Effect of tobacco use on Zenker's diverticulotomy outcomes

OBJECTIVE

To compare clinical outcomes in patients with and without history of tobacco use who underwent Zenker's diverticulotomy (ZD).

STUDY DESIGN

Single institution retrospective review.

SETTING

Tertiary care academic hospital.

METHODS

A retrospective review of patients who underwent ZD via an open stapler, rigid endoscopic CO2 laser, stapler or harmonic scalpel, and flexible endoscopic technique from January 2006 to December 2020 was performed. Data were abstracted for patient demographics, diverticular features, and rates of adverse events and symptomatic recurrence.

RESULTS

Out of 424 patients, 146 (34.4 %) had a history of tobacco use: 126 (29.7 %) were former smokers, and 20 (4.7 %) were active smokers. In univariable cross-sectional analyses, the likelihood of postoperative bleeding, perforation, emergency department visits, unplanned readmission, or recurrence did not demonstrate an association with tobacco use history even after adjustment for age, sex, and surgical approach. Similarly, in Cox Proportional Hazards regression, tobacco use was not associated with an increased risk of recurrence, even after correcting for age, sex, and type of surgery. The median time to recurrence observed in our cohort was 11.5 years amongst non-smokers, 8.7 years amongst former smokers, and 1.2 years amongst active smokers (p = 0.94).

CONCLUSIONS

There were no significant differences in post-operative adverse events or frequency of recurrence of ZD between active, former, and non-smokers. Although underpowered and not statistically significant, median time to recurrence appears to be shorter in smokers when compared with former and non-smokers following surgery.

Association Between Social Determinants of Health, Distance from Treatment Center, and Treatment Type with Outcomes in Human Papillomavirus Associated Oropharyngeal cancer

OBJECTIVES

Social determinants of health (SDOH) can influence access to cancer care, clinical trials, and oncologic outcomes. We investigated the association between SDOH, distance from treatment center, and treatment type with outcomes in human papillomavirus associated oropharyngeal squamous cell carcinoma [HPV(+)OPSCC] patients treated at a tertiary care center.

STUDY DESIGN

Retrospective review.

METHODS

HPV(+)OPSCC patients treated surgically from 2006 to 2021 were selected from our departmental Oropharyngeal Cancer RedCap database. Demographic data, treatment, and oncologic outcomes were extracted. Distance was calculated in miles between the centroid of each patient zip code and our hospital zip code (zipdistance).

RESULTS

874 patients (89 % male; mean age: 58 years) were identified. Most patients (96 %) reported Non-Hispanic White as their primary race. 204 patients (23 %) had a high-school degree or less, 217 patients (25 %) reported some college education or a 2-year degree, 153 patients (18 %) completed a four-year college degree, and 155 patients (18 %) had post-graduate degrees. Relative to those with a high-school degree, patients with higher levels of education were more likely to live further away from our institution (p < 0.0001). Patients who received adjuvant radiation therapy elsewhere lived, on average, 104 miles further away than patients receiving radiation at our institution (Estimate 104.3, 95 % CI 14.2-194.4, p-value = 0.02). In univariable Cox PH models, oncologic outcomes did not significantly differ by zipdistance.

CONCLUSIONS

Education level-and access to resources-varied proportionally to a patient's distance from our center. Patients travelling further distances for surgical management of OPSCC were more likely to pursue adjuvant radiation therapy at an outside institution. Distance traveled was not associated with oncologic outcomes. Breaking down barriers to currently excluded populations may improve access to clinical trials and improve oncologic outcomes for diverse patient populations.

Underrepresented in Medicine Student Perspectives on the Selection of a Summer Research Program

OBJECTIVES

Many summer research programs (SRPs) for URiM students exist; however, only a few have been established by otolaryngology programs, who have a unique opportunity to provide a diverse experience. We sought to assess URiM undergraduate student perspectives on the most valuable program features that influence decision-making and how this might be useful to otolaryngology programs seeking to establish pathway programs.

