Variance in 3D anatomic localization of surgical margins based on conventional margin labeling in head and neck squamous cell carcinoma.

OBJECTIVE: In head and neck cancer (HNC), positive margins are strongly predictive of treatment failure. We sought to measure the accuracy of localization of margin sampling sites based on conventional anatomic labels using a digital 3D-model. METHODS: Preoperative CT scans for 9 patients with HNC treated operatively at our institution were imported into a multiplanar radiology software, which was used to render a digital 3D model of each tumor intended to represent the resection specimen. Surgical margin labels recorded during the operative case were collected from pathology records. Margin labels (N = 64) were presented to participating physicians.Participants were asked to mark the anatomic location of each surgical margin using the 3D-model and corresponding radiographic planes for reference.For each individual margin, the 3D coordinates of each participant's marker were used to calculate a mean localization point called the geometric centroid. Mean distance from individual markers to the centroid was compared between participantsand margin types. RESULTS: Amongst 7 surgeons, markers were placed a mean distance of 12.6 mm ([SD] = 7.5) from the centroid.Deep margins were marked with a greater mean distance than mucosal/skin margins (19.6 [24.8] mm vs. 15.3 [14.9] mm, p = 0.034). When asked to relocate a margin following re-resection, surgeons marked a point an average of 20.6 [12.4] mm from their first marker with a range of 3.9- 45.1 mm. CONCLUSIONS: Retrospective localization of conventionally labeled margins is an imprecise process with variability across the care team. Future interventions targeting margin documentation and communication may improve sampling precision.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy.

OBJECTIVES: There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision. STUDY DESIGN: Level III, retrospective case-control study. SETTING: A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware). METHODS: A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls. RESULTS: A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy. CONCLUSION: Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Outcomes in Head and Neck Free Flap Reconstruction Among Patients With a History of Venous Thromboembolism.

OBJECTIVE: To investigate if a history of venous thromboembolism (VTE) is a risk factor for complications in head and neck free flap surgery by assessing outcomes among patients with a history of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary care center. METHODS: All patients undergoing head and neck free flap reconstruction at our institution between September 1, 2006, and April 2, 2020, were assessed for inclusion. Patients with and without a history of DVT or PE preoperatively were identified and grouped for comparison. Groups were compared for demographics, comorbidities, and 30-day complications. Significance was assessed with chi-square and binary logistic regression analyses. RESULTS: Of the 1061 patients meeting inclusion criteria, 40 (3.8%) had a history of VTE. These patients were significantly older (mean [SD], years: 67.8 [11.7] vs 63.0 [14.1], P = .038) and significantly more likely to have history of chemotherapy (35.0% vs 18.7%, P = .010) and stroke (27.5% vs 4.5%, P < .001). After accounting for patient characteristics via binary logistic regression, VTE was independently associated with an increased risk for postoperative thrombosis of the free flap pedicle (odds ratio [95% CI] = 3.65 [1.12-11.90], P = .032) and reoperation (2.45 [1.25-4.80], P = .009). Patients with history of PE had a significantly increased risk for flap failure (7.70 [1.77-33.52], P = .007). Prior VTE was not independently associated with an increased risk for medical complications or readmission. CONCLUSION: Patients with a history of VTE may be at an increased risk for free flap compromise secondary to postoperative pedicle thrombosis. This risk should be considered in preoperative workup and postoperative monitoring.

Evaluating pediatric intensive care unit utilization after tonsillectomy.

OBJECTIVES: To identify patients at risk for a pediatric intensive care unit (PICU) level intervention after adenotonsillectomy. STUDY DESIGN: Retrospective cross-sectional study. SETTING: Tertiary Children's Hospital. SUBJECTS AND METHODS: Ninety-four patients who were admitted to the PICU after adenotonsillectomy were included. The need for PICU level intervention, defined as high flow oxygen by nasal cannula, positive airway pressure (PAP), heliox, and intubation, was documented. The age, gender, BMI percentile, polysomnography (PSG) data, home PAP use, and accompanying comorbidities of patients who required a PICU level intervention were compared to those who did not. RESULTS: Of the 94 patients admitted post-adenotonsillectomy to the PICU, most had at least one comorbidity, with obesity being the most common. PICU admission was unplanned in 29 (30.9%) patients. Postoperatively, 25 (26.5%) patients required a PICU level intervention, with PAP being the most common intervention. On chi-square analysis, there was no significant difference in the age, BMI percentile, or PSG parameters of children who required PICU intervention. Significantly more children who used preoperative PAP were started on PAP in PICU (p = 0.018). Only the comorbidity of neuromuscular disorder was associated with PICU intervention (p = 0.04). Using binary logistic regression, the use of home PAP and an oxygen nadir <80% on preoperative PSG were found to be independent predictors of PICU intervention (p = 0.04 and 0.025, respectively). CONCLUSION: Home PAP use, the presence of a neuromuscular disorder, and an oxygen nadir <80% on preoperative PSG is related to a PICU level intervention.

