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Stevens MN, Freeman MH, Shinn JR, Kloosterman N, Carr S, Mannion K, Rohde SL. Preoperative Predictors of Free Flap Failure. Otolaryngol Head Neck Surg 2023; 168:180-187. [PMID: 35412879 DOI: 10.1177/01945998221091908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure. STUDY DESIGN Retrospective cohort study of 1070 patients. SETTING Head and neck surgical oncology service at a tertiary care center from 2005 to 2019. METHODS Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery). RESULTS In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure. CONCLUSION Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.
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Affiliation(s)
- Madelyn N Stevens
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael H Freeman
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Austin, Texas, USA
| | | | - Shane Carr
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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2
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Shinn JR, Carey RM, Mady LJ, Shimunov D, Parhar HS, Cannady SB, Rajasekaran K, Lukens JN, Lin A, Swisher-McClure S, Cohen RB, Bauml JM, Rassekh CH, Newman JG, Chalian AA, Basu D, Weinstein GS, Brody RM. Sex-based differences in outcomes among surgically treated patients with HPV-related oropharyngeal squamous cell carcinoma. Oral Oncol 2021; 123:105570. [PMID: 34742005 DOI: 10.1016/j.oraloncology.2021.105570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Sex differences in surgically treated HPV-associated oropharyngeal squamous cell carcinoma are not defined due to the low number of affected women. We explored the oncologic outcomes of men and women with p16-positive oropharyngeal squamous cell carinoma treated with primary surgery. MATERIALS AND METHODS Retrospective analysis of patients with HPV-related oropharyngeal cancer treated with surgery and pathology guided adjuvant therapy from 2007 to 2017. Primary end point was recurrence-free and overall survival. RESULTS Of 468 men (86.7%) and 72 women (13.3%), women presented more often with clinical N0 nodal disease (25% vs 12.2%). There were no differences in adverse pathologic features or T stage, although women were more likely to present with N0 disease (16.7% vs 10%), less N2 disease (6.9% vs 17.7%, p = 0.03), and more stage I disease (88.9% vs 75%). As a result, women were more likely to undergo surgery alone (30.6% vs 14.1%) while men were more likely to require adjuvant radiation therapy (47.2% vs 36.1%). Four women (5.6%) and 30 men (6.4%, p = 0.8) died during follow-up. Multivariate analysis controlling for age, sex, treatment, and pathologic stage demonstrated no differences in overall survival between men and women. There were no differences in recurrence-free or overall survival between men and women at two and five years. CONCLUSIONS Although women undergoing transoral robotic surgery for HPV+ oropharyngeal squamous cell carcinoma may have less advanced disease, upfront surgery with pathology-guided adjuvant therapy produces similar oncologic results in men and women while accounting for disease burden.
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Affiliation(s)
- Justin R Shinn
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Ryan M Carey
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Leila J Mady
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - David Shimunov
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Harman S Parhar
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Samuel Swisher-McClure
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Roger B Cohen
- Division of Hematology and Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Joshua M Bauml
- Division of Hematology and Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Jason G Newman
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Devraj Basu
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Robert M Brody
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
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3
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Freeman MH, Shinn JR, Fernando SJ, Totten D, Lee J, Malenke JA, Wood CB, Langerman AJ, Mannion K, Sinard RJ, Rohde SL. Impact of Preoperative Risk Factors on Inpatient Stay and Facility Discharge After Free Flap Reconstruction. Otolaryngol Head Neck Surg 2021; 166:454-460. [PMID: 34399644 DOI: 10.1177/01945998211037541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the preoperative risk factors most predictive of prolonged length of stay (LOS) or admission to a skilled nursing facility (SNF) or inpatient rehabilitation center (IPR) after free flap reconstruction of the head and neck. STUDY DESIGN Retrospective cohort study. SETTING Tertiary academic medical center. METHODS Retrospective review of 1008 patients who underwent tumor resection and free flap reconstruction of the head and neck at a tertiary referral center from 2002 to 2019. RESULTS Of 1008 patients (65.7% male; mean age of 61.4 years, SD 14.0 years), 161 (15.6%) were discharged to SNF/IPR, and the median LOS was 7 days. In multiple linear regression analysis, Charlson Comorbidity Index (CCI; P < .001), American Society of Anesthesiologists (ASA) classification (P = .021), female gender (P = .023), and inability to tolerate oral diet preoperatively (P = .006) were statistically significantly related to increased LOS, whereas age, body mass index (BMI), modified frailty index (MFI), a history of prior radiation or chemotherapy, and home oxygen use were not. Multiple logistic regression analysis demonstrated that CCI (odds ratio [OR] = 1.119, confidence interval [CI] 1.023-1.223), age (OR = 1.082, CI 1.056-1.108), and BMI <19.0 (OR = 2.141, CI 1.159-3.807) were the only variables statistically significantly related to posthospital placement in an SNF or IPR. CONCLUSION Common tools for assessing frailty and need for additional care may be inadequate in a head and neck reconstructive population. CCI appears to be the best of the aggregate metrics assessed, with significant relationships to both LOS and placement in SNF/IPR.