MATERIALS AND METHODS

An externally facing REDCap survey composed of 37 questions in scaled, multiple-choice, and open-ended form. The survey was delivered to applicants via email over two time periods in April 2021 and February 2022. All survey responses were analyzed using descriptive statistics and categorized according to demographic information, program features, and advertising mechanisms.

RESULTS

Seventy-one percent of our applicants self-identified as URiM. Over 60% experienced financial hardship, and 31% experienced educational hardship. The single most important feature when selecting a summer research program (SRP) was access to mentorship followed by clinical shadowing and research opportunities. When program features were aggregated into groups, institutional features were the most important, followed closely by funding features. Finally, students prefer to learn about SRPs through their university, followed by social media, despite many students learning about our program through other means.

CONCLUSIONS

Paid programs with effective advertising, research, mentoring, and clinical shadowing are highly valued by URiM undergraduate students. Understanding student perspectives is critical for programs aiming to address the "leaky pipeline" while being deliberate in their support of underrepresented students.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:637-644, 2024.

The Effects of Gross Cranial Nerve Invasion on Oncologic Outcomes in Patients with HPV(+)OPSCC

OBJECTIVES

This study examines oncologic outcomes in patients with HPV-related oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) who had evidence of gross cranial nerve invasion (CNI) identified at the time of surgery.

STUDY DESIGN

Retrospective cohort study comparing demographics, clinical features, and outcomes of HPV(+)OPSCC patients with and without gross CNI.

METHODS

Patients with biopsy proven HPV(+)OPSCC involving the base of tongue, tonsil, or unknown primary site, who underwent surgery as a part of their treatment between 1/1/2006-12/31/2020 (n = 874), were included in this study. Gross CNI was identified during operative intervention (n = 36). Statistical analyses were performed using SAS version 9.4 and R version 3.6.2. P-values <0.05 were considered statistically significant.

RESULTS

HPV(+)OPSCC patients with gross CNI were nearly 5 times as likely to suffer death by cancer (HR = 5.41, 95% CI 2.51 to 11.67, p < 0.0001), over 4 times as likely to see disease progression (HR = 4.25, 95% CI 2.31 to 7.84, p < 0.0001), and nearly 5 times as likely to experience metastasis (HR = 4.46, 95% CI 2.20 to 9.06, p < 0.0001) when compared to patients without CNI. Patients with gross CNI had significantly lower overall survival, cancer-specific survival, progression-free survival, and distant-metastasis free survival (p < 0.0001). Patients with gross CNI were significantly more likely to present with higher clinical N stage, higher pathological N stage and extracapsular spread than patients without gross CNI.

CONCLUSIONS

Our findings indicate that the presence of CNI is associated with significantly poorer oncologic outcomes in HPV(+)OPSCC patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:170-177, 2024.

Patterns and distribution of regional nodal involvement and recurrence in a surgically treated oropharyngeal squamous cell carcinoma cohort at a tertiary center

OBJECTIVES

To investigate and describe the patterns of regional metastases and recurrences after surgical treatment of oropharyngeal squamous cell cancer (OPSCC).

MATERIALS AND METHODS

Retrospective study of patients diagnosed with OPSCC from 2006 to 2021 at a tertiary referral center. Only patients treated with surgery including a neck dissection were included. Patients with unknown human papillomavirus (HPV) status, prior head and neck cancer, distant metastases, or synchronous head and neck cancer were excluded.

RESULTS

A total of 928 patients were included. 89% were males, the average age was 58.6 years (range: 25.2-87.5), 874 (94%) were HPV(+), and 513 (55.3%) had a tonsil cancer. Among cN + patients, the most commonly involved levels at presentation were level II (85.2%), level III (33.3%), and level IV (9.4%). In cN0 patients, metastases were only observed in level II (16.2%) and level III (9.2%). Nodal recurrence occurred in 48 (5.2%) patients after a median time of 1.0 years (interquartile range: 0.6-2.0). Nodal recurrence incidence was similar in HPV(+) and HPV(-) patients (5.0% vs. 7.4%, p = 0.44). The most common levels for regional recurrence were ipsilateral level II (45.8%), contralateral level II (43.8%), and ipsilateral level V (25.0%). Multivariable analysis revealed that pN was a significant predictor for regional recurrence (p = 0.02).

