The effect of a statewide prescription drug monitoring program on opioid prescribing patterns.

PURPOSE: Determine whether opioid prescribing patterns have changed as a result of implementation of a prescription drug monitoring program (PDMP) in the state of Massachusetts. MATERIALS AND METHODS: A multicentered retrospective study was performed including patients who received tonsillectomy, parotidectomy, thyroidectomy or direct laryngoscopy and biopsy with or without rigid esophagoscopy and/or rigid bronchoscopy at Lahey Hospital and Medical Center (Burlington, MA) or Boston Medical Center (Boston, MA). Opioid prescribing patterns were compared for the 12 months prior to implementation of the Massachusetts Prescription Awareness Tool (MassPAT) to 36 months of prescribing patterns post implementation. Quantity of opioids prescribed was based on morphine milligram equivalents (MME). Continuous variables were compared using analysis of variance (ANOVA) while categorical variables were compared using chi-squared test or Fisher's exact test. Multivariate analysis was performed using linear regression. RESULTS: A total of 2281 patients were included in the study. There was a significant association in mean overall MME prescribed comparing pre-MassPAT and post-MassPAT data [tonsillectomy: 635.9 ± 175.6 vs 463.3 ± 177.7 (p < 0.0001), parotidectomy: 250.4 ± 71.33 vs 169.8 ± 79.26 (p < 0.0001), thyroidectomy: 186.2 ± 81.14 vs 118.3 ± 88.79 (p < 0.0001), direct laryngoscopy with biopsy: 308.3 ± 246.9 vs 308.3 ± 246.9 (p = 0.0201)]. There was also a significant association between length of opioid prescription (days) and implementation of MassPAT, but there was no significant difference in the percent of patients requiring refills pre- MassPAT and post-MassPAT. CONCLUSION: This study demonstrates that prescribers have been able to significantly decrease the amount of opioids prescribed for tonsillectomy, parotidectomy, thyroidectomy, and direct laryngoscopy and biopsy and patients have not required additional opioid refills.

Pneumonia, urinary tract infection, bacteremia, and Clostridioides difficile infection following major head and neck free and pedicled flap surgeries.

OBJECTIVES: Medical postoperative infections (MPIs) are important causes of morbidity following major head and neck free and pedicled flap reconstruction, but the incidence, time of onset, and microbiology are not well characterized. MATERIALS AND METHODS: Medical records were reviewed of all head and neck flap surgeries performed 2009-2014 at an academic medical center. Postoperative pneumonia, urinary tract infection (UTI), bloodstream infection (BSI), Clostridioides difficile (CDI), and surgical site infections (SSI) were noted. Catheter-associated UTI (CAUTI), central line-associated BSI (CLABSI), and methicillin-resistant Staphylococcus aureus (MRSA) BSI were also evaluated. RESULTS: Following 715 free (540) or pedicled (175) flap surgeries, 14.1% of patients developed ≥one MPI including pneumonia (10.6%), UTI (2.1%), BSI (0.7%), and CDI (2.4%). Onset was ≤7 days in 77%. The MPI incidence in free vs pedicled flaps was similar. By multivariate analysis, age ≥65 and clindamycin perioperative prophylaxis were associated with increased MPI risk, clean class surgery with decreased risk. The incidence of CAUTI (<1.0%), CLABSI (0.1%), and hospital-onset MRSA BSI (0.1%) was low. SSI rate (7.8% overall) was higher in patients who developed pneumonia (18.4 vs 6.6, p = 0.004). MPI cultures grew gram-negative bacilli or S. aureus in 75%. The length of stay was longer in patients who developed a MPI than those who did not (17.4 vs 10.4 days, p < 0.0001). CONCLUSIONS: One-seventh of major head and neck flap surgeries were complicated by MPIs, three-quarters of infections developed within 1 week postoperatively. Gram-negative bacilli and S. aureus were the predominant pathogens.

The Impact of MassPAT on Opioid Prescribing Patterns for Otolaryngology Surgeries.