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Affiliation(s)
- Michael Hartley Freeman
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Otolaryngology, Head and Neck Surgery, University of Texas Southwestern, Dallas, TX
| | - Shanik J Fernando
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglas Totten
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jaclyn Lee
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jordan A Malenke
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Burton Wood
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Otolaryngology, Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Alexander J Langerman
- Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kyle Mannion
- Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert J Sinard
- Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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4
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Habib AM, Carey RM, Prasad A, Mady LJ, Shinn JR, Bur AM, Brody RM, Cannady SB, Rajasekaran K, Ibrahim SA, Newman JG, Brant JA. Impact of Race and Insurance Status on Primary Treatment for HPV-Associated Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2021; 166:1062-1069. [PMID: 34253112 DOI: 10.1177/01945998211029839] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the impact of sociodemographic factors on primary treatment choice (surgery vs radiotherapy) in patients with human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN Retrospective analysis of the National Cancer Database. SETTING Data from >1500 Commission on Cancer institutions (academic and community) via the National Cancer Database. METHODS Our sample consists of patients diagnosed with HPV+ OPSCC from 2010 to 2015. The primary outcome of interest was initial treatment modality: surgery vs radiation. We performed multivariable logistic models to assess the relationship between treatment choice and sociodemographic factors, including sex, race, treatment facility, and insurance status. RESULTS Of the 16,043 patients identified, 5894 (36.7%) underwent primary surgery while 10,149 (63.3%) received primary radiotherapy. Black patients were less likely than White patients to receive primary surgery (odds ratio [OR], 0.80; 95% CI, 0.66-0.96). When compared with privately insured patients, those who were uninsured or on Medicaid or Medicare were also less likely to receive primary surgery (OR, 0.70 [95% CI, 0.56-0.86]; OR, 0.77 [95% CI, 0.65-0.91]; OR, 0.85 [95% CI, 0.75-0.96], respectively). Patients receiving treatment at an academic/research cancer program were more likely to undergo primary surgery than those treated at comprehensive community cancer programs (OR, 1.33; 95% CI, 1.14-1.56). CONCLUSION In this large sample of patients with HPV+ OPSCC, race and insurance status affect primary treatment choice. Specifically, Black and nonprivately insured patients are less likely to receive primary surgery as compared with White or privately insured patients. Our findings illuminate potential disparities in HPV+ OPSCC treatment.
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Affiliation(s)
- Andy M Habib
- School of Medicine, Georgetown University, Washington, DC, USA
| | - Ryan M Carey
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aman Prasad
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leila J Mady
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrés M Bur
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas, Kansas City, Kansas, USA
| | - Robert M Brody
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Said A Ibrahim
- Department of Population Health Sciences, Weill Cornell, New York, New York, USA
| | - Jason G Newman
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason A Brant
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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5
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Shinn JR, Davis SJ, Lang-Kuhs KA, Rohde S, Wang X, Liu P, Dupont WD, Plummer WD, Thorstad WL, Chernock RD, Mehrad M, Lewis JS. Oropharyngeal Squamous Cell Carcinoma With Discordant p16 and HPV mRNA Results: Incidence and Characterization in a Large, Contemporary United States Cohort. Am J Surg Pathol 2021; 45:951-961. [PMID: 33739785 PMCID: PMC8192336 DOI: 10.1097/pas.0000000000001685] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early studies estimate that 5% to 10% of oropharyngeal squamous cell carcinomas overexpress p16 but are unassociated with transcriptionally-active high-risk human papillomavirus (HPV). Patients with discordant HPV testing may experience clinical outcomes that differ from traditional expectations. To document the rate of p16 and HPV mRNA positivity, characterize patients with discordant testing, and identify features that may warrant selective use of HPV-specific testing after p16 IHC, a multi-institutional, retrospective review of oropharyngeal squamous cell carcinoma patients with p16 IHC and HPV mRNA testing by reverse transcriptase polymerase chain reaction was performed. Of the 467 patients, most had T1 or T2 tumors (71%), 82% were p16 positive, and 84% were HPV mRNA positive. Overall, most tumors were nonkeratinizing (378, 81%), which was strongly associated with p16 and HPV positivity (93% and 95%, respectively). Overall, 81% of patients were double positive, 14% double negative, and 4.9% discordant (3.4% p16 negative/HPV mRNA positive and 1.5% p16 positive/HPV mRNA negative). The survival rates of these discordant patient groups fell squarely between the 2 concordant groups, although in multivariate analysis for both disease-free survival and overall survival, discordant patients were not found to have statistically significantly different outcomes. Reclassifying patients by applying HPV mRNA testing when p16 results and morphology do not match, or when p16 results are equivocal, improved prognostication slightly over p16 or HPV mRNA testing alone. Patients with discordant testing demonstrate a borderline significant trend toward survival differences from those with concordant tests. When evaluated independently, patients who were p16 negative but HPV mRNA positive had a prognosis somewhat closer to double-positive patients, while those who were p16 positive, but HPV mRNA negative had a prognosis closer to that of double-negative patients. We suggest an algorithm whereby confirmatory HPV mRNA testing is performed in patients where p16 status is not consistent with tumor morphology. This captures a majority of discordant patients and improves, albeit modestly, the prognostication.
