Shared Decision-making in Head and Neck Surgery: A Review

Importance

Shared decision-making is a partnership between physicians and patients whereby patient values and preferences are incorporated with the best medical evidence. Shared decision-making may reduce decisional conflict, improve value-choice congruence, and increase patient involvement. Despite potential benefit in many key areas of otolaryngology-head and neck surgery, both clinical and research focuses on shared decision-making are scarce. Head and neck surgical oncology is of particular interest owing to the frequency by which preference-sensitive decisions must be made. Information used in this review was obtained between January 1 and February 1, 2020.

Observations

Various conceptual models have been developed in an attempt to define the concept of shared decision-making. More than 40 instruments have endeavored to measure the construct of shared decision-making. However, in head and neck surgery, few studies to date have explicitly done so. Situations of clinical equipoise, such as in the management of indeterminate thyroid nodules and in the treatment of laryngeal cancer, are frequent. In contrast, value-option incongruence may occur when patient values do not align with the most oncologically sound treatment choice, such as when the resection and reconstruction of oral cancer may leave patients with significant sequelae. Several patient decision aids have been developed to improve shared decision-making in specific clinical scenarios, for example, in considering total laryngectomy or primary chemoradiotherapy.

Conclusions and Relevance

Despite its potential benefit, there is a dearth of research and clinical applications of shared decision-making in head and neck surgery. Shared decision-making represents an area of substantial need in this regard, and additional efforts should be put forth.

Association of Immigration Status and Chinese and South Asian Ethnicity With Incidence of Head and Neck Cancer

Importance

Head and neck cancer (HNC) incidence varies worldwide, although it remains one of the most common cancers among those of East Asian and South Asian ethnicity.

Objective

To determine the association of Chinese and South Asian ethnicity, independent of immigration status, with HNC incidence.

Design, Setting, and Participants

This was a retrospective population-based matched cohort study that examined data collected between 1994 and 2017 in Ontario, Canada. Data were analyzed between July 2019 and March 2020. Individuals who immigrated to Canada between 1985 and 2017 were classified as immigrants, whereas Canadian-born individuals and those who immigrated prior to 1985 were classified as long-standing residents. Two separate, matched cohorts were created: an immigration cohort, consisting of immigrants and long-standing residents hard matched on age and sex, and an ethnicity cohort, where participants were further matched on ethnicity (Chinese, South Asian, or non-Chinese/non-South Asian).

Exposures

Chinese ethnicity, South Asian ethnicity, and immigration status.

Main Outcomes and Measures

Patients newly diagnosed with primary HNC were captured in both the immigration and the ethnicity cohorts. Cause-specific hazard models were used to estimate the association of immigration status and ethnicity with HNC incidence.

Results

In the immigration cohort, 3 328 434 matched individuals (mean [SD] age, 36.73 [13.46] years; 52.8% female) were followed, across which 3173 unique HNC diagnoses were made. The hazard ratio (HR) for a new diagnosis of oropharynx cancer was lower in immigrants compared with long-standing residents (HR, 0.26 [95% CI, 0.22-0.31]). In the ethnicity cohort, after adjusting for age, sex, rurality, and deprivation, the rate of HNC diagnosis was higher for Chinese individuals (HR, 1.49 [95% CI, 1.36-1.64]) and South Asian individuals (HR, 1.29 [95% CI, 1.14-1.45]), although it was lower for immigrants (HR, 0.48 [95% CI, 0.44-0.52]) when compared with non-Chinese and non-South Asian individuals. There was no difference in the incidence of nasopharynx cancer when comparing immigrants and long-standing residents of Chinese ethnicity.

Conclusions and Relevance

Immigration status appears to offer a protective effect against a diagnosis of HNC. Chinese and South Asian ethnic groups may experience higher HNC incidence when compared with the general Ontario population.

Elective neck dissection versus positron emission tomography-computed tomography-guided management of the neck in clinically node-negative early oral cavity cancer: A cost-utility analysis

BACKGROUND

In early oral cavity cancer, elective neck dissection (END) for the clinically node-negative (cN0) neck improves survival compared with observation. This paradigm has been challenged recently by the use of positron emission tomography-computed tomography (PET-CT) imaging in the cN0 neck. To inform this debate, we performed an economic evaluation comparing PET-CT-guided therapy with routine END in the cN0 neck.

METHODS

Patients with T1-2N0 lateralized oral tongue cancer were analyzed. A Markov model over a 40-year time horizon simulated treatment, disease recurrence, and survival from a US health care payer perspective. Model parameters were derived from a review of the literature.