OBJECTIVE: Determine whether opioid prescriber patterns have changed for tonsillectomy, parotidectomy, and thyroidectomy after implementation of the Massachusetts Prescription Awareness Tool (MassPAT). STUDY DESIGN: Retrospective cohort study. SETTING: Single-center tertiary care hospital. METHODS: Patients were included if they received tonsillectomy, parotidectomy, or thyroid surgery at Lahey Hospital and Medical Center (Burlington, Massachusetts) between October 1, 2015, and October 1, 2019. Prescribing patterns were compared prior to implementation of MassPAT, October 1, 2015, to October 14, 2016, to postimplementation of MassPAT, October 15, 2016, to October 1, 2019. Quantity of opioids prescribed was described using total morphine milligram equivalents (MME). Data were analyzed using univariate analysis, multivariate analysis, and trend line using line of best fit. RESULTS: A total of 737 subjects were included in the study. There was a downward trend in the quantity of opioids prescribed for all 3 surgeries during the study period. There was a significant difference in the quantity of opioids prescribed pre- and postimplementation of MassPAT for tonsillectomy (647.70 ± 218.50 MME vs 474.60 ± 185.90 MME, P < .001), parotidectomy (241.20 ± 57.66 MME vs 156.70 ± 72.99 MME, P < .001), and thyroidectomy (171.20 ± 93.77 MME vs 108.50 ± 63.84 MME, P < .001). There was also a decrease in the number of patients who did not receive opioids for thyroidectomy pre- and post-MassPAT (7.56% vs 24.14%). CONCLUSION: We have demonstrated that there is an association with state drug monitoring programs and decrease in the amount of opioids prescribed for acute postoperative pain control for common otolaryngology surgeries.

Does Preoperative Calcium and Calcitriol Decrease Rates of Post-Thyroidectomy Hypocalcemia? A Randomized Clinical Trial.

BACKGROUND: Postoperative hypocalcemia is the most common complication after thyroidectomy. Postoperative supplementation with calcium and calcitriol reduces its occurrence; however, prophylactic preoperative supplementation has not been studied systematically. The primary objective of this study was to determine whether pre- and postoperative calcium and calcitriol supplementation reduces postoperative hypocalcemia after total thyroidectomy compared with postoperative supplementation alone. STUDY DESIGN: We conducted a single-institution prospective randomized trial enrolling 82 patients undergoing total thyroidectomy from July 2017 through May 2019. Those undergoing partial thyroidectomy or concurrent planned parathyroidectomy were excluded. The intervention group started calcitriol 0.25 µg po bid and calcium carbonate 1,500 mg po tid 5 days preoperatively and continued postoperatively. The control group started these medications postoperatively. The primary end point was clinical or biochemical hypocalcemia. Secondary outcomes were postoperative calcium levels, need for intervention, length of stay, and readmission. RESULTS: Thirty-eight patients were randomized to the intervention group and 44 to the control group. There were 12 episodes of hypocalcemia; 5 (13.2%) in the intervention and 7 (15.9%) in the control group (p = 0.76). No differences were found in secondary outcomes; including postoperative calcium levels at each measured time point, need for intervention (n = 10 [26.3%], n = 15 [34.1%]; p = 0.48), length of stay (mean [SD] 32.3 [15.6] hours, 30.7 [10.5] hours; p = 0.6), or readmissions (n = 0 [0.0%], n = 3 [6.8%]; p = 0.24). CONCLUSIONS: Starting supplementation with calcium and calcitriol preoperatively does not reduce postoperative hypocalcemia compared with postoperative supplementation alone after total thyroidectomy. These findings do not support the practice of routine calcium and calcitriol supplementation before total thyroidectomy.

Risk factors for thirty-day readmission following flap reconstruction of oncologic defects of the head and neck.

OBJECTIVES: Unplanned 30-day readmission rate following hospital discharge is an important metric of healthcare quality. This study sought to characterize the rate, risk factors, and common causes of readmission in head and neck cancer patients following free or pedicled flap reconstruction. STUDY DESIGN: Retrospective cohort study. METHODS: Charts were reviewed of all patients who underwent free or pedicled flap reconstruction following resection of head and neck cancer at the Massachusetts Eye and Ear Infirmary 2009 to 2014. Readmission risk factors were evaluated by univariate and multivariate analysis. RESULTS: Of 682 patients with free (76%) or pedicled flap reconstruction, 135 patients (19.8%) were readmitted. Factors not associated with readmission included age, gender, American Society of Anesthesiologists status, operative time, prior radiation therapy, primary cancer site, and free (vs. pedicled) flap type. Significant readmission risk factors included surgical site infections (SSI) (45.2% vs. 9.9%), use of hardware (18.5% vs. 11.3%), and clean-contaminated or contaminated surgery (15.2% vs. clean 8.2%). Surgical site infections (P < 0.001) and use of hardware (P = 0.03) remained predictive of readmission on multiple regression analysis. Primary reasons for readmission included wound complications (61.5%) and supportive care (15.6%). The median time to readmission was 8 days, and 41% of readmissions occurred within 1 week. Seventy percent of readmissions occurred within 2 weeks, including 77% of readmissions for SSIs and 86% for supportive care. CONCLUSION: Readmissions occurred in nearly one-fifth of patients following flap surgery. SSIs and use of hardware were risk factors, whereas wound complications were the most common cause of readmission. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:343-349, 2018.