CONCLUSION

There is no difference in the distribution of regional metastases and recurrences in HPV(+) and HPV(-) OPSCC patients. Our findings align with the established understanding that regional metastases predominantly manifest in the ipsilateral level II-IV at presentation. Moreover, the data support the clinical recommendation to restrict elective neck dissection in cN0 patients to ipsilateral levels IIa and III, excluding level IIb. Regional recurrence is significantly associated with pN status.

Comparing Open Versus Rigid Endoscopic and Flexible Endoscopic Techniques for the Treatment of Zenker's Diverticulum

OBJECTIVE

To describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum.

STUDY DESIGN

Single institution retrospective review.

SETTING

Tertiary care academic hospital.

METHODS

We retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020.

RESULTS

A total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure-related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups.

CONCLUSION

The flexible endoscopic technique was associated with the highest rate of procedure-related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long-term follow-up are needed.

Safety outcomes and patient convenience in outpatient parotidectomy

BACKGROUND

Parotidectomies have historically been performed on an inpatient basis despite being well-tolerated surgeries with minimal postoperative wound care and low rates of complications at high-volume institutions. Past studies have supported the safety of outpatient surgery for parotidectomy but have been limited to superficial parotidectomy and have not addressed the patient experience surrounding the surgical intervention such as pre-operative and post-operative care and communication.

PURPOSE

This study assesses the impact of outpatient superficial, deep, and partial parotid surgery on various parameters including surgical safety, distance traveled for care, utilization of telehealth, and patient-initiated communication.

MATERIALS AND METHODS

Retrospective study from January 2020 to October 2021. Patients undergoing superficial lobe, deep lobe, and partial parotidectomies for benign and malignant pathologies were divided into inpatient and outpatient cohorts. A multivariable model examined the relationship between admission status and surgical complications, adjusted for age, sex, and tumor size.

RESULTS

159 patients total, 94 outpatient and 65 inpatients. No statistical difference in rates of surgical complications with the exception of salivary leak. There was an increased rate of salivary leak reported in the inpatient group (OR 5.4, 95 % CI 1.6 to 18.0, p = 0.01). Mean patient travel distance of 354 miles one-way. Post-operatively, 76 % were evaluated via video visit. Following discharge, >55 % of patients initiated communication with the surgical team, which was not statistically different between the groups.

CONCLUSIONS

Outpatient parotidectomy is safe and can be more convenient, but telehealth communication must be balanced with rigorous attention to patient education.

Recurrence Following Endoscopic Laser Wedge Excision and Triple Medical Therapy for Idiopathic Subglottic Stenosis

OBJECTIVE

We present the outcomes for patients with idiopathic subglottic stenosis (iSGS) following their first carbon dioxide laser wedge excision (LWE) procedure, additionally examining the effect of compliance with adjuvant medical therapy (triple therapy) after the operation.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary center.

METHODS

A retrospective review was performed on 183 patients with iSGS following their first LWE and their compliance to adjuvant medical therapy (inhaled corticosteroid, proton pump inhibitor, trimethoprim-sulfamethoxazole) following the operation, with all reviewed to December 31, 2020. The primary outcome variable was median time to recurrence (MTR). Patients were stratified by whether the LWE was their first operation (LWE primary or secondary), by compliance to triple therapy, and by compliance with trimethoprim-sulfamethoxazole. Kaplan-Meier analysis and Cox proportional hazards were used to evaluate the MTR across the stratifications.