RESULTS

The END strategy was dominant, with a cost savings of $1576.30 USD, an increase of 0.055 quality-adjusted life years (QALYs), a net monetary benefit of $4303 USD, and a 0.22 life-year advantage. END was sensitive to variation in cost and utilities in deterministic and probabilistic sensitivity analyses. PET-CT became the preferred strategy when decreasing occult nodal disease to 18% and increasing the negative predictive value (NPV) of PET-CT to 89% in 1-way sensitivity analyses. In probabilistic sensitivity analysis, assuming a cost effectiveness threshold of $50,000 USD/QALY, END was dominant in 64% of simulations and cost effective in 69.8%.

CONCLUSION

END is a cost-effective strategy compared with PET-CT in patients who have node-negative oral cancer. Although lower PET standardized uptake value thresholds would result in fewer false negatives and improved NPV, it is still uncertain that PET-CT would be cost effective, as this would likely result in more false positive tests.

Outpatient versus inpatient superficial parotidectomy: clinical and pathological characteristics

Background

Superficial parotidectomy has a potential to be performed as an outpatient procedure. The objective of the study is to evaluate the safety and selection profile of outpatient superficial parotidectomy compared to inpatient parotidectomy.

Methods

A retrospective review of individuals who underwent superficial parotidectomy between 2006 and 2016 at a tertiary care center was conducted. Primary outcomes included surgical complications, including transient/permanent facial nerve palsy, wound infection, hematoma, seroma, and fistula formation, as well as medical complications in the postoperative period. Secondary outcome measures included unplanned emergency room visits and readmissions within 30 days of operation due to postoperative complications.

Results

There were 238 patients included (124 in outpatient and 114 in inpatient group). There was no significant difference between the groups in terms of gender, co-morbidities, tumor pathology or tumor size. There was a trend towards longer distance to the hospital from home address (111 Km in inpatient vs. 27 in outpatient, mean difference 83 km [95% CI,- 1 to 162 km], p = 0.053). The overall complication rates were comparable between the groups (24.2% in outpatient group vs. 21.1% in inpatient, p = 0.56). There was no difference in the rate of return to the emergency department (3.5% vs 5.6%, p = 0.433) or readmission within 30 days (0.9% vs 0.8%, p = 0.952).

Conclusion

Superficial parotidectomy can be performed safely as an outpatient procedure without elevated risk of complications.

Graphical abstract

Patient-Reported Symptom Burden as a Predictor of Emergency Department Use and Unplanned Hospitalization in Head and Neck Cancer: A Longitudinal Population-Based Study

PURPOSE

To determine the association between patient-reported symptom burden and subsequent emergency department use and unplanned hospitalization (ED/Hosp) in a head and neck cancer (HNC) patient population.

METHODS

This was a population-based study of patients diagnosed with HNC who had completed at least one outpatient Edmonton Symptom Assessment System (ESAS) assessment between January 2007 and March 2018 in Ontario, Canada. Logistic regression models were used to determine the relationship between outpatient ESAS scores and subsequent 14-day ED/Hosp use. A generalized estimating equation approach with an exchangeable correlation structure was incorporated to account for patient-level clustering.

RESULTS

There were 11,761 patients identified, completing a total of 73,282 ESAS assessments and experiencing 5,203 ED/Hosp events. Six of the nine ESAS symptom scores were positively associated with ED/Hosp use, with pain, appetite, shortness of breath, and tiredness demonstrating the strongest associations. A global ESAS score was calculated by selecting the highest individual symptom score (h-ESAS). Among patients reporting a maximum h-ESAS score of 10, 15.1% had an ED/Hosp event within 14 days compared with 1.5% for those with the lowest possible score of zero. In adjusted analysis, the odds of ED/Hosp use increased with h-ESAS (1.23 per one-unit increase [95% CI, 1.22 to 1.25]). When treated as a categorical variable, patients with the maximum h-ESAS score of 10 had 9.23 (95% CI, 7.22 to 11.33) higher odds of ED/Hosp use, relative to the minimum score of zero.

CONCLUSION

ESAS scores are strongly associated with subsequent ED/Hosp events in patients with HNC. Clinician education around how ESAS data might inform patient care may enhance symptom detection and management.

Chinese and South Asian ethnicity, immigration status and head and neck cancer outcomes: A population based study

OBJECTIVE

While it is known that certain ethnic and immigrant groups are at increased risk of developing head and neck cancer, the individual effects of immigration status and ethnicity on head and neck cancer outcomes is less clear. We sought examine the independent effects of immigration and Chinese and South Asian ethnicity on overall survival in a head and neck cancer patient population.

