Improving Mortality Attribution in Otolaryngology - Head and Neck Surgery.

OBJECTIVE/HYPOTHESIS: Mortality attribution can have significant implications for reimbursement, hospital/department rankings, and perceptions of safety. This work seeks to compare the accuracy of externally assigned diagnosis-related group (DRG)-based service line mortality attribution in otolaryngology to an internal review process that assigns mortality to the teams that cared for a patient during hospitalization. STUDY DESIGN: Retrospective case series. METHODS: Mortality events at Vanderbilt University Medical Center (VUMC) from 2012 to 2018 were compared. Included events were assigned to the otolaryngology service line (OSL) via the following methods: an external agency (Vizient) using DRG, utilization management assignment based on the service that provided care at admission (admission service), discharge (discharge service), or throughout hospitalization (major service line), or through the internal VUMC mortality review committee. Internal review was considered the standard for comparison. RESULTS: Of the 28 mortality events assigned to OSL by the DRG-based external method, nine (32%) were actually attributable to OSL. Of the 23 total mortality events attributable to OSL at our institution, external DRG-based review captured nine (39%). The designation of major service during hospitalization was correct 95% of the time and captured 87% of mortality events. Differences between external and internal attribution methods were statistically significant (P < .001). CONCLUSIONS: DRG-based models are frequently utilized but can be inaccurate when attributing mortality for an individual otolaryngology department. Otolaryngology mortalities appear to be captured and assigned more accurately by assigning deaths to the service that renders the majority of care during hospitalization. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1805-E1810, 2021.

Otolaryngology and the Global Burden of Disease.

The Global Burden of Disease (GBD) project provides longitudinal analysis of the global burden of otolaryngologic diseases by measuring the all-cause mortality, years of life lost, the years of life lived with disability, and disability-adjusted life years. Hearing loss burden is assessed overall and as sequelae of other diseases, such as otitis media or meningitis. Using these measures, we can appreciate the high prevalence and disability related to hearing loss globally. Other otolaryngologic diseases that contribute to the GBD include otitis media, cleft lip and palate, head and neck cancer, facial trauma, and oral disorders.

Mortality pattern in otorhinolaryngology ward: A 5 years retrospective study at an urban tertiary health care center in India.

BACKGROUND: To recognize deaths in the otorhinolaryngology indoor wards, determine the reason behind the mortalities and recommend modifications for betterment of patient care and surgical outcomes. METHOD: Data was collected from the mortality register, operation theatre registers, ward registers and case notes of patients declared dead at an urban tertiary health care center in India for a period of 5 years; from January 2012 to December 2016. The data included date of admission, age, sex, educational status, residence, and clinical diagnosis, course of hospital stay and medical cause of death. Data acquired was reviewed and statistically interpreted and presented in graphical and descriptive formats. RESULTS: 6157 admissions were made in otorhinolaryngology (ENT) ward in the 5 year period which included 3969 males and 2188 female patients. 58 deaths were recorded during this period which gives overall death per admission crude mortality rate of 9.42% at an average of about 12 (11.60) deaths per year. The major causes of death were malignancy and septicemia. CONCLUSION: The significance of health education, aggressive healthcare campaigns, enhancement of healthcare services and wide accessibility of healthcare services to remote areas has been emphasized. Role of structured study and protocols in the management of serious cases is highlighted along with the need for prompt referral and better interdepartmental cooperation.

Morbi-mortalité hospitalière du sujet âgé en O.R.L. au CHU Yalgado Ouedraogo de Ouagadougou