Comparing endoscopic resection and open resection for management of sinonasal mucosal melanoma.

BACKGROUND: Sinonasal mucosal melanoma (SMM) is a rare, aggressive cancer, optimally managed with complete surgical resection. This study aimed to assess the impact of surgical approach on outcomes by comparison of cases managed with open vs endoscopic resection. METHODS: The National Cancer Database 2010-2015 datasets were queried for all cases of non-metastatic SMM initially managed with definitive surgery. Patients were grouped according to surgical approach (open vs endoscopic) and compared for patient, tumor, and treatment variables using chi-square analyses. Case-control matching was used to generate subgroups of cases paired 1:1 between groups, matched for significantly distributed variables. Subgroups were compared for perioperative outcomes and overall survival (OS) using Kaplan-Meier analyses. RESULTS: Of the 686 cases of SMM managed with definitive surgery, 46.2% were treated endoscopically. Open and endoscopic groups did not differ significantly by T-stage, primary site, or rates of adjuvant therapies. Case-control matching for these variables generated a subpopulation of 240 paired cases. Comparison of matched groups found no significant differences in 30-day or 90-day mortality. Endoscopically managed patients had higher rates of unplanned readmission whereas open resection patients had longer length of stay (LOS). There was no significant difference in OS between groups. CONCLUSION: In surgically managed SMM, open resection patients have significantly longer LOS, whereas endoscopic patients have higher rates of unplanned readmission. Surgical approach does not appear to influence OS.

Refusal of Cancer-Directed Surgery in Head and Neck Squamous Cell Carcinoma Patients.

OBJECTIVES/HYPOTHESIS: To investigate the risk factors for refusal of recommended surgery in head and neck squamous cell carcinoma (HNSCC) treatment STUDY DESIGN: Retrospective review of a national database. METHODS: The Surveillance, Epidemiology, and End Results database was queried for all cases of HNSCC from 1989 to 2014. Patients who underwent recommended surgery (N = 98,270) were identified and compared to patients who refused recommended surgery (N = 3,582). Groups were compared for patient demographics, socioeconomic variables, and tumor characteristics including stage, grade, and primary site. Binary logistic regression was performed to determine independent predictors of surgery refusal. RESULTS: Of the total population, 1.8% of patients refused cancer directed surgery. Following regression, the strongest predictors of surgery refusal were found to be age greater than 75years (odds ratio [OR]: 4.23 [95% confidence interval {CI}: 3.00-5.96]), and stage III (OR: 4.19 [95% CI: 3.15-5.57]) or stage IV at diagnosis (OR: 4.49 [95% CI: 3.46-5.80]). Black race was significantly predictive (OR: 1.71 [95% CI: 1.37-2.13]) as well as marital status other than married (OR: 1.76 [95% CI: 1.49-2.07]) and Medicaid insurance status (OR:1.46 [95% CI: 1.20-1.77]). Primary site of larynx (OR: 2.01 [95% CI: 1.71-2.37]) or base of tongue (OR: 2.34 [95% CI: 1.87-2.92]) additionally predicted surgery refusal. CONCLUSIONS: A number of demographic, socioeconomic, and tumor-related variables are associated with refusal of cancer-directed surgery in head and neck squamous cell carcinoma. Recognition of these factors may help identify situations where more active education and support are needed to help patients accept optimal care. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1368-1373, 2019.

Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery.

IMPORTANCE: Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck. OBJECTIVE: To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using χ2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018. MAIN OUTCOMES AND MEASURES: Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked. RESULTS: Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications. CONCLUSIONS AND RELEVANCE: Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit. LEVEL OF EVIDENCE: NA.