METHODS

This was a population-based retrospective matched cohort study using linked Ontario administrative databases between 1994 and 2017. Incident cancer cases were captured in long-standing residents of Chinese and South Asian ethnicity, Chinese and South Asian immigrants, as well as a reference population. Subjects were followed until death. A hard-matching approach was used to adjust for key differences and ensure both groups were balanced with respect to age, sex and cancer site. Cox proportional hazard models were used to estimate the impact of Chinese and South Asian ethnicity on overall survival while further adjusting for baseline covariates.

RESULTS

Among 1639 immigrants with head and neck cancer, matched to 3278 controls, the overall 5-year survival rate was 66% and 59%, respectively. After adjusting for between group-differences, all-cause mortality was lower for immigrants (HR 0.76[95%CI 0.69-0.83]) and individuals of Chinese ethnicity (HR 0.78[95%CI 0.68-0.90]), relative to the general population.

CONCLUSIONS

In Ontario, immigrants experience lower mortality rates following a head and neck cancer diagnosis. Individuals of Chinese ethnicity with head and neck cancer experience a survival advantage, relative to South Asian individuals and the general population.

The abscopal effect in head-and-neck squamous cell carcinoma treated with radiotherapy and nivolumab: a case report and literature review

Introduction

The abscopal effect is a rarely observed outcome of radiotherapy wherein there is a reduction in metastatic disease burden outside of the targeted treatment area. Likely due to an in situ vaccine effect of radiotherapy, the abscopal effect may be augmented by immunotherapy. This report is the first case of the abscopal effect observed in metastatic head-and-neck squamous cell carcinoma (hnscc) treated with concurrent radiotherapy and single-agent nivolumab.

Case Description

An otherwise healthy 57-year-old man underwent craniofacial resection and adjuvant chemoradiotherapy for advanced sinonasal squamous cell carcinoma. Distant metastatic disease developed shortly after primary treatment, and immunotherapy in the form of nivolumab was initiated. Subsequent oligometastatic progression despite immunotherapy prompted palliative radiotherapy to a single metastasis due to pending symptomatology. Post-radiotherapy, the abscopal effect was observed with all distant sites of metastatic disease shrinking. Five months following treatment, a sustained reduction in disease burden has been demonstrated.

Summary

We present the first case of the abscopal effect in a patient with metastatic hnscc treated with palliative radiotherapy concurrent with single-agent nivolumab immunotherapy, and only the third case of the abscopal effect in metastatic head-and-neck cancer. Dual treatment with immunotherapy and radiotherapy may be an important treatment option in the future, mediated through the abscopal effect.

Needs assessment for a decision support tool in oral cancer requiring major resection and reconstruction: a mixed-methods study protocol

INTRODUCTION

Advanced oral cancer and its ensuing treatment engenders significant morbidity and mortality. Patients are often elderly with significant comorbidities. Toxicities associated with surgical resection can be devastating and they are often highlighted by patients as impactful. Given the potential for suboptimal oncological and functional outcomes in this vulnerable patient population, promotion and performance of shared decision making (SDM) is crucial.Decision aids (DAs) are useful instruments for facilitating the SDM process by presenting patients with up-to-date evidence regarding risks, benefits and the possible postoperative course. Importantly, DAs also help elicit and clarify patient values and preferences. The use of DAs in cancer treatment has been shown to reduce decisional conflict and increase SDM. No DAs for oral cavity cancer have yet been developed.This study endeavours to answer the question: Is there a patient or surgeon driven need for development and implementation of a DA for adult patients considering major surgery for oral cancer?

METHODS AND ANALYSIS

This study is the first step in a multiphase investigation of SDM during major head and neck surgery. It is a multi-institutional convergent parallel mixed-methods needs assessment study. Patients and surgeon dyads will be recruited to complete questionnaires related to their perception of the SDM process (nine-item Shared Decision-Making Questionnaire, SDM-Q-9 and SDM-Q-Doc) and to take part in semistructured interviews. Patients will also complete questionnaires examining decisional self-efficacy (Ottawa Decision Self-Efficacy Scale) and decisional conflict (Decisional Conflict Scale). Questionnaires will be completed at time of recruitment and will be used to assess the current level of SDM, self-efficacy and conflict in this setting. Thematic analysis will be used to analyse transcripts of interviews. Quantitative and qualitative components of the study will be integrated through triangulation, with matrix developed to promote visualisation of the data.

ETHICS AND DISSEMINATION

This study has been approved by the research ethics boards of the Nova Scotia Health Authority (Halifax, Nova Scotia) and the University Health Network (Toronto, Ontario). Dissemination to clinicians will be through traditional approaches and creation of a head and neck cancer SDM website. Dissemination to patients will include a section within the website, patient advocacy groups and postings within clinical environments.

