How Many Nodes to Take? Lymph Node Ratio Below 1/3 Reduces Papillary Thyroid Cancer Nodal Recurrence.

INTRODUCTION: Papillary thyroid carcinoma (PTC) accounts for the majority of thyroid malignancies; risk of PTC recurrence over a 30-year period is approximately 30%, of which 70% occur as nodal metastases. Patients with nodal disease who are treated with therapeutic dissection are at higher risk for recurrence, but optimal nodal yield has not been defined. We aim to determine variables predictive of nodal recurrence of PTC within the first 5 years of surgery, with a focus on lymph node ratio (LNR), to inform clinical decision-making. METHODS: Retrospective chart review identified 41 patients with nodal recurrence of PTC and 284 without nodal recurrence following thyroid surgery from 2000 to 2015. Cohorts were compared with regards to clinical history, surgical findings, and tumor characteristics. RESULTS: The fraction of the patients who underwent therapeutic central or lateral lymph node dissection was significantly higher in the nodal recurrence cohort. Maximum tumor size, presence of extrathyroidal extension, largest lymph node focus, LNR, postoperative thyroglobulin level, and administration of postoperative radioactive iodine were significantly increased in the PTC nodal recurrence group. LNR greater than 0.3 held the highest level of significance as a binary cutoff and captured the larger proportion of patients in the nodal recurrence cohort (68.3%). CONCLUSION: This study demonstrates characteristics to help assess risk of nodal recurrence of PTC and suggests LNR of lower than 0.3 is optimal to reduce risk of recurrence. The next steps include cohort studies to validate findings and weight variable analysis to optimize the extent of surgical therapeutic dissection. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1883-1887, 2022.

The Impact of Upper Lateral Cartilage Release on Patient-Perceived Nasal Appearance and Obstruction.

OBJECTIVES/HYPOTHESIS: Although upper lateral cartilages are commonly released from the dorsum of the septum during spreader graft placement in septorhinoplasty (SRP), there has been a focus on maintaining integrity of connections in the middle vault. Avoiding release of upper lateral cartilages in certain patient groups may represent an early step in this paradigm shift. We aim to assess satisfaction with nasal appearance and correction of nasal obstruction in patients who underwent SRP with spreader graft placement without upper lateral cartilage release and compared it to the traditional upper lateral cartilage release cohort. STUDY DESIGN: Prospective cohort study. METHODS: A total of 559 patients who underwent SRP with spreader graft placement with upper lateral cartilage release and 30 patients who underwent SRP with spreader graft placement without release between 2012 and 2020 were administered the Nasal Obstruction Symptom Evaluation (NOSE), FACE-Q Satisfaction with Nose, and FACE-Q Social Functioning scales pre- and postoperatively. Pre- and postoperative NOSE FACE-Q, and negative inspiratory force (NIF) scores and changes were compared between groups. RESULTS: Results demonstrated clinically and statistically significant improvement at follow-up for both groups. There was no significant difference between groups in mean improvement of NOSE, FACE-Q, and NIF scores at time of last follow-up. CONCLUSION: SRP with spreader graft placement with and without upper lateral cartilage release provide clinically and statistically significant improvement, and no significant difference in functional outcome. This suggests that upper lateral cartilages do not need to be released to achieve functional improvement and that surgeons should consider whether release is necessary to achieve goals of surgery. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1189-1195, 2022.

Patient-Perceived Nasal Appearance After Septorhinoplasty With Spreader Versus Extended Spreader Graft.