Second primary lung malignancy following head and neck squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Analyze the characteristics of second primary lung malignancies (SPLMs) following an index head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN: Retrospective cohort study. METHODS: The Surveillance, Epidemiology and End Results database was queried for all cases of HNSCC between 1973 and 2014 (N = 101,856). This population was compared to a standard population to assess relative risk for lung cancer, calculated as the standardized incidence ratio (SIR). Patients who developed SPLMs were extracted (N = 8,116) and compared to all other cases of lung cancer (N = 1,160,853) to assess histopathological differences. SPLM subpopulations divided by head and neck primary site were compared for lung cancer histology and time interval between cancer diagnoses. RESULTS: Overall, 8.0% of HNSCC patients developed SPLMs (SIR = 4.22, P < .001), diagnosed an average of 6.7 years later. Patients with HNSCC of the supraglottis and hypopharynx were at the highest risk relative to a standard population, with SIRs of 8.10 and 6.34, respectively. When comparing SPLMs to all other lung cancers, there was no difference in the distribution of lung lobe affected, but SPLMs were significantly more likely to be of squamous cell carcinoma histology (42.0% vs. 21.0%, P < .001). Among head and neck subsites, lung cancers following larynx tumors had a significantly higher proportion of small cell histology, and those following oropharyngeal or hypopharyngeal tumors had significantly higher proportions of squamous cell histology. CONCLUSIONS: Patients who undergo curative treatment of HNSCC are at high risk for developing SPLMs. Subsite-specific differences may help elucidate the degree of risk attributable to smoking, genetic susceptibility, human papillomavirus infection, or metastasis masquerading as an SPLM. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:903-909, 2019.

The Impact of Duty-Hour Restrictions on Complication Rates Following Major Head and Neck Procedures.

OBJECTIVES/HYPOTHESIS: To assess the impact of resident duty-hour restrictions (DHR) in otolaryngology via comparison of postoperative outcomes between otolaryngology teaching hospitals (Oto-TH) and nonteaching hospitals (NTH) before and after complete implementation. STUDY DESIGN: Retrospective database review. METHODS: The Nationwide Inpatient Sample was queried for all major head and neck cases between 2000 and 2002 (n = 34,064) and 2008 and 2010 (n = 33,094). Cases were stratified into Oto-TH (n = 28,771) and NTH (n = 38,387) and assessed for procedure type, patient comorbidities, and complications. A subpopulation matched by procedure type was generated for direct comparison of complication rates using χ2 and binary logistic regression analyses. RESULTS: In the years following DHR, total case volume and average case complexity increased at Oto-TH only. Using a case-matched subpopulation, regression analysis found Oto-TH status to be protective for medical complications both before (odds ratio [OR]: 0.60, P < .001) and after (OR: 0.76, P = .001) DHR. In contrast, Oto-TH cases had lower risk for surgical complications in 2000 to 2002 (OR: 0.77, P < .001) but not 2008 to 2010 (OR: 1.07, P = .275). When comparing time periods, the years following DHR were associated with a significant decrease in medical complications and mortality across hospital cohorts. For surgical complications, rates significantly improved at NTH only (OR: 0.82, P = .002), with no difference at Oto-TH (OR: 0.95, P = .450). CONCLUSIONS: In the years following DHR, rates of medical complications, surgical complications, and mortality have significantly improved at NTH. At Oto-TH, there has been a lack of similar improvement in surgical complications, even after accounting for increasing case volume and complexity in more recent years. While the cause is likely multifactorial, DHR in otolaryngology residency may play a role. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2804-2810, 2018.

Impact of Body Mass Index on Operative Outcomes in Head and Neck Free Flap Surgery.

OBJECTIVE: Analyze the risk for perioperative complications associated with body mass index (BMI) class in patients undergoing head and neck free flap reconstruction. STUDY DESIGN AND SETTING: Retrospective cohort study. SUBJECTS AND METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for all cases of head and neck free flaps between 2005 and 2014 (N = 2187). This population was stratified into underweight, normal-weight, overweight, and obese BMI cohorts. Groups were compared for demographics, comorbidities, and procedure-related variables. Rates of postoperative complications were compared between groups using χ2 and binary logistic regression analyses. RESULTS: Underweight patients (n = 160) had significantly higher rates of numerous comorbidities, including disseminated cancer, preoperative chemotherapy, and anemia, while obese patients (n = 447) had higher rates of diabetes and hypertension. Rates of overall surgical complications, medical complications, and flap loss were insignificantly different between BMI groups. Following regression, obese BMI was protective for perioperative transfusion requirement (odds ratio [OR] = 0.63, P = .001), while underweight status conferred increased risk (OR = 2.43, P < .001). Recent weight loss was found to be an independent predictor of perioperative cardiac arrest (OR = 3.16, P = .006) while underweight BMI was not (OR = 1.21, P = .763). However, both weight loss and underweight status were associated with significantly increased risk for 30-day mortality (OR = 4.48, P = .032; OR = 4.02, P = .010, respectively). CONCLUSION: Obesity does not increase the risk for postoperative complications in head and neck free flap surgery and may be protective in some cases. When assessing a patient's fitness for surgery, underweight status or recent weight loss may suggest a reduced ability to tolerate extensive free flap reconstruction.

