Opioid-Sparing Protocol for Endocrine Surgery (OSPREY): A Prospective Study.

BACKGROUND: Thyroid and parathyroid operations are among the most commonly performed surgeries in the world; however, there remains a paucity of prospective clinical trials evaluating the efficacy of opioid-sparing protocols after surgery. STUDY DESIGN: This prospective nonrandomized study was performed between March and October 2021. Participants self-selected their cohort of either an opioid-sparing protocol of acetaminophen/ibuprofen or a treatment-as-usual protocol with opioids. Primary endpoints were Overall Benefit of Analgesia Scores (OBAS) and opioid use as reported in daily medication logs. Data were recorded for 7 days. Multivariable regression, pooled variance t -tests, Mann-Whitney test, and chi-square tests were used to evaluate the results. RESULTS: A total of 87 participants were recruited; 48 participants opted for the opioid-sparing arm, and 39 participants opted for the treatment-as-usual arm. Patients in the opioid-sparing arm used significantly fewer opioids (morphine equivalents 0.77 ± 1.71 vs 3.34 ± 5.87, p = 0.042) but had no significant difference in OBAS (p = 0.37). Multivariable regression analysis demonstrated no significant difference in mean OBAS between treatment arms when controlling for age, sex, and type of surgery (p = 0.88). There were no major adverse events in either group. CONCLUSIONS: An opioid-sparing treatment algorithm based on the use of acetaminophen/ibuprofen may offer a safe and effective treatment algorithm compared to a primary opioid-focused treatment pathway. Randomized adequately powered studies are needed to confirm these findings.

Impact of Histologic Risk Factors on Recurrence Rates for Oral Cavity Squamous Cell Carcinoma.

OBJECTIVES: This study assesses the impact of adverse histologic risk factors including worst pattern of invasion (WPOI), predominant pattern of invasion (PPOI), tumor budding, and tumor infiltrating lymphocytes (TILS), on risk of recurrence in patients with early-stage Oral Cavity Squamous Cell Carcinoma (OCSCC). METHODS: Retrospective chart review was performed at a single institution to identify patients with OCSCC who underwent surgical excision. Inclusion criteria included T1-T2 stage disease based on AJCC seventh edition guidelines, no cervical lymph node involvement, no perineural invasion (PNI), no lymphovascular invasion (LVI), no post-operative adjuvant radiation therapy, and cancer involving only the oral tongue or floor of mouth. Patients were excluded if they had positive final margins. A subset of 35 patients were selected for additional histologic review to determine WPOI, PPOI, TB, and TILS. Bivariable and multivariable cox analysis were performed to determine variables associated with recurrence. RESULTS: One hundred and sixty-one patients met criteria and were included in the analysis. Variables that were significantly associated with recurrence on bivariable analysis included tumors with high risk PPOI (groups 4 and 5; P = .021), TB with 10 or more buds (P = .021), T-stage (P = .001), neck dissection (P = .03), and depth of invasion (DOI) >4 mm (P = .044). Multivariable cox proportional hazards found T-stage (HR: 6.40; 95% CI 1.67, 24.50; P = .007), neck dissection (HR: 0.23; 95% CI 0.07, 0.82; P = .023), and TBs (HR: 1.17; 95% CI 1.05, 1.30; P = .006) to be most predictive of recurrence. CONCLUSIONS: TB is a strong predictor of recurrence. WPOI, PPOI, and TILS were not statistically significant risk factors for recurrence.

Cost-Effectiveness of Depression Screening for Otolaryngology-Head and Neck Surgery Residents.