Introduction : Les personnes âgées du fait de la particularité de leur terrain, ont-elles des spécificités du point de vue de la pathologie ORL au Burkina Faso ? Cette étude s'est fixée pour objectif de répondre à cette question en étudiant la morbidité et la mortalité du sujet âgé en ORL au CHU YO de Ouagadougou. Patients et méthodes : Il s'est agi d'une étude rétrospective à visée descriptive qui a inclus tous les patients âgés de 60 ans et plus reçus dans le service d'O.R.L. du CHU YO de janvier 2007 à décembre 2011, soit une période de 5 ans. Résultats : Trois-cent trente-trois (333) sujets âgés ont été reçus dans le service pendant la période de l'étude sur un total de 16.404 patients, soit une fréquence de 2,03%. Le sex-ratio H/F était de 1,19. L'âge moyen des patients était de 67,61 ans avec des extrêmes de 60 et 91 ans. L'HTA était le facteur de comorbidité le plus observé, soit 20,1% des cas. La pathologie pharyngo-laryngée représentait 35,1%, suivie de la pathologie cervico-faciale 26,9% et de la pathologie otologique 23,5%. Les principaux motifs de consultation étaient : la tuméfaction cervicale 17,9% la dysphagie 10,7% et l'hypoacousie 5,7%. Les anti-inflammatoires et les antibiotiques étaient les médicaments les plus prescrits. L'endoscopie sous anesthésie était l'acte de chirurgie le plus réalisé dans 24,6%. Conclusion : La fréquentation du service ORL par les sujets âgés est relativement faible, cependant des besoins accrus en matière de prise en charge des pathologies pharyngo-laryngées en ORL se dégagent dans ce groupe spécifique de la population

Postdischarge complications predict reoperation and mortality after otolaryngologic surgery.

OBJECTIVES: (1) Determine procedure-specific rates of postdischarge complications (PDCs) and their risk factors in the first 30 days following inpatient otolaryngologic surgery. (2) Evaluate association between PDCs and risk of reoperation and mortality. STUDY DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program (2005-2011). SUBJECTS AND METHODS: We identified 48,028 adult patients who underwent inpatient otolaryngologic surgery. Outcomes of interest included complications, reoperation, and mortality in the first 30 days following surgery. Statistical analysis included chi-square, t tests, and multivariate regression. RESULTS: Laryngectomy, lip, and tongue/floor of mouth surgery had the highest PDC rates (8.0%, 7.4%, and 4.1%, respectively). Within the first 48 hours, week, and 2 weeks post discharge, 10%, 44%, and 73% of PDCs occurred, respectively. Common PDCs included surgical site infections (53.6%), other infections (37.4%), and venous thromboembolic events (7.4%). Multivariate analysis demonstrated that increasing age (odds ratio [OR] = 1.01; 95% confidence interval [CI], 1.01-1.02), prolonged operative time (OR = 1.68; 95% CI, 1.39-2.03), hospital stay >1 day (OR = 1.49; 95% CI, 1.18-1.86), and American Society of Anesthesiologists (ASA) class ≥ 3 (OR = 1.45; 95% CI, 1.18-1.78) were independently associated with PDCs. Patients with PDCs were more likely to die (0.9% vs 0.1%, P < .001) or have a reoperation (10.4% vs 1.2%, P < .001). CONCLUSION: This is the first study of overall postdischarge events after otolaryngologic surgery. PDC rates in otolaryngology occur soon after discharge, are procedure specific, and are associated with reoperation and mortality. Targeted procedure-specific triage and follow-up plans for high-risk patients may improve outcomes.

Necrotizing fasciitis of the head and neck: 34 cases of a single institution experience.

We analyzed 34 patients with necrotizing fasciitis (NF) of the head and neck. According to the clinical presentation, we classified NF into the cervical and cranial type. Infection can spread along the superficial lamina or along the pretracheal lamina of the deep cervical fascia. In the first type, skin necrosis is the main sequelae, while in the second case, descending infection and mediastinitis are the main complications. Of the 34 patients, in 17 the infection progressed in the mediastinum. Due to aggressive surgical therapy and postoperative intensive care, the mortality rate remained low (1/17; 6%). In this analysis, we emphasize the importance of an accurate and fast diagnosis, followed by aggressive surgical therapy and a multidisciplinary approach.

[Adequacy analysis of bacteriological studies of pyo-inflammatory diseases of ENT organs with fatal outcome].

Results of analysis of the case history patients that died from complications of pyo-inflammatory diseases of ear, nose, and throat in multifield hospitals of Moscow during the last 10 years are presented. Data of microbiological studies for the entire period of each patient's stay in the hospitals are extracted They indicate that bacteriological studies are not prescribed as frequently as needed. As a rule, seeding is conducted after a patient is transferred to the intensive therapy department in 16 or more days following admission to the hospital. The materials seeded are largely biological fluids rather than pathological excreta from primary inflammatory foci.

Nonoperative catheter management for cervical necrotizing fasciitis with and without descending necrotizing mediastinitis.