Oral literacy in pediatric otolaryngology surgical consultations amongst parents with high levels of decisional conflict

OBJECTIVES

Oral literacy is an important aspect of physician and patient/family communication. Adequate communication is essential in the shared decision-making process and is inherently important in pediatric surgical consultations where parents must make decisions for their children. The aim of this study was to describe oral literacy in pediatric otolaryngology consultations and how it may relate to shared decision-making in a cohort of parents experiencing significant decisional conflict.

METHODS

Thirty-six parent/patient-physician interactions from two pediatric otolaryngology clinics were recorded. Parents completed the Decision Conflict Scale (DCS), and both parents and physicians completed the Shared Decision-making (SDM-Q-9/SDM-Q-Doc) questionnaires. Language complexity was assessed by the Flesch Reading Ease Scale (FRES), the Simple Measure of Gobbledygook (SMOG) Readability Formula, and a series of grammar statistics. The Pearson product-moment was used to examine the correlation between measures.

RESULTS

The mean age of parents was 32.3 (mother) and 34.8 (father) years, with the majority having a college education or greater (77.8%). The mean DCS score was 85.8 (range 56-100), and all parents reported clinically significant conflict scores (DCS score > 25). Physicians spoke at a higher-grade level (mean difference SMOG 1.2 (95% CI: 0.8-1.6)), with more words per sentence (mean difference 3.7 (95% CI: 2.4-4.9)), and longer words (mean difference 0.1 (95% CI: 0.03-0.16)). Parents who had higher language complexity experienced less decisional conflict (SMOG vs DCS, r = -0.471, p = 0.004; words per sentence, r = -0.414, p = 0.012; word length, r = -0.419, p = 0.011), but there was no correlation between physician language complexity and DCS or SDM-Q-9 scores.

CONCLUSION

Physicians demonstrated higher language complexity than that of parents in this study. Differences in language complexity between physicians and parents do not appear to play a substantial role in decisional conflict or the perception of shared decision-making in general. However, parents who use a more complex vocabulary may experience less conflict.

Predictors of surgical readmission, unplanned hospitalization and emergency department use in head and neck oncology: A systematic review

OBJECTIVE

To identify predictors of unplanned hospitalization and emergency department (ED) use among head and neck oncology patients.

METHODS

Peer reviewed publications were identified through a systematic search of MEDLINE, Embase and Cochrane CENTRAL. Studies describing a cohort of HNC patients that detailed predictors of unplanned hospitalization or ED use in risk-adjusted models were eligible for inclusion. The methodologic quality of included studies was assessed using the Quality In Prognostic Studies (QUIPS) tool and an adapted version of the GRADE framework.

RESULTS

Of the 932 articles identified, 39 studies met our inclusion criteria with 31/39 describing predictors of surgical readmission and 10/39 describing predictors of ED use or unplanned hospitalization during radiation/chemoradiation treatment. Risk factors were classified into either 'patient-related', 'cancer severity' or 'process' factors. In the subset of studies looking at readmission following surgery wound complications (10/14 studies), presence of comorbidity (16/28 studies), low socioeconomic status (8/17 studies), cancer stage (9/14 studies), and prolonged hospital stay (7/18 studies) were the variables most frequently associated with readmission on multivariable analysis. Presence of comorbidity (6/10) and chemotherapy use (4/10) were more frequently associated with ED use and unplanned hospitalization.

CONCLUSIONS

Several consistent predictors have been identified across a variety of studies. This work is a critical first step towards the development of readmission and ED prediction models. It also enables meaningful comparison of hospital readmission rates with risk adjustment in HNC patients.

Decision Modeling for Economic Evaluation in Otolaryngology-Head and Neck Surgery: Review of Techniques

Decision making in health care is complex, and substantial uncertainty can be involved. Structured, systematic approaches to the integration of available evidence, assessment of uncertainty, and determination of choice are of significant benefit in an era of "value-based care." This is especially true for otolaryngology-head and neck surgery, where technological advancements are frequent and applicable to an array of subspecialties. Decision analysis aims to achieve these goals through various modeling techniques, including (1) decision trees, (2) Markov process, (3) microsimulation, and (4) discrete event simulation. While decision models have been used for decades, many clinicians and researchers continue to have difficulty deciphering them. In this review, we present an overview of various decision analysis modeling techniques, their purposes, how they can be interpreted, and commonly used syntax to promote understanding and use of these approaches. Throughout, we provide a sample research question to facilitate discussion of the advantages and disadvantages of each technique.