Predictors of clinical-pathologic stage discrepancy in oral cavity squamous cell carcinoma: A National Cancer Database study.

BACKGROUND: Few studies have examined the frequency and survival implications of clinicopathologic stage discrepancy in oral cavity squamous cell carcinoma (SCC). METHODS: Oral cavity SCC cases with full pathologic staging information were identified in the National Cancer Database (NCDB). Clinical and pathologic stages were compared. Multivariate logistic regressions were performed to identify factors associated with stage discrepancy. RESULTS: There were 9110 cases identified, of which 67.3% of the cases were stage concordant, 19.9% were upstaged, and 12.8% were downstaged. The N classification discordance (28.5%) was more common than T classification discordance (27.6%). In cases of T classification discordance, downstaging is more common than upstaging (15.4% vs 12.1% of cases), but in cases of N classification discordance, the reverse is true; upstaging is much more common than downstaging (20.1 vs 8.4% of cases). CONCLUSION: Clinicopathologic stage discrepancy in oral cavity SCC is a common phenomenon that is associated with a number of clinical factors and has survival implications.

Association of Anesthesia Duration With Complications After Microvascular Reconstruction of the Head and Neck.

IMPORTANCE: Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking. OBJECTIVE: To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck. DESIGN, SETTING, AND PARTICIPANTS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016. EXPOSURES: Microvascular reconstructive surgery of the head and neck. MAIN OUTCOMES AND MEASURES: Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality. RESULTS: A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16). CONCLUSIONS AND RELEVANCE: Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery. LEVEL OF EVIDENCE: 3.

Updates in the management of sinonasal mucosal melanoma.

PURPOSE OF REVIEW: Sinonasal mucosal melanoma (SNMM) is an aggressive cancer with a poor prognosis. Although there is significant study surrounding the treatment of sinonasal malignancies and cutaneous melanomas, the rarity of this tumor has largely precluded robust outcomes analyses. The authors of this review seek to provide an overview of the recent literature related to the treatment of SNMM with added context from our institutional experience with this disease. RECENT FINDINGS: In the surgical management of sinonasal malignancies and SNMM specifically, resection via endoscopic endonasal technique appears to offer comparable oncologic outcomes versus an open approach. The role of adjuvant therapy continues to be debated, but there is strong evidence for improved rates of local control with radiotherapy after complete resection. In the last few years, significant developments have been made in the study of systemic therapies for cutaneous melanoma. The identification of genetic mutations common to mucosal melanoma has allowed for early trials of targeted therapies, but study is ongoing. SUMMARY: Although the study of SNMM is largely limited to small retrospective case series, treatment continues to evolve. Until effective systemic therapies can be identified, endoscopic resection with adjuvant radiotherapy may offer the best disease-free survival with acceptably low morbidity.

Impact of diabetes on free flap surgery of the head and neck: A NSQIP analysis.

OBJECTIVE: Diabetes is associated with microvascular pathology and may predispose patients undergoing microvascular surgery to complications. This study assesses diabetes as a risk factor for complications following free flap surgery of the head and neck. PATIENTS AND METHODS: In this retrospective cohort study, data on free flap surgeries of the head and neck between 2005 and 2014 was collected from the National Surgical Quality Improvement Program (NSQIP) database. A propensity-matching algorithm (PSM) was used to equilibrate distribution of numerous covariates between the diabetic and nondiabetic cohorts. A sub-analysis was performed to examine the impact of insulin-dependency. RESULTS: The initial dataset contained 2187 free flaps of the head and neck. After implementing PSM, a new population was created containing 506 total cases with 253 DM patients. The majority of cases were male and white. The matched cohort did not contain any demographics or comorbidities associated with DM. Complications significantly elevated in the DM group were severe bleeding (P = .046), postoperative ventilation greater than 48 hours (P < .001), and pneumonia (P < .048). In patients with insulin-dependent diabetes, reintubation (P = .005), cardiac arrest (P = .010), severe bleeding (P = .006), overall surgical complications (P = .015), and overall complications (P = .005) were significantly increased. CONCLUSION: This study examines the impact of diabetes on postoperative complications following free flap reconstruction of the head and neck. Propensity score matching was utilized. Analysis of the PSM cohort suggests that diabetic patients have elevated rates of postoperative pulmonary complications. Additionally, patients with insulin-dependent diabetes have significantly elevated rates of medical and surgical complications.

Laryngectomy and smoking: An analysis of postoperative risk.