OBJECTIVE: To evaluate the clinical utility of catheter drainage for cervical necrotizing fasciitis (CNF) with and without descending necrotizing mediastinitis (DNM). DESIGN: Retrospective analysis. SETTING: Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine. PATIENTS: Thirty-two patients with clinically and radiographically diagnosed CNF with and without DNM were included. INTERVENTIONS: Catheters were introduced into the infected space through the patients' necks under sonographic and x-ray fluoroscopic guidance. MAIN OUTCOME MEASURES: Treatments, clinical course, complications, and mortality were evaluated. RESULTS: Catheter drainage was successfully performed in all patients. The CNF was due to pharyngeal infection in 14 patients (44%) and dental infection in 14 other patients (44%). Mediastinal extension occurred in 14 patients (44%). Overall mortality was 3.1%; only 1 patient with DNM died due to Clostridium sepsis. Both pharyngeal origin and diabetes mellitus were significantly associated with the development of DNM. More intensive treatment is necessary for patients with CNF with DNM than for patients with CNF without DNM. CONCLUSION: Percutaneous catheter drainage may be used as an effective treatment for CNF with and without DNM.

Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature.

Fasciocutaneous (FC) free flaps are gaining widespread popularity for the reconstruction of head and neck defects. The radial forearm free flap and the anterolateral thigh flap are now widely used for pharyngolaryngo-oesophageal (PLO) reconstruction. In many units these flaps are used in preference to enteric free flap reconstructions. This review examined the literature regarding the morbidity, mortality and functional outcomes of FC free flap reconstruction of PLO defects, particularly with respect to the recent modifications reported in the literature. A Medline search was performed for reports published between 1994 and 2005 and a total of 20 papers were reviewed. Cumulative fistula and stricture rates were 13% and 16.1%, respectively, and many surgeons have incorporated modifications in the technique to further reduce these rates. These results compared favourably to recent reports of enteric reconstructions. Functional outcome with the FC free flaps were superior to those reported with jejunal flaps, especially with regard to speech following tracheo-oesophageal puncture. Following a fasciocutaneous reconstruction, hospital admission time and ICU stay were shorter and there were fewer perioperative deaths. Based on this comprehensive review of the literature with respect to morbidity, mortality and functional outcomes, FC free flap reconstruction of the PLO defect can be considered an excellent first line treatment of these difficult defects.

Mortalidad nacional en otorrinolaringología / National mortality in otorhinolaryngology

Introducción: La mortalidad nacional en otorrinolaringología no ha sido analizada en nuestro medio desde 1985, en esa fecha Kirschbaum y Aracena demostraron que el cuerpo extraño en la vía aérea era la causa de muerte más frecuente. Objetivos: Describir la tendencia de las tasas de mortalidad por causa otorrinolaringológicas y compararlas con los resultados de estudios anteriores. Material y método: Estudio descriptivo de mortalidad en el que se realizó una revisión retrospectiva de los anuarios de demografía del INE entre 1991-2003 en base a la clasificación internacional de enfermedades CIÉ IXy CIÉ X. Resultados: Se observó una media aritmética de mortalidad por causas otorrinolaringológicas de 7,34 por 100.000 habitantes, con una tendencia a la disminución en los años estudiados que va desde 10,12 a 4,81 por 100.000 habitantes entre los años 1991 y 1999 respectivamente, lo que equivale a una disminución de 53 por ciento. Esto se explica principalmente por una baja significativa de la tasa de mortalidad por cuerpo extraño en la vía aérea, siendo ésta también la principal causa de muerte en otorrinolaringología, ya que las otras patologías, en su mayoría tumores malignos de distinta localización, presentan una estabilidad en su tasa de mortalidad. Discusión: Al igual que en estudios anteriores, el cuerpo extraño en la vía aérea, sigue siendo la principal causa de mortalidad en otorrinolaringología, seguido por el cáncer de laringe, que continúa siendo de predominio masculino. No se observó una variación significativa de la mortalidad por patología maligna en los años estudiados, como tampoco en comparación con el estudio realizado por Kirschbaum y Aracena en 1985; pero destaca la importante disminución de la tasa de mortalidad por otitis media supurativa en relación a ese estudio, lo que se explicaría por una mayor accesibilidad de la población a tratamiento médico.

Pediatric deaths due to otolaryngologic causes: a population-based study in Massachusetts, 1990-2002.