Blunt Versus Penetrating Neck Trauma: A Retrospective Cohort Study

OBJECTIVES/HYPOTHESIS

Despite being common, neck injuries have received relatively little attention for important quality of care metrics. This study sought to determine the association between blunt and penetrating neck injuries on mortality and length of stay, and to identify additional patient and hospital-level characteristics that impact these outcomes.

STUDY DESIGN

Retrospective cohort study utilizing the American College of Surgeons Trauma Quality Improvement Program database.

METHODS

Adult patients (≥18) who sustained traumatic injuries involving the soft tissues of the neck between 2012 and 2016 were eligible. Multiple imputation was used to account for missing data. Logistic regression and negative binomial models were used to analyze 1) in-hospital mortality and 2) length of stay respectively while adjusting for potential confounders and accounting for clustering at the hospital level.

RESULTS

In a cohort of 20,285 patients, the crude mortality rate was lower in those sustaining blunt neck injuries compared to penetrating injuries (4.9% vs. 6.0%, P < .01), while length of hospital stay was similar (median 9.9 vs. 10.2, P = 0.06). In adjusted analysis, blunt neck injuries were associated with a reduced odds of mortality during hospital admission (odds ratio: 0.66, 95% confidence intervals [0.564, 0.788]), as well as significant reductions in length of stay (rate ratio: 0.92, 95% confidence intervals [0.880, 0.954]).

CONCLUSIONS

Blunt neck injuries are associated with lower mortality and length of stay compared to penetrating injuries. Areas of future study have been identified, including elucidation of processes of care in specific organs of injury.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 131:E1109-E1116, 2021.

Shared Decision Making for Surgical Care in the Era of COVID-19

The global pandemic caused by severe acute respiratory syndrome coronavirus 2 has upended surgical practice. In an effort to preserve resources, mitigate risk, and maintain health system capacity, nonurgent surgeries have been deferred in many jurisdictions, with urgent procedures facing increasing wait times and unpredictability given potential future surges. Shared decision making, a process that integrates patient values and preferences with the scientific expertise of clinicians, may be of particular benefit during these unprecedented times. Aligning patient choices with their values, reducing unnecessary health care use, and promoting consistency between providers are now more critical than ever before. We review important aspects of shared decision making and provide guidance for its perioperative application during the coronavirus disease 2019 pandemic.

Development and validation of a Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN) in a scarce resource setting: Response to the COVID-19 pandemic

Background

In the wake of the coronavirus disease 2019 (COVID‐19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes.

Methods

Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high‐priority, intermediate‐priority, and low‐priority indications for surgery were established and subdivided. A point‐based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient.

Results

A total of 62 indications for surgical priority were rated. Weights for each indication ranged from −4 to +4 (scale range; −17 to 20). The response rate for the validation exercise was 100%. The SPARTAN‐HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha, .91 [95% CI, 0.88‐0.93]; and rho, 0.81 [95% CI, 0.45‐0.95]).

Conclusions

The SPARTAN‐HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID‐19 era. Formal evaluation and implementation are required.

Lay Summary

Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID‐19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability.

Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden.

The current study sought to develop what to the authors' knowledge is the first cancer–specific surgical prioritization tool for use in the COVID‐19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID‐19 era and provides evidence for the initial uptake of the SPARTAN‐HN.

To the authors' knowledge, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN) is the first cancer surgery–specific prioritization tool for use during the coronavirus disease 2019 (COVID‐19) pandemic. The SPARTAN‐HN algorithm is reliable and valid for the stratification of patients with head and neck cancer who require urgent cancer care in resource‐restricted practice environments.

Otolaryngology needs among an adult homeless population: a prospective study

BACKGROUND

Homeless individuals frequently experience poor access to healthcare, delayed clinical presentation, and higher disease burden. Providing subspecialty otolaryngology care to this population can be challenging. We previously reported on the prevalence of hearing impairment in Toronto's homeless community. As a secondary objective of this study, we sought to define otolaryngology specific need for this population.

METHODS

One hundred adult homeless individuals were recruited across ten homeless shelters in Toronto, Canada using a stratified random sampling technique. An audiometric evaluation and head and neck physical examination were performed by an audiologist and otolaryngology resident, respectively. Basic demographic and clinical information was captured through verbal administration of a survey. Descriptive statistics were used to estimate frequency of otolaryngology specific diseases for this population.