OBJECTIVES: This study aims to determine the cost-effectiveness of screening and treating otolaryngology-head and neck surgery residents for depression. METHODS: A Markov model was built using TreeAgePro, version 2019 (TreeAge Software Inc.; Williamstown, MA) to assess the cost-effectiveness of five potential treatment algorithms: 1) treat all residents with psychotherapy, 2) screen and treat depressed residents with psychotherapy, 3) screen and treat depressed residents with pharmacotherapy, 4) screen and treat depressed residents with combination psychotherapy/pharmacotherapy, and 5) no intervention. A Monte Carlo probabilistic sensitivity analysis (PSA), consisting of 1 thousand simulations over a cumulative 5-year period, was performed to evaluate both base case values and a range of values for model variables. RESULTS: Screening residents for depression and treating with combination psychotherapy/pharmacotherapy was cost-effective and the optimal strategy at a willingness-to-pay threshold of $50 thousand per quality-adjusted life year (QALY). This option demonstrated an incremental cost-effectiveness ratio of $27,578 per QALY for base case values. PSA confirmed these results and demonstrated that screening residents for depression and treating with either combination pharmacotherapy/psychotherapy, pharmacotherapy alone, or psychotherapy alone were cost-effective options in 94.9% of simulations. CONCLUSION: Depression and burnout remain crucial issues among resident physicians. This study demonstrates that actively screening residents for depression is cost-effective. Based on these results, residency programs may consider trialing standardized depression screening protocols. LEVEL OF EVIDENCE: I and II. Laryngoscope, 131:502-508, 2021.

Comparison of Parotidectomy With Observation for Treatment of Pleomorphic Adenoma in Adults.

Importance: There is no consensus regarding optimal management of pleomorphic adenoma in adults. Objectives: To compare parotidectomy with observation for the management of pleomorphic adenoma in patients 50 years or older by age. Design and Setting: This decision analytical model was performed from November 21, 2019, to June 15, 2020, using a Markov model. Model variables and ranges were selected based on a literature review. A 1-way sensitivity analysis was performed to evaluate the age threshold at which each algorithm, either upfront elective parotidectomy or observation, would be favored. A Monte Carlo probabilistic sensitivity analysis using variable ranges was then performed 5 times with patients in the model assigned a starting age of 50, 60, 70, 80, and 90 years to assess how age at diagnosis would be associated with the model results. Main Outcomes and Measures: Model outcomes were measured with quality-adjusted life-years (QALYs). Results: In the study models, the age thresholds at which observation became more beneficial than parotidectomy were 88.5 years for patients with superficial lobe tumors (5.37 QALYs in favor of parotidectomy below this age, and 5.37 QALYs in favor of observation above this age) and 83.4 years for patients with deep lobe tumors (7.51 QALYs in favor of surgery below this age, and 7.51 QALYs in favor of observation above this age). There was no significant difference in outcomes between parotidectomy and observation among patients aged 70 to 80 years. Conclusions and Relevance: This study suggests that the outcomes associated with parotidectomy and observation are similar at 70 years or older among patients with pleomorphic adenoma and that observation may be the favorable treatment in that age group.

Challenges facing otolaryngologists in low- and middle-income countries during the COVID-19 pandemic.

The COVID-19 pandemic poses significant challenges for otolaryngologists practicing in low- and middle-income countries (LMICs). This commentary highlights some of the particular challenges in low resource settings, including limited testing, insufficient personal protective equipment, small numbers of surgeons, and competing socio-economic demands. The commentary focuses on specific examples from around the world to draw attention to these challenges and also highlight examples of success and innovation. Amidst the crisis an opportunity exists for otolaryngologists from around the world to share resources, ideas, and innovations to best serve patients and improve the health system globally for the future.

Physician-Assisted Suicide for Patients with Head and Neck Cancer.

A retrospective observational cohort study was conducted using data from Oregon's Death with Dignity Act (DWDA) to characterize patients with head and neck cancer (HNC) who seek physician-assisted suicide (PAS). Between 1998 and 2018, a total of 57 patients with HNC received DWDA prescriptions, of whom 39 (68.4%) died by administration of the prescribed medication. There were no associated complications with medication administration. The most commonly involved subsites were oral cavity (33.3%) and oropharynx (30.8%), and the most commonly cited end-of-life concerns were loss of ability to engage in activities that make life enjoyable (79.5%) and loss of autonomy (74.4%). There were no differences in age, race, marital status, or hospice enrollment rates between patients with HNC who died by administration and those who were prescribed but did not administer the medication. Patients who died by administration were generally less educated as compared to those who were prescribed but did not administer the medication (P = .015).

Managing head and neck cancer patients with tracheostomy or laryngectomy during the COVID-19 pandemic.