OBJECTIVES/HYPOTHESIS: Standard spreader grafts (SSGs) are commonly used in septorhinoplasty to treat internal nasal valve narrowing and have been shown to improve nasal airway obstruction. Extended spreader grafts (ESGs) have also been proven effective for correcting nasal deviation. To date, the effectiveness of ESGs using patient-reported outcome measures has not been demonstrated, and results of ESGs have not been compared to SSGs. This study aims to assess satisfaction and nasal appearance in patients who have undergone septorhinoplasty with SSG versus ESG. STUDY DESIGN: Prospective cohort study. METHODS: Five hundred sixty-eight patients who underwent septorhinoplasty with SSGs and 126 patients who underwent septorhinoplasty with ESGs between 2012 and 2018 were administered the Nasal Obstruction Symptom Evaluation (NOSE) scale and FACE-Q Satisfaction With Nose, FACE-Q Satisfaction With Nostrils, and FACE-Q Social Functioning scales pre- and postoperatively. Pre- and postoperative NOSE and FACE-Q scores, negative inspiratory force (NIF), and changes in these values were compared between groups. RESULTS: Results demonstrated clinically and statistically significant improvement at follow-up for both groups. There was no significant difference between the SSG and ESG groups in mean improvement of NOSE scores, FACE-Q scores, and NIF at follow-up of 6 months and at 12 months. CONCLUSIONS: This study demonstrates that SSGs and ESGs both provide clinically and statistically significant improvement, and no significant difference in functional outcome. Both techniques can be effective. The etiology of the nasal obstruction and/or deformity should be considered when deciding which type of spreader graft to use. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:765-772, 2021.

A Comparative Health Utility Value Analysis of Outcomes for Patients Following Septorhinoplasty With Previous Nasal Surgery.

IMPORTANCE: Using health utility values (HUVs) as an outcome measure for surgical procedures, including rhinoplasty, allows for a standardized measurement of the qualitative and financial benefit of that procedure on overall health. OBJECTIVE: To use Euroqol 5-Dimension (EQ-5D)-derived HUVs to evaluate nasal obstruction outcomes following surgery between primary rhinoplasty (PSRP) and rhinoplasty with previous nasal surgery (RNS) in a prospective cohort study. DESIGN, SETTING, AND PARTICIPANTS: A single-institution prospective cohort study between 2013 and 2017 was carried out including 185 patients who underwent RNS before functional rhinoplasty and 278 patients who underwent PSRP for nasal obstruction. The analysis was carried out between December 2018 and February 2019. MAIN OUTCOMES AND MEASURES: Patients in the RNS cohort and PSRP cohort who completed the EQ-5D questionnaire immediately prior to surgery and postoperatively at 2, 4, 6, and 12 months were included in the study. The EQ-5D scores were converted to HUV scores and compared to evaluate for improvement in health status following surgery. RESULTS: Of the 185 patients in the RNS cohort, 97 (52%) were women and the mean (SD) age was 42.6 (13.4) years. Of the 278 in the PSRP cohort, 156 (55%) were women and the mean (SD) age was 36.0 (15.8) years. Both cohorts experienced significant improvement in HUV postoperatively. The mean (SD) HUV values were decreased in the RNS cohort versus the PSRP cohort both preoperatively (0.85 [0.16] versus 0.89 [0.14]) and postoperatively at 1 year (0.92 [0.14] versus 0.94 [0.11]); however, the difference in HUV was not statistically significant after 6 months postoperatively. Patients in the RNS cohort were typically older (76 [41%] older than 40 years vs 84 [31%], P = .02) and more likely to have sleep apnea (31 [19%] vs 24 [10%], P = .01) than in the PSRP cohort. On multivariable analysis, the use of spreader grafts and alar rim grafts in the PSRP cohort was significantly associated with improved HUV at 12 months. (r = -0.06; 95% CI, -0.11 to -0.01, P = .03). CONCLUSIONS AND RELEVANCE: Patients with a history of prior nasal surgery may represent a unique cohort when assessing health utility outcomes. Euroqol 5-dimension questionnaire-derived HUVs are a valid predictor of outcomes in all patients who undergo septorhinoplasty. Although outcomes were significantly improved for both cohorts, previous surgical history should be considered when performing cost utility analysis on the benefits of functional rhinoplasty. LEVEL OF EVIDENCE: 3.