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Affiliation(s)
- Justin R. Shinn
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Seth J. Davis
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Krystle A. Lang-Kuhs
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - Sarah Rohde
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Xiaowei Wang
- Department of Pharmacology and Regenerative Medicine, The University of Illinois at Chicago, IL
| | - Ping Liu
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - W. Dale Plummer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Wade L. Thorstad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Rebecca D. Chernock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Mitra Mehrad
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - James S. Lewis
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
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6
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Carey RM, Brody RM, Shimunov D, Shinn JR, Mady LJ, Rajasekaran K, Cannady SB, Lin A, Lukens JN, Bauml JM, Cohen RB, Basu D, O'Malley BW, Weinstein GS, Newman JG. Locoregional Recurrence in p16-Positive Oropharyngeal Squamous Cell Carcinoma After TORS. Laryngoscope 2021; 131:E2865-E2873. [PMID: 34076275 DOI: 10.1002/lary.29659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/07/2021] [Accepted: 05/12/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To analyze the patterns, risk factors, and salvage outcomes for locoregional recurrences (LRR) after treatment with transoral robotic surgery (TORS) for HPV-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC). STUDY DESIGN Retrospective analysis of HPV+ OPSCC patients completing primary TORS, neck dissection, and NCCN-guideline-compliant adjuvant therapy at a single institution from 2007 to 2017. METHODS Features associated with LRR, detailed patterns of LRR, and outcomes of salvage therapy were analyzed. Disease-free survival (DFS) and overall survival (OS) were calculated for subgroups of patients receiving distinct adjuvant treatments. RESULTS Of 541 patients who completed guideline-indicated therapy, the estimated 5-year LRR rate was 4.5%. There were no identifiable clinical or pathologic features associated with LRR. Compared to patients not receiving adjuvant therapy, those who received indicated adjuvant radiation alone had a lower risk of LRR (HR 0.28, 95% CI [0.09-0.83], P = .023), but there was no difference in DFS (P = .21) and OS (P = .86) between adjuvant therapy groups. The 5-year OS for patients who developed LRR was 67.1% vs. 93.9% for those without LRR (P < .001). Patients who initially received adjuvant chemoradiation and those suffering local, in-field, and/or retropharyngeal node recurrences had decreased disease control after salvage therapy. CONCLUSION LRR rates are low for HPV+ OPSCCs completing TORS and guideline-compliant adjuvant therapy. Patients without indication for adjuvant therapy more often suffer LRR, but these recurrences are generally controllable by salvage therapy. Improved understanding of the patterns of recurrence most amenable to salvage therapy may guide treatment decisions, counseling, and adjuvant therapy de-escalation trials. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Ryan M Carey
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Robert M Brody
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - David Shimunov
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Justin R Shinn
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Leila J Mady
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - John N Lukens
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Joshua M Bauml
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Roger B Cohen
- Department of Internal Medicine, Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Devraj Basu
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- University of Maryland Medical Center, Baltimore, Maryland, U.S.A
| | - Gregory S Weinstein
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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7
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Smith DK, Freundlich RE, Shinn JR, Wood CB, Rohde SL, McEvoy MD. An improved predictive model for postoperative pulmonary complications after free flap reconstructions in the head and neck. Head Neck 2021; 43:2178-2184. [PMID: 33783905 DOI: 10.1002/hed.26689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Commonly used predictive models for postoperative pulmonary complications (PPCs) do not perform when applied to head and neck cases. A head and neck-specific risk prediction tool is needed. METHODS Data on 794 free flap head and neck surgery cases at a single center were abstracted from the electronic medical record. Each case was reviewed for the development of PPCs. A predictive model was developed and was then compared to existing predictive models for PPCs. RESULTS The least absolute shrinkage and selection operator procedure identified age, alcohol use, history of congestive heart failure, preoperative packed cell volume, preoperative oxygen saturation, and preoperative metabolic equivalents as predictors of PPCs in the head and neck population. The model demonstrated an area under the receiving operating characteristic curve of 0.75 (0.69-0.80) with moderately good calibration. Comparisons to the performance of existing models demonstrate superior performance. CONCLUSIONS The model for the development of PPCs developed in this article displays superior performance to existing models.
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Affiliation(s)
- Derek K Smith
- Department of Oral and Maxillofacial Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Burton Wood
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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8
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Rodney JP, Shinn JR, Amin SN, Portney DS, Mitchell MB, Chopra Z, Rees AB, Kupfer RA, Hogikyan ND, Casper KA, Tate A, Vinson KN, Fletcher KC, Gelbard A, St Jacques PJ, Higgins MS, Morrison RJ, Garrett CG. Multi-Institutional Analysis of Outcomes in Supraglottic Jet Ventilation with a Team-Based Approach. Laryngoscope 2021; 131:2292-2297. [PMID: 33609043 DOI: 10.1002/lary.29431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/11/2020] [Accepted: 01/10/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the safety and complications of endoscopic airway surgery using supraglottic jet ventilation with a team-based approach. STUDY DESIGN Retrospective cohort study. METHODS Subjects at two academic institutions diagnosed with laryngotracheal stenosis who underwent endoscopic airway surgery with jet ventilation between January 2008 and December 2018 were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted from the electronic health record. Records were reviewed for treatment approach, intraoperative data, and complications (intraoperative, acute postoperative, and delayed postoperative). RESULTS Eight hundred and ninety-four patient encounters from 371 patients were identified. Intraoperative complications (unplanned tracheotomy, profound or severe hypoxic events, barotrauma, laryngospasm) occurred in fewer than 1% of patient encounters. Acute postoperative complications (postoperative recovery unit [PACU] rapid response, PACU intubation, return to the emergency department [ED] within 24 hours of surgery) were rare, occurring in fewer than 3% of patient encounters. Delayed postoperative complications (return to the ED or admission for respiratory complaints within 30 days of surgery) occurred in fewer than 1% of patient encounters. Diabetes mellitus, active smoking, and history of previous tracheotomy were independently associated with intraoperative, acute, and delayed complications. CONCLUSIONS Employing a team-based approach, jet ventilation during endoscopic airway surgery demonstrates a low rate of complications and provides for safe and successful surgery. LEVEL OF EVIDENCE Level 4 Laryngoscope, 2021.