Locoregional control of tongue base adenoid cystic carcinoma with primary resection and radial forearm free flap reconstruction.

Adenoid cystic carcinoma of the minor salivary glands can be challenging and marked by high rates of local recurrence despite appropriate surgical resection. Management of this pathology in the base of the tongue is particularly difficult given the poor functional outcomes traditionally associated with an aggressive surgical approach. This article presents a case series of patients who underwent up-front surgical resection followed by free tissue transfer reconstruction. A retrospective analysis was performed of patients with adenoid cystic carcinoma of the base of the tongue who underwent composite resection and reconstruction with a radial forearm free flap. Three patients met inclusion criteria and underwent analysis. All patients achieved locoregional control after at least 4 years of surveillance. In addition, all patients were decannulated and were swallowing without the need for gastrostomy tube feeding. This series demonstrates that for select patients with adenoid cystic carcinoma of the base of the tongue, excellent locoregional control can be achieved with acceptable functional outcomes and prolonged survival when appropriate reconstructive measures are employed.

Surgical Site Infections in Major Head and Neck Surgeries Involving Pedicled Flap Reconstruction.

OBJECTIVE: To evaluate surgical site infections (SSI) after pedicled reconstruction in head and neck surgery. METHODS: Records of patients with pedicled flap reconstructions between 2009 and 2014 at Massachusetts Eye and Ear were reviewed. Onset of SSI or fistula ≤30 days postoperatively was noted. A free flap cohort was reviewed for comparison. RESULTS: Two hundred and eight pedicled reconstructions were performed for cancer (83%), osteoradionecrosis (7%), and other reasons (10%). Most (72%) cases were clean-contaminated and American Society of Anesthesiologists classification 3 or higher (73%); 63% of patients had prior radiation. The SSIs occurred in 9.1% and were associated with a longer length of stay (P = .004) but no particular risk factors. Seventeen patients developed a fistula (11 without SSI). The SSI rates were not significantly different between pedicled and free flaps, but pedicled flap patients were older, more likely to have had prior surgery and/or radiation, and be methicillin-resistant Staphylococcus aureus positive. In the combined population, multivariate analysis demonstrated clean-contaminated wound classification (P = .03), longer operating time (P = .03), and clindamycin prophylaxis (P = .009) as SSI risk factors. CONCLUSIONS: The SSI rate following pedicled flap surgeries was low and similar to free flap surgeries despite a significantly different population. No specific risk factors were associated with developing a pedicled flap SSI.

Risk factors for surgical site infection after supraclavicular flap reconstruction in patients undergoing major head and neck surgery.

BACKGROUND: Surgical site infections can adversely affect flaps in head and neck reconstruction. The purpose of this study was to evaluate the risk factors of surgical site infections in supraclavicular artery island flap reconstructions. METHODS: Records of patients undergoing head and neck surgery from 2011 to 2014 with supraclavicular artery island flap reconstruction at a single specialty hospital were reviewed; surgical site infections ≤30 days postoperatively were noted. RESULTS: Of 64 patients, 86% underwent resection for malignancy, 55% previously received radiation. Sixty-three percent of surgeries were clean-contaminated. Seven patients (11%) developed recipient site surgical site infections, all in patients who underwent clean-contaminated surgery for malignancy. There was no complete flap loss. No significant differences in demographics or perioperative factors were noted. Oral cavity and laryngeal reconstructions (p = .014) and clean-contaminated surgery (p = .04) were factors associated with increased surgical site infection risk on univariate but not multivariate analysis. Patients with surgical site infections had longer hospitalizations (p = .003). CONCLUSION: The supraclavicular artery island flap can be used for head and neck reconstruction with a low rate of surgical site infection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Head and neck free flap surgical site infections in the era of the Surgical Care Improvement Project.

BACKGROUND: Compliance with Surgical Care Improvement Project (SCIP) parameters regarding antibiotic prophylaxis may affect surgical site infection rates. The purpose of this study was for us to report SCIP compliance, surgical site infection rates, and risk factors in a large series of head and neck free flap surgeries. METHODS: A retrospective review of 480 free flap cases was performed. Surgical site infections occurring within 30 days postoperatively were noted. RESULTS: Surgical site infection occurred in 13.3% of cases. Prophylaxis was given in 99.8% of cases; ampicillin-sulbactam (83%) and clindamycin (9%) were most common. Prophylaxis was "on-time" in 92.3% of cases. There were no significant associations between surgical site infection and tumor stage, American Society of Anesthesiologists (ASA) classification, tumor subsite, or flap type. Prior radiation was a risk factor for surgical site infection in patients treated for malignancy. CONCLUSION: A surgical site infection rate of 13.3% was noted. In this cohort, with a compliance rate with prophylactic antibiotic measures, prior radiation was found to be a risk factor only in patients with cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E392-E398, 2016.

Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy.

IMPORTANCE: The optimal reconstruction of total glossectomy defects with or without total laryngectomy is controversial. Various pedicled and free tissue flaps have been advocated, but long-term data on functional outcomes are not available to date. OBJECTIVES: To compare various total glossectomy defect reconstructive techniques used by multiple institutions and to identify factors that may lead to improved long-term speech and swallowing function. DESIGN, SETTING, AND PARTICIPANTS: A multi-institutional, retrospective review of electronic medical records of patients undergoing total glossectomy at 8 participating institutions between June 1, 2001, and June 30, 2011, who had a minimal survival of 2 years. INTERVENTION: Total glossectomy with or without total laryngectomy. MAIN OUTCOMES AND MEASURES: Demographic and surgical factors were compiled and correlated with speech and swallowing outcomes. RESULTS: At the time of the last follow-up, 45% (25 of 55) of patients did not have a gastrostomy tube, and 76% (42 of 55) retained the ability to verbally communicate. Overall, 75% (41 of 55) of patients were tolerating at least minimal nutritional oral intake. Feeding tube dependence was not associated with laryngeal preservation or the reconstructive techniques used, including flap suspension, flap innervation, or type of flap used. Laryngeal preservation was associated with favorable speech outcomes, such as the retained ability to verbally communicate in 97% of those not undergoing total laryngectomy (35 of 36 patients) vs 44% (7 of 16) in those undergoing total laryngectomy (P < .001), as well as those not undergoing total laryngectomy achieving some or all intelligible speech in 85% (29 of 34 patients) compared with 31% (4 of 13) undergoing total laryngectomy achieving the same intelligibility (P < .001). CONCLUSIONS AND RELEVANCE: In patients with total glossectomy, feeding tube dependence was not associated with laryngeal preservation or the reconstructive technique, including flap innervation and type of flap used. Laryngeal preservation was associated with favorable speech outcomes such as the retained ability to verbally communicate and higher levels of speech intelligibility.

Transfusion in head and neck free flap patients: practice patterns and a comparative analysis by flap type.

OBJECTIVE: To characterize patterns of utilization and outcomes following transfusion in head and neck patients undergoing free flap reconstruction. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: Two hundred eighty-two head and neck patients undergoing free flap reconstruction from 2011 to 2013. Outcome parameters included post-transfusion hematocrit increase, length of stay (LOS), flap survival, and perioperative complications. RESULTS: Of all head and neck free flap patients, 48.9% received blood transfusions. Average pretransfusion hametocrit (Hct) was 24.7%±0.2% with 2.5±0.1 units of blood transfused. Transfused patients were more likely to have been taken back to the operating room. Rates of transfusion were similar between flap types, although anterolateral thigh (ALT) and fibular free flap (FFF) patients had higher transfusion requirements compared to radial forearm free flap (RFFF) patients. Further, FFF patients trended toward receiving transfusions earlier. Transfusion did not influence flap survival but was associated with wound dehiscence, myocardial infarction, congestive heart failure, respiratory distress, and pneumonia. Subset analyses by flap type revealed that differences were significant among the RFFF and FFF cohorts but not ALT patients. When comparing patients who were transfused for Hct<21 to those transfused for Hct<27, there were no differences in LOS, flap survival, or postsurgical complications. CONCLUSIONS: Among the different types of flaps, FFF and ALT are associated with higher transfusion requirements. Transfusion in patients undergoing free flap reconstruction does not significantly affect flap survival but was associated with perioperative complications. Our data support consideration of a restrictive transfusion policy in free flap patients.

The time course and microbiology of surgical site infections after head and neck free flap surgery.