OBJECTIVE: To identify the most common otolaryngologic causes of mortality in the 0 to 19 age group in the state of Massachusetts and to estimate the pediatric otolaryngologic mortality rate based on population data. STUDY DESIGN: Population-based retrospective cohort study. METHODS: The Massachusetts State Registry of Vital Records and Statistics electronic database was searched for all otolaryngology related causes of death from 1990 to 2002 for children aged 0 to 19. The individual death certificates were then reviewed, and a database of otolaryngology related pediatric deaths was created. RESULTS: A total of 59 otolaryngology related deaths were identified in the pediatric population from 1990 to 2002. Eighty-one percent of deaths occurred because of airway compromise caused by infection, anatomic obstruction, or congenital anomaly. The remaining 19% of deaths occurred because of aspiration, nonairway infections, and malignant neoplasms. Ninety-five percent of deaths in the children under age 10 were caused by airway compromise. Six of seven deaths (86%) in the age 15 to 19 group occurred because of malignant neoplasms. The overall mortality rate caused by otolaryngologic causes was estimated to be 0.28 per 100,000 population. CONCLUSIONS: The overall mortality rate for otolaryngology related deaths is low in the pediatric population. The vast majority of deaths are caused by airway compromise, primarily because of laryngotracheobronchitis or other upper airway obstruction. In older children (ages 15-19), malignant head and neck neoplasms are the leading cause of otolaryngology related deaths.

Primary systemic vasculitis: clinical features and mortality.

BACKGROUND: Wegener's granulomatosis (WG), Churg Strauss syndrome (CSS) and microscopic polyangiitis (MPA) are primary systemic vasculitides (PSV), the clinical features of which have been described from tertiary centres. AIM: To provide the first clinical description of MPA from a general hospital and compare clinical features with WG and CSS. DESIGN: Retrospective analysis of patient records. METHODS: Records of 99 PSV patients attending a single hospital, from 1988 to 2000, were reviewed for: clinical features, date/age at diagnosis, sex, duration of illness, anti-neutrophil cytoplasmic antibodies (ANCA), treatment, comorbidity and deaths. Cases were classified using ACR, CHCC and Lanham criteria/definitions. Birmingham vasculitis activity scores (BVAS) and damage index (VDI) were calculated. Survival was assessed using Cox proportional hazards model and standardized mortality ratios (SMRs). RESULTS: Compared to previous reports there was more ENT (29%) and respiratory (29%) but less renal (92%) involvement in MPA, and less ENT involvement in WG (81%). CSS showed high neurological (72%), cardiovascular (28%) and gastrointestinal (17%) involvement and the highest median (range) VDI (p = 0.01 vs. WG; p = 0.001 vs. MPA). BVAS1 was significantly lower in MPA than in WG [median (range) 15 (4-29) vs. 21 (6-39), (p = 0.001)] but not in CSS [20 (7-28), p = 0.08]. SMR (95%CI) for PSV was 4.8 (3.0-6.6); 5-year survival was 45.1% for MPA, 75.9% for WG and 68.1% for CSS. Age was a significant risk, but only to the same extent as in the reference population. When age was adjusted for, no other significant factor was found. DISCUSSION: The clinical characteristics seen here are similar to those in previous series. There are difficulties in using the MPA CHCC definitions in classification. There is a high proportion of neurological involvement in CSS, causing permanent damage. MPA may have a poorer prognosis than WG or CSS.

[Suffocation, an important lethal factor for otorhinolaryngological disease].

OBJECTIVE: To study the importance of supervision in respiratory tract for otorhinolaryngological disease. METHOD: Nine cases died of suffocation were reported and the causes were analyzed. In the 9 cases there were 3 cases with the foreign body in bronchus, 2 cases with the trachea bleeding, 2 cases with laryngopharyngeal tumor and 2 cases with bleeding from nasopharyngeal carcinoma. RESULT: All cases were died of suffocation. CONCLUSION: Suffocation is an important lethal factor for many otorhinolaryngological disease. Tracheotomy is a prompt and effective management for the suffocation resulting from upper respiratory tract obstruction. Tracheoscopy is the first choice for patients with lower respiratory tract obstruction. And the continuous inflating pressure with intubation in cases with trachea bleeding should be avoided.

Complications and determinants of length of stay for inpatient pediatric otolaryngologic procedures.