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Affiliation(s)
- Jennifer P Rodney
- Department of Otolaryngology-Head and Neck Surgery, The Ear, Nose, Throat and Plastic Surgery Associates, Orlando, Florida, U.S.A
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Shaunak N Amin
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - David S Portney
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Margaret B Mitchell
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Zoey Chopra
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Andrew B Rees
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Robbi A Kupfer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Norman D Hogikyan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Alan Tate
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Military Medical Center, San Antonio, Texas, U.S.A
| | - Kimberly N Vinson
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Kenneth C Fletcher
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Alexander Gelbard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Paul J St Jacques
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Michael S Higgins
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Robert J Morrison
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - C Gaelyn Garrett
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
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9
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Campbell BR, Shinn JR, Kimura KS, Lowery AS, Casey JD, Ely EW, Gelbard A. Unilateral Vocal Fold Immobility After Prolonged Endotracheal Intubation. JAMA Otolaryngol Head Neck Surg 2021; 146:160-167. [PMID: 31855261 DOI: 10.1001/jamaoto.2019.3969] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Endotracheal intubation and mechanical ventilation are life-saving treatments for acute respiratory failure but are complicated by significant rates of dyspnea and dysphonia after extubation. Unilateral vocal fold immobility (UVFI) after extubation can alter respiration and phonation, but its incidence, risk factors, and pathophysiology remain unclear. Objectives To determine the incidence of UVFI after prolonged (>12 hours) mechanical ventilation in a medical intensive care unit and investigate associated clinical risk factors for UVFI after prolonged mechanical ventilation. Design, Setting, and Participants This subgroup analysis of a prospective cohort study was conducted in a single-center medical intensive care unit from August 17, 2017, through May 31, 2018, among 100 consecutive adult patients who were intubated for more than 12 hours. Patients were identified within 36 hours of extubation and recruited for study enrollment. Those with an established tracheostomy prior to mechanical ventilation, known laryngeal or tracheal pathologic characteristics, or a history of head and neck radiotherapy were excluded. Exposure Invasive mechanical ventilation via an endotracheal tube. Main Outcomes and Measures The incidence of UVFI as determined by flexible nasolaryngoscopy. Results One hundred patients (62 men [62%]; median age, 58.5 years [range, 19.0-87.0 years]) underwent endoscopic evaluation after extubation. Seven patients had UVFI, of which 6 cases (86%) were left sided. Patients with hypotension while intubated (odds ratio [OR], 10.8; 95% CI, 1.6 to ∞), patients requiring vasopressors while intubated (OR, 16.7; 95% CI, 2.4 to ∞), and patients with a preadmission diagnosis of peripheral vascular disease (OR, 6.2; 95% CI, 1.2-31.9) or coronary artery disease (OR, 5.1; 95% CI, 1.0-25.5) were more likely to develop UVFI. Conclusions and Relevance Unilateral vocal fold immobility occurred in 7 of 100 patients in the medical intensive care unit who were intubated for more than 12 hours. Unilateral vocal fold immobility was associated with inpatient hypotension and preadmission vascular disease, suggesting that ischemia of the recurrent laryngeal nerve may play a role in disease pathogenesis.
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Affiliation(s)
- Benjamin R Campbell
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kyle S Kimura
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne S Lowery
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education and Clinical Center, Nashville.,Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University, Nashville, Tennessee
| | - Alexander Gelbard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Laryngology, Vanderbilt University Medical Center, Nashville, Tennessee
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10
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Ferguson DC, Mehrad M, Ely KA, Shinn JR, Lewis JS. Human Papillomavirus Testing in Head and Neck Squamous Cell Carcinoma: Impact of the 2018 College of American Pathologists Guideline Among Referral Cases at a Large Academic Institution. Arch Pathol Lab Med 2020; 145:1123-1131. [PMID: 33373453 DOI: 10.5858/arpa.2020-0220-oa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Given the growing clinical significance of human papillomavirus status in oropharyngeal squamous cell carcinoma, the College of American Pathologists established a set of evidence-based recommendations for high-risk human papillomavirus testing. OBJECTIVE.— To evaluate the impact of the recommendations on human papillomavirus ancillary test ordering habits by comparing compliance before and after the guideline was published. DESIGN.— We retrospectively reviewed head and neck squamous cell carcinoma biopsy or resection specimens from outside institutions during a 2.5-year period around guideline publication for whether or not human papillomavirus testing was performed in accordance with the guideline. RESULTS.— Human papillomavirus testing deviated from the guideline in 45 of 107 cases (42.1%) before and 93 of 258 cases (36.0%) after their publication (P = .29). This included 6 of 26 cases of oropharyngeal squamous cell carcinoma (23.1%) before and 5 of 55 cases (9.1%) after (P = .16), with 5 of 5 (100.0%) after due to not performing p16 immunohistochemistry. This also included 30 of 68 cases of nonoropharyngeal carcinoma (44.1%) before and 69 of 163 (42.3%) after the guideline was published (P = .88), with 29 of 30 (96.7%) before and 67 of 69 (97.1%) after due to unnecessary use of p16 immunohistochemistry. Nodal metastasis testing deviated in 9 of 13 cases (69.2%) before and 19 of 40 cases (47.5%) after (P = .21) with marked variability in testing, including 3 of 9 (33.3%) before and 8 of 19 (42.1%) after, for not confirming certain p16 immunohistochemistry-positive tumors with human papillomavirus-specific testing. CONCLUSIONS.— Pathologists continue to deviate from the testing guideline significantly in everyday practice. Further education and discussion about the appropriate handling of head and neck cancer specimens may be needed.