OBJECTIVES/HYPOTHESIS: Determine the time of onset and microbiology of surgical site infections (SSIs) following head and neck free flap reconstructive surgeries. STUDY DESIGN: Retrospective cohort study. METHODS: All 504 free flap surgical cases (484 patients) performed April 1, 2009 to September 30, 2013 were reviewed; SSIs occurring ≤30 days postoperatively were evaluated. Admission screening for methicillin-resistant Staphylococcus aureus (MRSA) colonization was performed on all patients. RESULTS: Flap-recipient site infections (flap SSIs) occurred in 67 cases (13.3%), one-third week 1 postoperatively, one-third week 2, one-third days 15 to 30; 45% occurred after hospital discharge. Wound cultures were polymicrobial, but 25% grew only normal oral flora, whereas 75% grew pathogens not part of normal oral flora, such as gram-negative bacilli (44% of cases), MRSA (20%), and methicillin-sensitive S aureus (MSSA) (16%). The frequency of these pathogens did not vary significantly by the time of SSI onset. In 67%, cultures included at least one pathogen resistant to the prophylactic antibiotic used. Clindamycin prophylaxis was a significant risk factor for flap SSI and for early partial or complete flap loss from infection. Donor SSIs occurred in 22 cases (4.4%), 95% >1 week postoperatively, and MRSA or MSSA were the primary pathogens in 89%. Of the 25 patients colonized with MRSA on admission, 40% developed a flap or donor SSI, a rate significantly higher than in non-colonized patients. CONCLUSIONS: Gram-negative bacilli, MRSA, and MSSA were significant SSI pathogens, and late onset of infection was common. Better screening, decolonization, and prophylaxis may reduce SSI rates. LEVEL OF EVIDENCE: 2b

Locoregional and free flap reconstruction of the lateral skull base.

Lateral temporal bone reconstruction after ablative surgery for malignancy, chronic infection, osteoradionecrosis, or trauma presents a challenge for the reconstructive surgeon. This complexity is due to the 3D nature of the region, potential dural exposure, and the possible need for external surface repair. Successful reconstruction therefore requires achieving separation of the dura, obliteration of volume defect, and external cutaneous repair. There is significant institutional bias on the best method of reconstruction of these defects. In this review, the advantages and disadvantages of reconstructive options will be discussed as well as the potential pitfalls and complications.

Venous thromboembolism in otolaryngology surgical inpatients receiving chemoprophylaxis.

BACKGROUND: The Caprini risk assessment model for stratifying patients' risk for venous thromboembolism (VTE) has been validated in the otolaryngology literature. We sought to determine the incidence of VTE in patients receiving chemoprophylaxis and correlate with the Caprini risk assessment model. METHODS: A retrospective chart review of adult surgical admissions to an academic otolaryngology service from 2007 to 2012 was performed. Caprini risk assessment model scores were calculated and compared to incidence of VTE based on diagnosis codes. RESULTS: Seven hundred four patients met our inclusion criteria. Fifteen (2.13%) developed VTE. The Caprini risk assessment model score averaged 5.7 (range, 2-16). Patients with VTE had an average score of 9.87 versus 5.62 for those without (p < .0001). No patients with a score of 6 and below, 3.01% with 7-8, and 13.16% with a score >9 developed VTE. CONCLUSION: The incidence of VTE increases with Caprini risk assessment model score, and a score of >8 predicts a high risk (>13%) of VTE in postoperative otolaryngology inpatients despite chemoprophylaxis.

Multifocal, recurrent sinonasal leiomyosarcoma: case report and review of literature.

Leiomyosarcoma is a rare tumor encountered in the sinus and skull base, and can be difficult to control. We present a case of an 83 year old female with a recurrent sinonasal leiomyosarcoma. The tumor exhibited variable growth rates of recurrences in non-contiguous sites despite having obtained clear surgical margins and use of adjuvant therapy. This case illustrates unusual characteristics of this rare tumor that are important for clinicians to know. Patient demographics, presenting symptoms, risk factors, treatment options, and prognosis are also reviewed.

Nasal valve dysfunction: diagnosis and treatment.

PURPOSE OF REVIEW: This article reviews the etiology and treatment options for nasal valve stenosis (NVS), a common cause of nasal obstruction. It is based on meta-analyses, published expert panel opinions, extensive literature review, and previously published results of our own clinical experience. RECENT FINDINGS: Diagnosis and management of NVS continue to evolve. Although most studies that describe the surgical techniques of nasal valve repair report an improvement in patient complaints, there is a paucity of controlled trials that point to the most effective method. Lack of high-grade evidence may be due to ambiguities in objectifying patient complaints, standardizing treatment, and the lack of adequate controls. Recent literature addresses these ambiguities and provides suggestions on future directives in research. There is also a trend towards minimally invasive treatments that are effective in treatment of appropriate patients. SUMMARY: The diagnosis of NVS is primarily based on the subjective feeling of nasal obstruction associated with specific findings on the physical examination. Patient complaints are best objectified with validated questionnaires. Treatment of this condition is typically surgical and, as is evident by the plethora of described surgical procedures, there is often no consensus as to the best choice even in patients with identical findings on physical examination.