RESULTS

An overall 113 patients underwent their first LWE, while 70 received the procedure after having undergone 1 to 13 procedures. The MTR between LWE primary and secondary was 4.6 and 2.9 years, respectively. Adjusted Cox proportional hazards comparing these 2 groups revealed the number of prior operations to be a confounding variable. A statistically increased MTR was demonstrated with greater degrees of medical compliance.

CONCLUSION

LWE conferred an MTR of 4.1 years in the iSGS cohort. The number of prior procedures preceding LWE behaved as a confounding variable. Patients who were completely or partially compliant to triple therapy appear to demonstrate increased intervals prior to recurrence.

Short and long-term outcomes of three-dimensional printed surgical guides and virtual surgical planning versus conventional methods for fibula free flap reconstruction of the mandible: Decreased nonunion and complication rates

BACKGROUND

To determine whether virtual surgical planning and three-dimensional printed cutting guides (3D/VSP) improved radiographic bone union compared to conventional methods (CM) in fibula free flap (FFF) reconstruction of the mandibles.

METHODS

Retrospective study from the years 2000-2018 at a tertiary hospital. Osseous union was evaluated by a radiologist blinded to each patient's treatment.

RESULTS

Two hundred sixty patients who underwent FFF tissue transfer, 28 with VSP and 3D cutting guides. Bony union was not achieved in 46 (20%) patients who underwent CM compared to 1 (4%) of patients with VSP and guides (p = 0.036). FFF complication was significantly higher in CM with 87 patients (38%) compared to three patients (11%) in 3D/VSP (p = 0.005). Median time to bony union for patients who underwent CM was 1.4 years compared to 0.8 years in 3D/VSP.

CONCLUSIONS

3D/VSP reduced the rate of radiographic nonunion and flap-related complications in FFF reconstruction for mandibular defects.

Disease Profile and Oncologic Outcomes After Delayed Diagnosis of Human Papillomavirus-Associated Oropharyngeal Cancer

OBJECTIVE

Diagnostic delay in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV(+)OPSCC) is common due to nonspecific symptoms. We aim to describe the disease burden and oncologic outcomes of patients with HPV(+)OPSCC diagnosed >12 months after symptom onset.

STUDY DESIGN

This is a retrospective cohort study of HPV(+)OPSCC patients receiving intent-to-cure treatment (including surgery ± adjuvant therapy or primary chemoradiation).

SETTING

2006-2016, tertiary care center.

METHODS

Tumor stage was compared between patients with and without delayed diagnosis using χ² tests. Kaplan-Meier survival analysis with univariate and multivariable Cox regressions were used to determine the effect of diagnostic delay on oncologic outcomes.

RESULTS

In total, 664 patients were included. Compared to patients diagnosed <12 months from symptom onset (n = 601), those diagnosed at >12 months (n = 63) were more likely to have T4 disease and higher overall American Joint Committee on Cancer (AJCC) clinical stage at presentation (P < .01 for both). At 5 years, rates of overall survival, cancer-specific survival, progression-free survival, and distant metastases-free survival in the delayed diagnosis cohort were 80%, 90%, 80%, and 89%, respectively. A >12-month delay in diagnosis did not significantly impact overall survival (adjusted hazard ratio [aHR], 1.16; 95% CI, 0.58-2.31), cancer-specific survival (aHR, 0.83; 95% CI, 0.29-2.39), progression-free survival (aHR, 1.15; 95% CI, 0.56-2.37), or distant metastases-free survival (aHR, 1.00; 95% CI, 0.42-2.40) after adjusting for age, sex, and clinical AJCC stage (P > .05 for all).

CONCLUSIONS

Delayed diagnosis of HPV(+)OPSCC is associated with greater burden of disease at presentation, but oncologic outcomes remain favorable across treatment modalities. When appropriate, intent-to-cure therapy should be pursued despite diagnostic delay.

LEVEL OF EVIDENCE

Level III.