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Affiliation(s)
- Donna C Ferguson
- From the Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York (Ferguson)
| | - Mitra Mehrad
- and the Departments of Pathology, Microbiology, and Immunology (Ferguson, Mehrad, Ely, Lewis Jr)
| | - Kim A Ely
- and the Departments of Pathology, Microbiology, and Immunology (Ferguson, Mehrad, Ely, Lewis Jr)
| | - Justin R Shinn
- and Otolaryngology - Head and Neck Surgery (Shinn, Lewis Jr), Vanderbilt University Medical Center, Nashville, Tennessee
| | - James S Lewis
- and the Departments of Pathology, Microbiology, and Immunology (Ferguson, Mehrad, Ely, Lewis Jr)
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11
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Chorath K, Go B, Shinn JR, Mady LJ, Poonia S, Newman J, Cannady S, Revenaugh PC, Moreira A, Rajasekaran K. Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis. Oral Oncol 2020; 113:105117. [PMID: 33360446 DOI: 10.1016/j.oraloncology.2020.105117] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined. OBJECTIVE To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction. METHODS We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes. RESULTS 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]). CONCLUSION There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.
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Affiliation(s)
- Kevin Chorath
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Beatrice Go
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Justin R Shinn
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Seerat Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Jason Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter C Revenaugh
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, TX, United States
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
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12
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Abstract
Background: This work seeks to better understand the triage strategies employed by head and neck oncologic surgical divisions during the initial phases of the coronavirus 2019 (COVID-19) outbreak. Methods: Thirty-six American head and neck surgical oncology practices responded to questions regarding the triage strategies employed from March to May 2020. Results: Of the programs surveyed, 11 (31%) had official department or hospital-specific guidelines for mitigating care delays and determining which surgical cases could proceed. Seventeen (47%) programs left the decision to proceed with surgery to individual surgeon discretion. Five (14%) programs employed committee review, and 7 (19%) used chairman review systems to grant permission for surgery. Every program surveyed, including multiple in COVID-19 outbreak epicenters, continued to perform complex head and neck cancer resections with free flap reconstruction. Conclusions: During the initial phases of the COVID-19 pandemic experience in the United States, head and neck surgical oncology divisions largely eschewed formal triage policies and favored practices that allowed individual surgeons discretion in the decision whether or not to operate. Better understanding the shortcomings of such an approach could help mitigate care delays and improve oncologic outcomes during future outbreaks of COVID-19 and other resource-limiting events. Level of Evidence: 4.
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Affiliation(s)
- Michael H Freeman
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Justin R Shinn
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander Langerman
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,International Center for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, USA
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13
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Campbell BR, Shinn JR, Gelbard A. Unilateral Vocal Fold Immobility-More Common Than We Think?-Reply. JAMA Otolaryngol Head Neck Surg 2020; 146:588. [PMID: 32215606 DOI: 10.1001/jamaoto.2020.0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benjamin R Campbell
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander Gelbard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Laryngology, Vanderbilt University Medical Center, Nashville, Tennessee
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14
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Amin SN, Shinn JR, Naguib MM, Netterville JL, Rohde SL. Risk Factors and Outcomes of Postoperative Recurrent Well-Differentiated Thyroid Cancer: A Single Institution's 15-Year Experience. Otolaryngol Head Neck Surg 2020; 162:469-475. [PMID: 32069184 DOI: 10.1177/0194599820904923] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Identify risk factors and outcomes of recurrent well-differentiated thyroid cancer. STUDY DESIGN Retrospective case-control analysis. SETTING Tertiary care academic center in Nashville, Tennessee. SUBJECTS AND METHODS This single-center analysis reviews 478 patients who underwent initial surgical management of well-differentiated thyroid carcinoma between 2002 and 2017. Patients were dichotomized with or without recurrent well-differentiated thyroid cancer. Demographic and clinicopathologic risk factors were carefully reviewed. Univariate, multiple regression, and survival analyses were used to evaluate predictors of recurrence. RESULTS Thirty-eight patients (7.9%) who received initial surgical intervention for well-differentiated thyroid carcinoma at our institution recurred, with an average time to recurrence of 24 months. Male sex, tumor size, multifocality, extrathyroidal extension, lymphovascular invasion, number of positive lymph nodes, and low lymph node yield were all significantly associated with locoregional recurrence (P < .05). Multiple regression analysis showed that extrathyroidal extension, number of positive lymph nodes, and low lymph node yield were independent factors predictive of posttreatment recurrence (P < .05). Metastatic lymph node ratio, the ratio of positive lymph nodes extracted to lymph node yield, of ≥0.3 is associated with increased risk of recurrence (P < .001) and decreased 5-year recurrence free survival (P < .001). CONCLUSION Extrathyroidal extension, number of positive lymph nodes, and low lymph node yield are independent clinicopathologic risk factors for postoperative recurrence of well-differentiated thyroid cancer. Metastatic lymph node ratio is uncommonly used but can be an important prognosticator of recurrence. Patients with metastatic lymph node ratio ≥0.3 should be counseled on their increased risk of recurrence and should undergo close surveillance following surgery.