RESULTS

Of the 132 individuals who were initially approached to participant, 100 (76%) agreed. There were 64 males, with median age of 46 years (IQR 37-58 years). The median life duration of homelessness was 24 months (IQR 6-72 months). Participants had a wide range of medical comorbidities, with the most common being current tobacco smoking (67%), depression (36%), alcohol abuse (32%), and other substance abuse (32%). There were 22 patients with otolaryngology needs as demonstrated by one or more abnormal findings on head and neck examination. The most common finding was nasal fracture with significant nasal obstruction (6%). Eleven patients required referral to a staff otolaryngologist based on concerning or suspicious findings, including two head and neck masses, 6 were later seen in follow-up.

CONCLUSION

There were substantial otolaryngology needs amongst a homeless population within a universal healthcare system. Future research should focus on further elucidating head and neck related issues in this population and expanding the role of the otolaryngologist in providing care to homeless individuals.

Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-analysis

OBJECTIVE

Peritonsillar abscesses (PTAs) are common emergency consultations for otolaryngologists. Medical management alone may offer satisfactory treatment without the risk associated with surgical drainage. Therefore, we performed a systematic review of medical treatment alone compared to surgical drainage for the treatment of PTA.

DATA SOURCES

MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov.

REVIEW METHODS

Studies comparing the outcomes of medically treated to surgically treated patients were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. All screening and data extraction were completed by 2 independent reviewers. Meta-analysis was performed using a random-effects model. Subgroup and sensitivity analyses were performed.

RESULTS

Ten cohort studies and 2 randomized studies were included (n_total = 33,468). Study quality was low, with only 1 study providing multivariable analysis. The combined rate of treatment failure in patients initially treated with medical management alone was 5.7% compared to 5.5% in the surgical group. There was no statistically significant difference in the odds of treatment failure between interventions through random-effects meta-analysis (odds ratio [OR], 1.10; 95% CI, 0.53-2.26; I ² = 41%; P = .13). Subgroup analysis excluding pediatric-specific studies revealed similar odds of treatment failure when initially managed with medical intervention (OR, 0.92; 95% CI, 0.56-1.50; P = .39; I ² = 0%).

CONCLUSION

Meta-analysis of available studies demonstrated no difference in odds of treatment failure for patients with PTA managed through medical intervention alone compared to surgical intervention. These findings should be interpreted with caution due to high probability of bias and overall low quality of studies.

Considerations for head and neck oncology practices during the coronavirus disease 2019 (COVID-19) pandemic: Wuhan and Toronto experience

The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our health care system by the Coronavirus disease 2019 (COVID-19) pandemic. Guidelines are emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.

Turn analysis and patient-centredness in paediatric otolaryngology surgical consultations

OBJECTIVES

Physician and patient/parent communication is of utmost importance in consultations to improve the shared decision-making (SDM) processes. This study investigated SDM-related outcomes through turn analysis and an assessment of patient-centred dialogue.

DESIGN

Multi-centre prospective cohort study analysing audio- and video-recorded patient/parent-physician interactions.

SETTING

Two tertiary paediatric hospitals in Halifax, Nova Scotia and Salt Lake City, Utah.

PARTICIPANTS

Paediatric otolaryngologists, patients and parents during consultation for adenotonsillectomy.

MAIN OUTCOME MEASURES

Medical dialogue measures (turn analysis, patient-centredness scores via the Roter Interaction Analysis System) and SDM questionnaires (SDM-Q-9).

RESULTS

Turn density was significantly higher for physicians than patients/parents (P < .001), as were total statements (P < .001), and total time talking (P < .001). The opening statement was completed by the physician in 91.5% of interactions and was significantly longer than family opening statements (P = .003). The mean number of informed consent elements addressed per interaction was 4.5 out of 6. The mean patient-centredness score was 0.2 (range 0-0.56). Significant negative correlations between patient-centredness score and physician turn density (r = -.390, P = .002), physician mean turn time (r = -.406, P = .001), total physician statements (r = -.426, P = .001) and total physician speaking time (r = -.313, P = .016) were noted. There were no correlations in SDM questionnaire scores with turn analysis variables, informed consent elements or patient-centredness scores.

CONCLUSIONS

Surgeons dominated the consultation in terms of talking, mostly in a unidirectional manner. Neither patient-centredness nor turn analysis correlated with perceptions of SDM from the parents' perspective.

Outpatient versus Inpatient Parotidectomy: A Systematic Review and Meta-analysis

OBJECTIVE

Parotidectomies are commonly performed procedures by head and neck surgeons. Although parotidectomies are historically inpatient procedures, recent observational evidence has highlighted the potential for parotidectomies to be performed on an outpatient basis. This systematic review and meta-analysis sought to compare complications and unplanned health care utilization between patients undergoing outpatient versus inpatient parotidectomy.