Health Utility Values as an Outcome Measure in Patients Undergoing Functional Septorhinoplasty.

IMPORTANCE: By measuring health utility values (HUVs) for patients with nasal obstruction after septorhinoplasty, the association of nasal congestion with overall health can be measured and the functional outcomes of septorhinoplasty can be determined. OBJECTIVE: To use the EuroQol 5-Dimension (EQ-5D) questionnaire to evaluate nasal obstruction outcomes after septorhinoplasty and to determine HUVs. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included patients who underwent septorhinoplasty for nasal obstruction at a single institution by a single surgeon from January 1, 2013, through December 31, 2017. Participants completed the EQ-5D questionnaire immediately before surgery and postoperatively at 2, 4, 6, and 12 months. The EQ-5D scores were converted to HUVs using population-based data for individuals with chronic diseases. Data were analyzed from May 1 through December 31, 2018. EXPOSURE: Functional septorhinoplasty. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative EQ-5D scores were compared to evaluate improvement in overall health after septorhinoplasty. RESULTS: A total of 463 patients (53.8% women; mean [SD] age, 36.8 [15.7] years) who underwent septorhinoplasty and completed EQ-5D surveys at baseline and postoperatively were included in the study population. Overall mean (SD) preoperative HUV was 0.872 (0.01), compared with 1.00 for those with a perfect state of health. On univariate analysis, female sex (mean [SD] HUV, 0.853 [0.01]; P = .004), previous nasal surgery (mean [SD] HUV, 0.85 [0.16]; P = .02), previous septoplasty (mean [SD] HUV, 0.88 [0.15]; P = .02), and previous sinus surgery (mean [SD] HUV, 0.79 [0.20]; P = .009) were associated with significantly lower baseline HUVs. On multivariate regression including these variables, only previous septoplasty was significantly associated with a positive change in mean (SD) HUV (0.88 [0.15] vs 0.85 [0.16]; P = .02). Mean (SD) HUV was significantly improved at 2 months postoperatively to 0.91 (0.14; P = .001) and remained significantly improved from baseline at 12 months, at 0.93 (0.13; P < .001). CONCLUSIONS AND RELEVANCE: Nasal obstruction is associated with significant detriment to overall health, in line with other chronic conditions affecting the US population. Functional septorhinoplasty appears to substantially improve overall health, as measured by HUV, in an immediate and sustained fashion. LEVEL OF EVIDENCE: 3.

A Facial Plastic and Reconstructive Surgery Training Module Using Surgical Simulation for Capacity Building.

OBJECTIVE: To introduce 3 novel intensive facial plastic and reconstructive surgery teaching modules for surgical capacity building using simulation in a low-middle income country. DESIGN: Prospective cohort study. SETTING: University-based medical center in Quito, Ecuador. PARTICIPANTS: First- and second-year otolaryngology residents in Quito, Ecuador. RESULTS: Residents participated in an intensive 3-day teaching program focused on microtia, nasoseptal abnormalities, and facial paralysis that included didactic lectures, simulation workshops, and live surgery. Residents underwent rigorous pre- and postmodule testing including written, oral, and practical examinations in each subject area. All participants completed anonymous feedback surveys with ratings on a Likert scale from 0 (very poor) to 10 (excellent). Nineteen residents completed both pre- and postmodule testing. The training module was successfully implemented and testing performance across all 3 subject areas significantly improved. Resident feedback was exceedingly positive, with average scores for each component ranging from 8.9 to 9.8, with highest scores given to the simulation workshops. The postmodule survey indicated that all residents found the course helpful and they desired additional courses covering more subject areas. CONCLUSIONS: Implementation of an intensive surgical training module combining didactics, surgical simulation, and live surgery resulted in the successful transfer of both skills and knowledge. While the long-term benefit of this program is yet to be determined, this model of training may prove to be a useful tool to help address surgical capacity building in the developing world.