Head and neck cancer patients with tracheostomies and laryngectomies, as well as their healthcare providers, face unique challenges in the context of the current COVID-19 pandemic. This document consolidates best available evidence to date and presents recommendations to minimize the risks of aerosolization and SARS-CoV-2 exposures in both the inpatient and outpatient settings. The cornerstones of these recommendations include the use of closed-circuit ventilation whenever possible, cuffed tracheostomy tubes, judicious use of heat moisture exchange units, appropriate personal protective equipment for providers and patients, meticulous hand hygiene, and minimal manipulation of tracheostomy tubes.

Tracheostomy Complications in the Emergency Department: A National Analysis of 38,271 Cases.

BACKGROUND: Greater than 100,000 tracheotomies are performed annually in the USA, yet little is known regarding patients who present to the emergency department (ED) with tracheostomy complications. OBJECTIVES: To characterize patient and hospital characteristics, outcomes, and charges associated with tracheostomy complications and to identify predictors of admission and mortality. METHODS: The 2009-2011 Nationwide Emergency Department Sample (NEDS) was queried for patients with a principle diagnosis of tracheostomy complication. A descriptive analysis was performed and multivariable logistic regression was used to identify predictors of admission and mortality. RESULTS: A total of 69,371 nationwide visits to the ED had tracheostomy complication as an associated ICD-9 diagnosis, of which 55.2% (n = 38,293) carried a primary diagnosis of tracheostomy complication. Unspecified tracheostomy complications were most common (61.4%), followed by mechanical complications (31.3%), and lastly by tracheostomy infections (7.3%). Pediatric patients were significantly more likely to have tracheostomy infections than adults (p < 0.0001). A total of 35.5% of patients with tracheostomy complications were admitted to the hospital, and death occurred with 1.4% of visits. Patients from higher-income ZIP codes had increased odds of admission (adjusted odds ratio [OR]: 1.35; p = 0.0009), as did patients with tracheostomy infections (OR: 4.425; p < 0.0001). Patients with tracheostomy infections (OR: 3.14; p = 0.0062) and unspecified tracheostomy complications (OR: 2.00; p = 0.0076) had increased odds of mortality. CONCLUSION: These findings may help improve overall outcomes amongst patients with tracheostomies by preventing unnecessary ED admissions and improving healthcare provider preparedness and awareness.

Morbidity and mortality among patients with head and neck cancer in the emergency department: A national perspective.

BACKGROUND: Emergency departments are playing an increasing role in cancer management. Emergency department utilization by patients with head and neck cancer, however, is unknown. METHODS: The 2009-2011 Nationwide Emergency Department Sample was queried for patients with a principle diagnosis of head and neck cancer. Descriptive analysis was performed to characterize patient and hospital characteristics, outcomes, and charges. Logistic regression identified predictors of admission and mortality. RESULTS: A total of 31 390 patients were seen in the emergency department with head and neck cancer: 72.8% were admitted, 0.5% died in the emergency department, and 5.0% died during admission. Patients with cancer of unknown primary site had the greatest odds of admission (odds ration [OR]: 2.83; P < 0.0001). Privately insured patients (OR: 1.78; P = 0.001), those from higher income zip codes (OR: 1.56; P = 0.008), and those with oropharyngeal cancer (OR: 2.02; P = 0.0003) had the greatest odds of death. CONCLUSION: These findings have direct implications for preventing unnecessary and costly emergency department visits, improving hospital and physician preparedness, and improving patient outcomes.

Head and Neck Cancer in Haiti: A Case Series from Hopital de L'Universite d'Etat d'Haiti.

This manuscript characterizes the demographics, presenting symptoms and risk factors of patients diagnosed with head and neck cancer at Hopital de L'Universite d'Etat d'Haiti (HUEH), Haiti's single largest healthcare facility. We conducted a prospective study of patients who presented to HUEH between January and March of 2016 with a lesion of the head or neck suspicious for cancer. All patients who met eligibility criteria received a biopsy, which was interpreted by a Haitian pathologist and when the specimen was available was confirmed by a team of pathologists from Stanford University. A total of 34 participants were identified. The biopsy-confirmed diagnoses were squamous cell carcinoma (n=7), benign (n=7), large cell lymphoma (n=2), ameloblastoma (n=2), pleomorphic adenoma (n=1), and adenocarcinoma (n=1). Fourteen patients were unavailable for biopsy. Patients with head and neck cancer had a mean age of 63.4 years, were majority male (62.5%), waited on average 10.9 months to seek medical attention, and most commonly presented with T-stage 3 or higher disease (87.5%). By characterizing patterns of head and neck cancer at HUEH we hope to facilitate efforts to improve early detection, diagnosis, and management of this important public health condition.