DATA SOURCES

A systematic review was performed using MEDLINE, EMBASE, and the Cochrane Library.

REVIEW METHODS

Studies comparing the outcomes of outpatient parotidectomy with those of inpatient parotidectomy were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. Postoperative complications (hematoma, facial nerve dysfunction, seroma, fistulisation, Frey syndrome, and wound infection) and rates of 30-day readmission, reintervention, and emergency department presentation were compared.

RESULTS

We screened 1018 nonduplicate articles to include 5 studies, all of which were retrospective cohort studies. There were fewer complications found in the outpatient group (relative risk = 0.61, 95% confidence interval: 0.40-0.93). Outpatient procedures were more commonly performed on patients who lived close to the hospital, had fewer comorbidities, and had less extensive planned surgery.

CONCLUSION

Outpatient parotidectomy appears safe in select patients with outcomes comparable with inpatient surgery. However, evidence overall is of low quality, and further work is needed to delineate a satisfactory set of criteria for appropriate patient identification.

Open resection and reconstruction of a Nasoseptal Chondrosarcoma: case report and literature review

BACKGROUND

Primary chondrosarcomas of the nasal septum are rare, with a variety of clinical features that evade detection and treatment. While endoscopic surgery has become increasingly accessible, open approaches may be needed to provide adequate visualization for tumour ablation and reconstruction. We report the resection and reconstructive considerations of a septal chondrosarcoma.

CASE PRESENTATION

A 75-year-old woman presented with a 3-year history of a slow growing, firm mass in the nasal tip causing protrusion and septal fullness. Computed Tomography scan of the paranasal sinuses revealed a well-circumscribed, 2.2 cm mass at the anterior nasal septum extending into the right vestibule. Biopsy of the cartilaginous lesion confirmed the diagnosis of a low-grade chondrosarcoma by histopathology. The tumour was removed using a transcolumellar open rhinoplasty approach with a large septal resection. Primary reconstruction of the surgical defect was performed using an L-shaped strut from the nasal keystone area to the columella. Follow-up examinations demonstrated no evidence of recurrent disease with satisfactory functional and cosmetic outcomes at 1-year.

CONCLUSION

This report describes a case of nasal septal chondrosarcoma successfully treated with surgical excision using an open rhinoplasty approach. Only 5-10% of chondrosarcomas are located in the head and neck region and arise rarely in the nasal septum in approximately 2-4%. With this mass, an open rhinoplasty approach was required to allow optimal exposure of the margins and to facilitate reconstruction without disruption of normal sinonasal anatomy and function. Although rare, chondrosarcoma of the nasal septum should be considered in the differential diagnosis of nasal masses.

Oncological and functional outcomes after repeat transoral laser microsurgery for the treatment of recurrent early glottic cancer

BACKGROUND

Transoral laser microsurgery for glottic squamous cell carcinoma is the standard of care at many institutions. Repeat transoral laser microsurgery for recurrence may avoid the need for radiotherapy and total laryngectomy. This study aimed to identify oncological and functional outcomes in a cohort of patients who had undergone repeat transoral laser microsurgery procedures.

METHOD

A retrospective review of prospectively collected data of patients treated with transoral laser microsurgery for carcinoma in situ or tumour stages T1 or T2 glottic cancer, from 2003 to 2018.

RESULTS

Twenty patients were identified. Additional treatment was not needed in 45 per cent of patients. The five-year overall survival rate was 90 per cent. The disease-specific survival rate was 100 per cent. The laryngeal preservation rate was 85 per cent. There was improvement in mean Voice Handicap Index-10 scores following repeat transoral laser microsurgery treatment, when comparing the pre- and post-operative periods (mean scores = 15.5 vs 11.5, p = 0.373).

CONCLUSION

Repeat transoral laser microsurgery can be an oncologically safe alternative to other salvage therapies for glottic squamous cell carcinoma recurrence, without sacrificing functional outcomes.

Oncological and functional outcomes following transoral laser microsurgery in patients with T2a vs T2b glottic squamous cell carcinoma

Background

There is a paucity of evidence comparing oncological and voice outcomes between T2a and T2b glottic squamous cell carcinoma (SCC) patients treated with transoral laser microsurgery (TLM). This study identified functional and oncological outcomes in this cohort.

Methods

Retrospective review of prospectively collected data of patients treated with TLM for T2 glottic SCC from 2003 to 2017.