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Affiliation(s)
- Shaunak N Amin
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark M Naguib
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - James L Netterville
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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15
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Shinn JR, Nwabueze NN, Du L, Patel PN, Motamedi KK, Norton C, Ries WR, Stephan SJ. Treatment Patterns and Outcomes in Botulinum Therapy for Patients With Facial Synkinesis. JAMA FACIAL PLAST SU 2020; 21:244-251. [PMID: 30703206 DOI: 10.1001/jamafacial.2018.1962] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In the last decade, there has been a significant increase in the number of practitioners administering botulinum toxin for facial synkinesis. However, there are few resources available to guide treatment patterns, and little is known about how these patterns are associated with functional outcomes and quality of life. Objective To evaluate botulinum treatment patterns, including the dosing and frequency of muscle targeting, for treatment of facial synkinesis and to quantify patient outcomes. Design, Setting, and Participants This prospective cohort study of 99 patients treated for facial synkinesis was conducted from January 2016 through December 2018 at the Vanderbilt Bill Wilkerson Center in Nashville, Tennessee, a tertiary referral center. Intervention Onabotulinum toxin A treatment of facial synkinesis. Main Outcomes and Measures Patient-reported outcomes on the Synkinesis Assessment Questionnaire and botulinum treatment patterns, including the dosages and frequency of injection for each facial muscle, were compared at the initiation of treatment and at the end of recorded treatment. Results In total, 99 patients (80 female patients [81%]) underwent botulinum injections for treatment of facial synkinesis. The median (interquartile range) age was 54.0 (43.5-61.5) years, and the median (interquartile range) follow-up was 27.1 (8.9-59.7) months. Most patients underwent injections after receiving a diagnosis of Bell palsy (41 patients, 41%) or after resection of vestibular schwannoma (36 patients [36%]). The patients received a total of 441 treatment injections, and 369 pretreatment and posttreatment Synkinesis Assessment Questionnaire scores were analyzed. The mean botulinum dose was 2 to 3 U for each facial muscle and 9 to 10 U for the platysma muscle. The dose increased over time for the majority of all muscles, with steady state achieved after a median of 3 treatments (interquartile range, 2-3). Linear regression analysis for cluster data of the mean total questionnaire score difference was -14.2 (95% CI, -17.0 to -11.5; P < .001). There was a significant association of postinjection questionnaire score with younger patients, female sex, total dose, and synkinesis severity. Oculo-oral synkinesis may respond more to treatment compared with oro-ocular synkinesis. Conclusion and Relevance Patients with facial synkinesis responded significantly to botulinum treatment. Treatment began with 6 core facial muscles that were injected during most treatment sessions, and dosages increased after the first injection until steady state was achieved. Those with a greater degree of morbidity, younger patients, and females showed significant improvement, and the larger the dose administered, the greater the response. Oculo-oral synkinesis may be more responsive than oro-ocular synkinesis. Level of Evidence 3.
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Affiliation(s)
- Justin R Shinn
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Liping Du
- Department of Biostatistics, Center for Quantitative Sciences, Vanderbilt University, Nashville, Tennessee
| | - Priyesh N Patel
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin K Motamedi
- Department of Head and Neck Surgery, Kaiser Permanente, Lafayette, Colorado
| | - Cathey Norton
- Pi Beta Phi Institute, Bill Wilkerson Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William R Ries
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Facial Plastics and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott J Stephan
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Facial Plastics and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Shinn JR, Zuniga MG, Macharia I, Reppart J, Netterville JL, Jayawardena ADL. Community health workers obtain similar results using cell-phone based hearing screening tools compared to otolaryngologists in low resourced settings. Int J Pediatr Otorhinolaryngol 2019; 127:109670. [PMID: 31518844 DOI: 10.1016/j.ijporl.2019.109670] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 09/01/2019] [Accepted: 09/03/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To establish community health workers as reliable hearing screening operators in a technology-based pre-surgical hearing screening program in a low and middle-income country (LMIC). METHODS This is a cross sectional study that evaluated community health worker driven hearing screening that took place in semi-rural Malindi, Kenya during an annual two-week otolaryngology surgical training mission in October 2017. At five separate locations (four schools) near Malindi, Kenya, children between the ages of 2-16 underwent hearing screening using screening audiometry (Android-based HearX Group). Children were screened by a community health worker who underwent a short training course, a senior otolaryngology resident, or both. Hearing screening results were compared to determine the reliability and concordance between independent, blinded community health worker and otolaryngology resident testing. RESULTS One hundred and four participants (53% males) underwent hearing screening. Hearing screening pass rate was 93%. Community health workers obtained a similar result to otolaryngology residents 96% of the time (McNemar test: p = 0.16, OR 0.96, 95% CI 0.9-1.0). CONCLUSION Community health workers can obtain reliable results using a technology-based, pre-surgical hearing screening platform when compared to otolaryngology residents. This finding has profound implications in low-resourced settings where hearing healthcare specialists (audiologists and otolaryngologists) are limited and can ultimately improve the surgical yield of patients presenting to local otolaryngologists in these settings.