OBJECTIVE: To identify clinical factors associated with morbidity, mortality, and length of stay (LOS) for inpatient pediatric otolaryngologic procedures. STUDY DESIGN: Retrospective cohort study. METHODS: Records of patients undergoing pediatric otolaryngologic procedures were extracted from the National Hospital Data Survey for the calendar years 1995 through 1999. These records were examined to determine demographics, morbidity, mortality, type of procedure (as defined by anatomic subsite), and LOS. The effects of morbidity and type of procedure on LOS were identified. RESULTS: A total of 4861 children underwent inpatient otolaryngologic procedures. The overall morbidity rate was 4.6%. The most common morbidity was pneumonia, occurring in 171 patients (3.5%). The presence of any morbidity was associated with a significantly increased LOS (18.4 days vs 4.6 days; P<.001). The occurrence of pneumonia was associated with an increase in LOS to 19.7 days vs 4.7 days in patients without pneumonia (P<.001). Procedures involving the larynx, trachea, or esophagus carried the longest LOS (12.3 days; P<.001) among all procedural categories. The overall mortality rate was distinctly low at 0.4%. However, the occurrence of morbidity was associated with an increased risk of death, with an odds ratio of 8.0 (P =.001). Mortality was highest (13 of 18 deaths) after procedures on the larynx, trachea, or esophagus. CONCLUSIONS: Medical complications in children undergoing inpatient otolaryngologic procedures are associated with significantly increased LOS. Despite procedural complexity, overall mortality is remarkably low. Efforts to decrease medical morbidity in this population may result in decreased LOS and improved clinical outcomes.

[Diagnosis and treatment of necrotizing fasciitis of the head and neck region]. / Diagnose und Behandlung der nekrotisierenden Fasziitis in der Kopf-Hals-Region.

BACKGROUND: Necrotizing fasciitis of the head and neck is a rare occurrence. It spreads rapidly along fascial planes causing extensive necrosis; it often results in gangrene of the overlying skin. Mostly involved are immunodeficient patients with banal infections of the upper aerodigestive tract, small traumas, but also after surgical procedures. The "Federal Health Agency" of the Federal Republic of Germany estimates a number of 40 cases a year in Germany for all regions of the body. The mortality is about 20%-50% dependent on the localisation of this soft tissue infection. PATIENTS: Four cases of necrotizing fasciitis of the head and neck region, which were treated at the ENT-Department of the Martin Luther University Halle-Wittenberg since 1995, were described. RESULTS: Despite aggressive surgical debridement and intensive care medicine two patients died because of streptococcus-associated-toxic-shock-syndrome. In all patients we found a diabetes mellitus as a known risk factor for this necrotizing soft tissue disease. In two of four patients with cervical involvement mediastinitis was diagnosed as a complication. The CT-scan showed this mediastinal spread only in one case. CONCLUSIONS: Only rapid diagnosis and surgical treatment with radical debridement can influence the disease positively. Thoracal CT-scan is necessary in all cases of cervical necrotizing fasciitis because of the high risk of mediastinal involvement. A strong complication is a streptococcus-associated-toxic-shock-syndrome, which should be prevented because it is often associated with a lethal outcome. Penicillin G and clindamycin are advocated for antibiotic treatment.

[Possible medical errors as a cause of death in ENT patients]. / O vozmozhnykh vrachebnykh oshibkakh kak prichine smerti LOR-bol'nykh.

The analysis of 116 case histories of the patients who had died in the Moscow Regional Research Clinical Institute throughout the last 12 years has revealed diagnostic, therapeutic and technical errors in 44% of the cases. The death was due to misdiagnosis, inappropriate therapeutic policy, mediastinitis consequent to esophageal perforation made in the search of a foreign body, unqualified surgery in 4, 3, 3 and 2 patients, respectively.

[Structure of causes of mortality of patients with otorhinolaryngologic diseases]. / Struktura prichin letal'nosti bol'nykh otorinolaringologicheskogo profilia.

42 lethal outcomes have been registered for 9 years in the ENT department of the Andizhan regional hospital and in the department of the head and neck tumors of the regional cancer hospital. Among the causes of the patients' death, ENT cancer ranked the first (73.6%) followed by intracranial otogenic complications. The least frequent causes were esophageal and respiratory foreign bodies, acute stenotic laryngotracheitis. The averaged annual lethality was stable (0.25%). A further decrease of lethality depends on fitting out updated medical units and instruments, on perfection of the personal's skill, on earlier hospitalization of priority cases with ENT diseases.