OBJECTIVES: To investigate the impact of smoking on complication rates following total laryngectomy. STUDY DESIGN AND METHODS: The National Surgical Quality Improvement Program database was queried for all total laryngectomies between 2005 and 2014. Patients were identified as smokers (n = 561) or nonsmokers (n = 513) and compared via univariate and multivariate analyses. A nearest-neighbor propensity score-generating algorithm was used to build a subpopulation (n = 714) of matched cases and evaluated in a similar manner. Additionally, pack-year data was available for select cases and analyzed appropriately. RESULTS: On multivariate analysis of the unmatched cohort accounting for demographics and confounders, no significant difference in overall medical complications was identified between groups (odds ratio = 0.799, P = 0.495). Propensity matching corrected for all significantly distributed comorbidities, except for alcohol, which remained associated with the smoking group (P = < 0.001). In the matched population, there were no significant differences in complication rates between the two groups. Pack-year data was available for 340 patients. These cases were subdivided into cohorts with < 50 (n = 204) and 51+ (n = 136) pack-years. Postoperative pneumonia, ventilation for more than 48 hours, sepsis, and overall medical complications were associated with > 50 pack-years of smoking. After multivariate regression, sepsis and overall medical complications remained significant for the 51+ pack-year smoking cohort. CONCLUSION: After accounting for confounding comorbidities, smoking is found to play an insignificant role in the development of postoperative complications following total laryngectomy. However, those with 51+ pack-years are at an increased risk for postoperative sepsis and overall medical complications following these complex procedures. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2302-2309, 2017.

The effect of training level on complications after free flap surgery of the head and neck.

OBJECTIVES: Analyze postoperative complications after free flap surgery based on PGY training level. METHODS: Data on free flap surgeries of the head and neck performed from 2005 to 2013 was collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Cases identifying the status of resident participation in the surgery and the PGY level were included. RESULTS: There were 582 cases with primary surgeon data available. 63 cases were performed with a junior resident, 211 were performed with the assistance of a senior resident, 279 cases were performed with a fellow, and 29 cases were performed by an attending alone without resident involvement. The overall complication rate was 55.2%. There was no statistically significant difference in the rate of complications between groups (47.6%, 59.7%, 53.0%, 58.6%, p=0.277). After controlling for all confounding variables using multivariate analysis there was no significant difference in morbidity, mortality, readmissions, and reoperation amongst the groups. Furthermore, when comparing resident versus fellow involvement using multivariate analysis there were no significant differences in morbidity (OR=0.768[0.522-1.129]), mortality (OR=1.489[0.341-6.499]), readmissions (OR=1.018[0.458-2.262]), and reoperation (OR=0.863[0.446-1.670]). CONCLUSION: Resident and fellow participation in microvascular reconstructive cases does not appear to increase 30-day rates of medical, surgical, or overall complications.

Utility of early postoperative imaging after combined endoscopic and open ventral skull base surgery.

PURPOSE: Immediate postoperative imaging is frequently obtained after combined skull base surgery (SBS) with endoscopic endonasal and open transcranial approaches. The importance of early postoperative imaging for detecting complications in these patients is still debatable. In this study, we investigated the clinical utility of early postoperative imaging after combined SBS for determination of postoperative complications. METHODS: A retrospective chart analysis of 21 cases of combined SBS between 2009 and 2015 was performed. Data on postoperative computed tomography (CT) and magnetic resonance imaging (MRI), and the hospital course were collected. We separated interpretations of postoperative imaging into two groups: (1) when using the radiologist's interpretation alone, and (2) when using the surgeon's knowledge of the case in conjunction with imaging. RESULTS: Forty-two postoperative scans were obtained (21 CT, 21 MRI) within 48 hours of surgery. There was a significant statistical difference between imaging interpretation by surgeons and radiologists for CT interpretation only. For CT interpretation the true positive (TP), false positive (FP), true negative (TN), and false negative (FN) rates for radiologists (TP, 0/21; FP, 6/21; TN, 11/21; FN, 4/21) slightly deviated from surgeons' interpretation (TP, 1/21 [p = 0.9999]; FP, 0/21 [p = 0.0207]; TN, 17/21 [p = 0.1000]; FN, 3/21 [p = 1.000]). Rates for MRI interpretation by both groups were nearly identical, with no significant difference found. Overall, four patients experienced seven postoperative complications, which led to a complication rate of 19.0% (4/21). The patients exhibited clinical symptoms in all instances of postoperative complications that required further intervention. CONCLUSION: The benefit of early postoperative imaging to detect complications after combined SBS was limited. In this cohort of patients, positive imaging findings' effects on patient management were dictated by the presence of supporting clinical symptoms.