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Affiliation(s)
- Justin R Shinn
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - M Geraldine Zuniga
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ian Macharia
- Department of Otolaryngology, University of Nairobi, Nairobi, Kenya
| | | | - James L Netterville
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA; Caris Foundation, Malindi, Kenya
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17
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Nwabueze NN, Shinn JR, Owen S, Ries WR, Stephan SJ. Reconstructive septorhinoplasty in radiation-induced reactive bone dysplasia. Otolaryngology Case Reports 2019. [DOI: 10.1016/j.xocr.2019.100131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Abstract
The goal of this prospective cohort study was to characterize the ability of teachers to identify schoolchildren at risk of hearing loss in order to maximize hearing screening efficiency in low-resource settings. At 4 semirural schools in Malindi, Kenya, preselected schoolchildren perceived as hearing impaired were compared to children thought to have normal hearing using portable audiometry. Eight of 127 children (54% male) failed hearing screening, all of who were identified by schoolteachers as having a high risk of hearing loss. Thus, for every 5 children prescreened by schoolteachers, an average of 1 child would be identified as having hearing loss. Overall, teacher prescreening had a 100% hearing loss identification rate and a 20% referral rate. In conclusion, in resource-limited settings, where universal hearing screening is challenging, teachers can effectively identify children with hearing loss for early intervention.
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Affiliation(s)
- Justin R Shinn
- Department of Otolaryngology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Asitha D L Jayawardena
- Department of Otolaryngology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ankita Patro
- Department of Otolaryngology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Geraldine Zuniga
- Department of Otolaryngology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - James L Netterville
- Department of Otolaryngology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Head and Neck Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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19
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Dang S, Shinn JR, Sowder J, Ries WR, Stephan SJ. Peri-Incisional Botulinum Toxin Therapy for Treatment of Intractable Head Pain After Lateral Skull Base Surgery: A Case Series. Headache 2019; 59:1624-1630. [PMID: 31471906 DOI: 10.1111/head.13616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery. BACKGROUND Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes. METHODS In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months. RESULTS All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value. CONCLUSIONS Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings.
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Affiliation(s)
- Sabina Dang
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Justin R Shinn
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Justin Sowder
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Facial Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William Russell Ries
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Facial Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott J Stephan
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Facial Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Shinn JR, Amin SN, Cervenka B, Wootten C, Mannion K, Cobb RT, Netterville J. Subtropical infection leading to invasive noncutaneous squamous cell carcinoma in a 13-year-Old child. Otolaryngology Case Reports 2019. [DOI: 10.1016/j.xocr.2019.100111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Dang S, Shinn JR, Seim N, Netterville JL, Mannion K. Diagnosis and treatment considerations of parapharyngeal space masses – A review with case report. Otolaryngology Case Reports 2019. [DOI: 10.1016/j.xocr.2019.100120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Shinn JR, Gelbard A. Airway obstruction in Rosai-Dorfman disease. Assoc Med J 2019. [DOI: 10.1136/bmj.l1122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Shinn JR, Nwabueze NN, Patel P, Norton C, Ries WR, Stephan SJ. Contemporary Review and Case Report of Botulinum Resistance in Facial Synkinesis. Laryngoscope 2018; 129:2269-2273. [PMID: 30592301 DOI: 10.1002/lary.27709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Botulinum resistance poses significant treatment challenges for both patients and healthcare practitioners. We first present a case highlighting botulinum resistance in a patient who failed to respond to alternative formulations but who responded remarkably to incobotulinum toxinA, an identical toxin free of complexing proteins. Secondly, we provide a treatment algorithm and a review of the literature detailing clinical and immunochemical botulinum resistance. RESULTS Patients with botulinum resistance show a predisposition to failure on subsequent injections and possess a propensity toward neutralizing and nonneutralizing antibody development. The mechanisms of resistance are not entirely understood but thought to be secondary to an immunologic response. Risk factors for resistance include higher botulinum doses, more frequent injections, and high total lifetime dosage. Patients may still respond to other botulinum formulations or subtypes; however, this effect may be temporary. CONCLUSION This case report describes a patient who responded to incobotulinum toxinA after failing treatment with the identical toxin compounded with buffer proteins, ultimately supporting the possibility of immune-mediated resistance to the surrounding proteins and not the toxin itself. Often, impending treatment resistance is preceded by a poor or limited clinical response. Antibody testing is not indicated because it is neither sensitive nor specific and does not change clinical practice. Initially, higher doses of botulinum may overcome resistance without increasing treatment frequency, and side effects are far less common in those with clinical resistance. If higher dosages fail to produce a response, alternative botulinum formulations or subtypes can be considered. Laryngoscope, 129:2269-2273, 2019.
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Affiliation(s)
- Justin R Shinn
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Nkechi N Nwabueze
- Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Priyesh Patel
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Cathey Norton
- Pi Beta Phi Institute, Bill Wilkerson Center, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - W Russell Ries
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.,Division of Facial Plastics and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Scott J Stephan
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.,Division of Facial Plastics and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
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Shinn JR, Wood CB, Colazo JM, Harrell FE, Rohde SL, Mannion K. Cumulative incidence of neck recurrence with increasing depth of invasion. Oral Oncol 2018; 87:36-42. [DOI: 10.1016/j.oraloncology.2018.10.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 08/12/2018] [Accepted: 10/14/2018] [Indexed: 01/04/2023]
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Purcell PL, Shinn JR, Davis GE, Sie KCY. Children with unilateral hearing loss may have lower intelligence quotient scores: A meta-analysis. Laryngoscope 2015; 126:746-54. [PMID: 26452077 DOI: 10.1002/lary.25524] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS In this meta-analysis, we reviewed observational studies investigating differences in intelligence quotient (IQ) scores of children with unilateral hearing loss compared to children with normal hearing. DATA SOURCES PubMed Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO. METHODS A query identified all English-language studies related to pediatric unilateral hearing loss published between January 1980 and December 2014. Titles, abstracts, and articles were reviewed to identify observational studies reporting IQ scores. RESULTS There were 261 unique titles, with 29 articles undergoing full review. Four articles were identified, which included 173 children with unilateral hearing loss and 202 children with normal hearing. Ages ranged from 6 to 18 years. Three studies were conducted in the United States and one in Mexico. All were of high quality. All studies reported full-scale IQ results; three reported verbal IQ results; and two reported performance IQ results. Children with unilateral hearing loss scored 6.3 points lower on full-scale IQ, 95% confidence interval (CI) [-9.1, -3.5], P value < 0.001; and 3.8 points lower on performance IQ, 95% CI [-7.3, -0.2], P value 0.04. When investigating verbal IQ, we detected substantial heterogeneity among studies; exclusion of the outlying study resulted in significant difference in verbal IQ of 4 points, 95% CI [-7.5, -0.4], P value 0.028. CONCLUSIONS This meta-analysis suggests children with unilateral hearing loss have lower full-scale and performance IQ scores than children with normal hearing. There also may be disparity in verbal IQ scores. Laryngoscope, 126:746-754, 2016.