Intraoperative Corticosteroids for Voice Outcomes among Patients Undergoing Thyroidectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine if a preoperative dose of intravenous corticosteroids reduces the risk of postoperative recurrent laryngeal nerve palsy and improves subjective voice outcomes among patients undergoing thyroidectomy. DATA SOURCES: PubMed, Cochrane database, and EMBASE. REVIEW METHODS: Randomized controlled trials comparing corticosteroids with placebo on voice outcomes in thyroid surgery were extracted with standardized search criteria. Systematic review and meta-analysis were performed. With random effects models, trial data were pooled to determine the overall rate of recurrent laryngeal nerve palsy as well as secondary outcomes of adverse events, including wound infection and hyperglycemia. RESULTS: Four studies with a total of 517 patients met inclusion criteria. The overall rate of recurrent laryngeal nerve palsy was 5.78%. There was no difference in the rate of palsy between the corticosteroid and placebo groups (risk ratio, 0.70; 95% CI, 0.34-1.44). There was also no difference between the groups in regard to wound infection, healing, or hyperglycemia. CONCLUSIONS: Preoperative corticosteroids do not appear to reduce the risk of recurrent laryngeal nerve palsy following thyroid surgery. There is insufficient evidence to assess its effect on subjective voice outcomes. More robust randomized controlled trials are needed to assess the effectiveness of perioperative steroids in improving voice outcomes after thyroidectomy.

Retrograde Parotidectomy and facial nerve outcomes: A case series of 44 patients.

PURPOSE: The most common surgical method to remove benign parotid tumors remains the prograde approach. We examined if a retrograde surgical technique offers better outcomes than historical prograde controls. MATERIALS AND METHODS: A retrospective chart review at Stanford Hospital was conducted to identify retrograde parotidectomies between February 2012 and October 2014 that were staffed by the senior author (DS) with resident involvement. Facial nerve (FN) outcomes and other post-surgical parameters were recorded. RESULTS: We identified 44 consecutive cases and found that 18.2% (n=8) of patients experienced temporary paresis and 2.3% (n=1) experienced minor (HB 2) permanent paresis limited to one branch. The average hospital length of stay was 0.64 days and complication rate was 6.8%. CONCLUSION: The retrograde technique has complication rates comparable to historical rates for the prograde technique and is amenable to minimally invasive outpatient superficial parotidectomy.

Otorhinolaryngology/Head and Neck Surgery in a low income country: The Haitian experience.

OBJECTIVE: Little is known regarding the diagnosis and management of pediatric surgical conditions of the head and neck in low-income countries. Haiti, the western hemisphere's poorest country, recently developed its first Otorhinolaryngology (ORL) department at the Hopital de L'Universite d'Etat d'Haiti (HUEH). This manuscript assesses the caseload at HUEH with a special emphasis on pediatric cases, with the aim of characterizing ORL related conditions and their treatments in low-income countries. METHODS: We conducted a retrospective chart review of surgical case logs at HUEH for the calendar year of 2014 and recorded patient age, diagnosis, and surgical intervention for all ORL surgeries. RESULTS: A total of 229 ORL surgeries were performed at HUEH during this time. The average age of the patient was 21.8 years and 54.2% of patients were 18 years or younger. The five most common diagnoses were tonsillar hypertrophy (23.6%), ingested foreign body (18%), mandibular fracture (9.2%), unspecified head or neck mass (6%), and thyroid goiter (4.8%). The five most common surgeries performed were tonsillectomy (23.6%), foreign body retrieval (17.9%), open reduction of mandibular fracture with direct skeletal fixation (6.9%), thyroidectomy (7.9%), and excision of unspecified mass. Trauma accounted for 33.6% of all ORL surgeries. CONCLUSIONS: Diseases related to the head and neck constitute a common yet underserved surgical problem. Strengthening ORL surgical capacity in Haiti should focus on improving capacity for the most common conditions including tonsillar disease, ingested foreign bodies, and facial trauma, as well as improving capacity for rarely performed surgeries, such as ear surgery, nose and sinus surgery, and cancer resections.