Lack of Association of Spontaneous Coronary Artery Dissection With Autoimmune Disease

BACKGROUND

Case reports and referral-based studies suggest spontaneous coronary artery dissection (SCAD) is associated with autoimmune diseases and causes 2% to 4% of acute coronary syndromes.

OBJECTIVES

This study determined the association of SCAD with autoimmune diseases, together with incidence and recurrence, in a population-based study.

METHODS

This case-control study took place from 1995 to 2018 within the Rochester Epidemiology Project. The study identified cases with SCAD from diagnosis codes and verified them using coronary angiography images, matching each case to 3 control subjects on age, sex, county, and years of medical history. Autoimmune disease history came from a validated, code-based definition. A multivariable logistic regression model calculated the odds ratio (OR) for SCAD among patients with a history of autoimmune disease, adjusting for race and body mass index.

RESULTS

The study identified 114 cases with SCAD (mean age 51 years and 90% women) and 342 matched control subjects. Autoimmune disease occurred in 13 (11%) cases with SCAD and 40 (12%) control subjects (p = 0.93). Even after adjustment, autoimmune diseases were not associated with SCAD (OR: 0.81; 95% confidence interval [CI]: 0.40 to 1.66). SCAD incidence between 2010 and 2018 (2.7 per 100,000; 95% CI: 1.7 to 3.7) was 10-fold higher than the incidence between 1995 and 2009 (0.3 per 100,000; 95% CI: 0.0 to 0.6). SCAD recurrence was 10% (95% CI: 3% to 16%) at 5 years.

CONCLUSIONS

These findings suggested SCAD pathogenesis is noninflammatory and screening for autoimmune diseases based on SCAD alone is not warranted. The code-based incidence of SCAD has increased over time, highlighting the importance of considering SCAD among patients with acute coronary syndromes.

Barriers to Obtaining a Timely Diagnosis in Human Papillomavirus-Associated Oropharynx Cancer

OBJECTIVE

Failure to recognize symptoms of human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) at presentation can delay diagnosis and treatment. This study aims to identify patient factors and provider patterns that contribute to delayed diagnosis.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care center.

METHODS

Patients with HPV(+)OPSCC receiving intent-to-cure treatment from 2006 to 2016. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations.

RESULTS

Of 703 included patients, 627 (89%) were male, and mean (SD) age at diagnosis was 59 (9) years. The mean (SD) delay to diagnosis was 148.8 (243.51) days, with an average delay of 63 (154.91) days from symptom onset to first presentation and 82.8 (194.25) days from first presentation to diagnosis. Most patients visited at least 2 providers (n = 546, 78%) before diagnosis and saw their primary care physician at first presentation (n = 496, 71%). The most common imaging and biopsy obtained before diagnosis was neck computed tomography (n = 391, 56%) and neck fine-needle aspiration (n = 423, 60%), respectively. On multivariable linear regression, being a homemaker, being a current smoker, seeing 3 or more providers, and getting a magnetic resonance imaging scan were associated with significant delays in diagnosis (P < .01, all). Treatment with antibiotics and a suspicion for HPV(+)OPSCC at first presentation were associated with decreased delays in diagnosis (P < .01, both).

CONCLUSIONS

Patient delays in seeking medical attention and provider delays in recognizing the appropriate diagnosis both contribute to delays of care in HPV(+)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(+)OPSCC.