Results

In total, 75 patients were included. Five-year local control rates were significantly different between T2a and T2b patients (75.2% vs 57.0%, p = 0.022). There was no difference in five-year survival between patients with T2a disease and T2b disease (69.5% vs 73.4%, p = 0.627). There was no significant difference in mean VHI-10 scores in the pre-operative period (18.3 vs 21.4, p = 0.409). However, patients with T2b disease had significantly worse perceived voice outcomes post-operatively (6.6 vs 21.3 p = 0.001). Patients with T2a disease saw significant improvements in mean VHI-10 scores following surgery (18.3 vs 6.6, p = 0.000), while T2b patients did not (21.4 vs 21.3, p = 0.979). The overall laryngeal preservation rate was 94.7%, with 11.5% of T2b patients requiring salvage organ sacrifice.

Conclusions

This study highlights positive functional outcomes for T2a glottic SCC. Patients with T2b disease appear to have significantly worse oncological and functional outcomes, including worse voice quality following surgery and higher rates of salvage laryngectomy.

Risk stratification models in human papillomavirus-associated oropharyngeal squamous cell carcinoma: the Nova Scotia distribution

OBJECTIVE

The incidence of oropharyngeal squamous cell carcinoma is increasing with a growing proportion of diagnoses associated with human papillomavirus (p16 + OSCC), which generally confers a favorable prognosis. For these reasons, novel risk stratification models specific to the p16 + OSCC population have recently been proposed to guide future research on treatment de-intensification for appropriate patients. This study aimed to quantify patient risk distribution using multiple published risk models and investigate the hypothesis that the local p16 + OSCC population includes a smaller proportion of low-risk patients due to a high prevalence of concurrent tobacco exposure.

METHODS

A retrospective cohort study was performed including patients diagnosed with p16 + OSCC in Nova Scotia between 2011 and 2015. Patient identification was obtained through the CCNS registry and an institutional database. Exclusion criteria included HPV negative status, second primary cases, incomplete data availability, and local recurrence cases.

RESULTS

Following exclusion, 117 patients met study criteria. The majority had small primary tumors (70.9% ≤ T2) and advanced nodal status on presentation (60.7% ≥ N2b). Most patients had a positive smoking history (62.4%), with 53.0% of patients having a pack-year history greater than 10 pack-years. In four of the five risk stratification models, the majority of the study population fell into the lowest risk category. The risk stratification distribution of our local population was similar to the populations used to validate the published models, with the largest single category difference being 13.3% (range - 12.3 to + 13.3%).

CONCLUSIONS

This is the first study to compare multiple currently published risk stratification models to a local population and address the uncertainty of risk stratification in the Nova Scotian p16 + OSCC population. Despite a high prevalence of concurrent tobacco exposure, the study population was found to be overall low risk, with similar risk compared to model validation populations.

Late free flap failure in head and neck reconstruction: A systematic review

Our objectives were to review all reported cases of late flap failure in head and neck surgery and describe any relevant patterns. We conducted a systematic review of all published cases of free flap failure after postoperative day 7 in head and neck surgery from January 1990 to January 2018. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. A total of 45 cases of late free flap failure in the head and neck were identified. Among the 34 cases in which the necessary data were available for analysis, 50% of late failures occurred between postoperative day 7 and 14. Common reasons for failure were abscess and vascular compromise. We conclude that most late flap failures occur in the second postoperative week. In patients with risk factors for flap failure, close monitoring for up to 14 days after surgery could detect flap compromise before the flap is lost.

Secretory carcinoma: the eastern Canadian experience and literature review

Background

Secretory Carcinoma (SC) is a recently described malignancy affecting salivary glands of the head and neck, with a paucity of evidence regarding the natural history, morbidity, and mortality. This study aimed to investigate the current treatment options utilized for SC, as well as its presentation and outcomes.

Methods

This study is a retrospective case series and includes patients diagnosed with SC at four Maritime Canadian institutions. Literature review of patient outcomes following treatment of SC is also included.

Results

Thirteen patients were identified. Parotid was the most common subsite (69%), followed by minor salivary gland (23%) and submandibular gland (8%). All patients were S100 positive and had at least one additional positive confirmatory stain, including mammaglobin, CK7, or vimentin. Two patients had N2b disease. All patients were treated with primary surgery, and four were offered adjuvant radiotherapy. There was one instance of locoregional recurrence, and one of metastasis. Three patients displayed perineural invasion on pathology, and one patient displayed lymphovascular invasion.

Conclusion

Secretory Carcinoma remains understudied regarding its natural history, presentation, and treatment options. This study is the largest single case series in Canada, and highlights the young age and possible aggressiveness of SC. As well, we provide the most comprehensive literature review to date, with a focus on treatment and outcomes for this disease entity.

Electronic supplementary material

The online version of this article (10.1186/s40463-018-0315-6) contains supplementary material, which is available to authorized users.