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Affiliation(s)
- Patricia L Purcell
- Department of Otolaryngology, University of Washington, Seattle, Washington, U.S.A
| | - Justin R Shinn
- Department of Otolaryngology, University of Washington, Seattle, Washington, U.S.A
| | - Greg E Davis
- Department of Otolaryngology, University of Washington, Seattle, Washington, U.S.A
| | - Kathleen C Y Sie
- Department of Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
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Purcell PL, Shinn JR, Otto RK, Davis GE, Parikh SR. Nasoseptal flap reconstruction of pediatric sellar defects: a radiographic feasibility study and case series. Otolaryngol Head Neck Surg 2015; 152:746-51. [PMID: 25715351 PMCID: PMC10163894 DOI: 10.1177/0194599815571284] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 01/15/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES In this study, we used computed tomography measurements to investigate the feasibility of nasoseptal flap reconstruction of sellar defects in children, and we reviewed our institutional experience with the procedure. STUDY DESIGN Cross-sectional and case series. SETTING Pediatric tertiary care facility. METHODS We obtained 10 normal maxillofacial scans for each year of age from birth to 18. Computer-assisted nasal and skull-base measurements were performed. Patients with incomplete pneumatization were excluded from analysis. Reconstruction was presumed feasible if the ratio of nasoseptal flap length to associated sellar defect length was greater than 1. Chart review identified surgical patients. RESULTS Of 190 scans, 125 had complete pneumatization. Of these, 120 (96%) displayed a ratio of nasoseptal flap length to sellar defect length greater than 1, suggesting that reconstruction would be feasible. Mean ratio of flap length to defect length for all subjects was 1.47 (SD 0.33; 95% CI, 1.41-1.53). Only 5 of 125 patients (4%) had a ratio less than 1; the median age for these patients was 15 years, which is older than the median age of 12 years for subjects with a ratio greater than 1 (P = .02). An inverse relationship was identified between age and ratio of flap length to defect length (r = -0.49, P < .001). Case series identified 6 children, ages 5 to 17; flap length was never described as a limitation. CONCLUSIONS Nasoseptal flap length is not a limiting factor for reconstruction of pediatric sellar defects. When compared with older patients, younger patients tend to have greater nasoseptal flap length relative to sellar defect length.
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Affiliation(s)
- Patricia L Purcell
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA
| | - Justin R Shinn
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Greg E Davis
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
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Shinn JR, Purcell PL, Horn DL, Sie KCY, Manning SC. First branchial cleft anomalies: otologic manifestations and treatment outcomes. Otolaryngol Head Neck Surg 2014; 152:506-12. [PMID: 25524898 DOI: 10.1177/0194599814562773] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This study describes the presentation of first branchial cleft anomalies and compares outcomes of first branchial cleft with other branchial cleft anomalies with attention to otologic findings. STUDY DESIGN Case series with chart review. SETTING Pediatric tertiary care facility. METHODS Surgical databases were queried to identify children with branchial cleft anomalies. Descriptive analysis defined sample characteristics. Risk estimates were calculated using Fisher's exact test. RESULTS Queries identified 126 subjects: 27 (21.4%) had first branchial cleft anomalies, 80 (63.4%) had second, and 19 (15.1%) had third or fourth. Children with first anomalies often presented with otologic complications, including otorrhea (22.2%), otitis media (25.9%), and cholesteatoma (14.8%). Of 80 children with second branchial cleft anomalies, only 3 (3.8%) had otitis. Compared with children with second anomalies, children with first anomalies had a greater risk of requiring primary incision and drainage: 16 (59.3%) vs 2 (2.5%) (relative risk [RR], 3.5; 95% confidence interval [CI], 2.4-5; P<.0001). They were more likely to have persistent disease after primary excision: 7 (25.9%) vs 2 (2.5%) (RR, 3; 95% CI, 1.9-5; P=.0025). They were more likely to undergo additional surgery: 8 (29.6%) vs 3 (11.1%) (RR, 2.9; 95% CI, 1.8-4.7; P=.0025). Of 7 persistent first anomalies, 6 (85.7%) were medial to the facial nerve, and 4 (57.1%) required ear-specific surgery for management. CONCLUSIONS Children with first branchial cleft anomalies often present with otologic complaints. They are at increased risk of persistent disease, particularly if anomalies lie medial to the facial nerve. They may require ear-specific surgery such as tympanoplasty.
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Affiliation(s)
- Justin R Shinn
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA
| | - Patricia L Purcell
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA
| | - David L Horn
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Y Sie
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Scott C Manning
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
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