruction.

Trauma system overtriage: are we on track?

The American College of Surgeons (ACS) recommends trauma overtriage rate (OT) below 50 per cent to maximize efficiency while ensuring optimal care. This retrospective study was undertaken to evaluate OT rates in our Level I trauma center using the most recent criteria and guidelines. OT rates during a 12-month period were measured using six definitions based on combinations of Injury Severity Score (ISS), length of hospital stay (LOS, in days), procedures, and disposition after the emergency department. Reason for trauma activation was 55 per cent criteria, 16 per cent guidelines, 11 per cent paramedic judgment, five per cent no reason, and 13 per cent no documentation. OT rates ranged from 22.6 per cent (ISS less than 9, LOS 1 day or less, no consults) to 48.2 per cent (ISS less than 9, LOS 3 days or less, with procedures/consults) and were in compliance with ACS recommendations. Physiologic assessment criteria and anatomic injury had the lowest OT rates and contained all mortalities. Passenger space intrusion (PSI), pedestrian versus automobile (criterion and guideline), and extrication (guideline) all had consistently high rates of OT. We conclude that PSI should be reduced to a guideline, the pedestrian versus automobile criterion and guideline should be combined, and extrication could be removed from the triage scheme.