Preparation for and Implementation of Shared Medical Appointments to Improve Self-Management, Knowledge, and Care Quality Among Patients With Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and is associated with an increased risk of stroke, heart failure, and death. Therapy for this pervasive arrhythmia is complex, involving multiple options that chiefly manage symptoms and prevent stroke. Current therapeutic strategies are also of limited efficacy, and can present potentially life-threatening side effects and/or complications. Emerging research suggests that the burden of AF can be reduced by improving patient understanding of the arrhythmia and teaching patients to adopt and maintain lifestyle and behavior changes. Shared medical appointments (SMAs) have been successfully used to deliver education and develop patient coping and disease management skills for patients with complex needs, but there is a paucity of studies examining the use of SMAs for managing AF. Moreover, few studies have examined strategies for implementing SMAs into routine clinical care. We detail our approach for (1) adapting a patient-centered SMA curriculum; (2) designing an evaluation comparing SMAs to routine care on patient outcomes; and (3) implementing SMAs into routine clinical practice. We conclude that evaluation and implementation of SMAs into routine clinical practice requires considerable planning and continuous engagement from committed key stakeholders, including patients, family members, schedulers, clinical staff, nurse educators, administrators, and billing specialists.

Episode-based payment: evaluating the impact on chronic conditions

BACKGROUND

Policy makers are interested in aggregating fee-for-service reimbursement into episode-based bundle payments, hoping it will lead to greater efficiency in the provision of care. The focus of bundled payment initiatives has been upon surgical or discrete procedures. Relatively little is known about calculating and implementing episode-based payments for chronic conditions.

OBJECTIVE

Compare the differences in two different episode-creation algorithms for two common chronic conditions: diabetes and coronary artery disease (CAD).

STUDY DESIGN

We conducted a retrospective evaluation using enrollees with continuous coverage in a self-funded plan from 2003 to 2006, meeting Healthcare Effectiveness Data and Information Set (HEDIS) criteria for diabetes or CAD. For each condition, an annual episode-based payment was assessed using two algorithms: Episode Treatment Groups (ETGs) and the Prometheus model.

PRINCIPAL FINDINGS

We began with 1,580 diabetes patients with a 4-year total payment mean of $67,280. ETGs identified 1,447 (92%) as having diabetes with 4-year episode-based mean payments of $12,731; while the Prometheus model identified 1,512 (96%) as having diabetes, but included only 1,195 of them in the Prometheus model with mean diabetes payments of $23,250. Beginning with 1,644 CAD patients with a 4-year total payment mean of $65,661, ETGs identified 983 patients (60%) with a 4-year episode-based mean of $24,362. The Prometheus model identified 1,135 (69%) as CAD patients with 948 CAD patients having a mean of $26,536.

CONCLUSIONS

The two episode-based methods identify different patients with these two chronic conditions. In addition, there are significant differences in the episode-based payment estimates for diabetes, but similar estimates for CAD. Implementing episode-based payments for chronic conditions is challenging, and thoughtful discussions are needed to determine appropriate payments.

Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool

OBJECTIVE

To determine the inter-rater reliability of the Institute for Healthcare Improvement's Global Trigger Tool (GTT) in a practice setting, and explore the value of individual triggers.

DESIGN

Prospective assessment of application of the GTT to monthly random samples of hospitalized patients at four hospitals across three regions in the USA.

SETTING

Mayo Clinic campuses are in Minnesota, Arizona and Florida.

PARTICIPANTS

A total of 1138 non-pediatric inpatients from all units across the hospital.

INTERVENTION

GTT was applied to randomly selected medical records with independent assessments of two registered nurses with a physician review for confirmation.

MAIN OUTCOME MEASURE

The Cohen Kappa coefficient was used as a measure of inter-rater agreement. The positive predictive value was assessed for individual triggers.

RESULTS

Good levels of reliability were obtained between independent nurse reviewers at the case-level for both the occurrence of any trigger and the identification of an adverse event. Nurse reviewer agreement for individual triggers was much more varied. Higher agreement appears to occur among triggers that are objective and consistently recorded in selected portions of the medical record. Individual triggers also varied on their yield to detect adverse events. Cases with adverse events had significantly more triggers identified (mean 4.7) than cases with no adverse events (mean 1.8).

CONCLUSIONS

The trigger methodology appears to be a promising approach to the measurement of patient safety. However, automated processes could make the process more efficient in identifying adverse events and has a greater potential of improving care delivery and patient 'outcomes'.