Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery.

OBJECTIVE: To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. STUDY DESIGN: Retrospective cohort study. SETTING: County hospital otolaryngology practice. METHODS: A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. RESULTS: We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 (P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased (P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased (P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids. CONCLUSION: Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.

PD-L1 Expression and Tumor-Infiltrating Lymphocytes in High-Risk and Metastatic Cutaneous Squamous Cell Carcinoma.

OBJECTIVE: To characterize programmed death-ligand 1 (PD-L1) expression and tumor-infiltrating lymphocyte (TIL) positivity for locally aggressive or regionally metastatic cutaneous head and neck squamous cell carcinoma (cHNSCC). STUDY DESIGN: Retrospective chart review, followed by immunohistochemical staining of archived tumor specimens. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: After identification of 101 patients treated surgically for locally advanced or regionally metastatic cHNSCC, archived tissue was stained and graded for PD-L1 expression in addition to TIL presence. Cross-tabulation was performed to examine the association between either of these variables and clinicopathologic features and outcomes. RESULTS: A total of 101 patients met inclusion criteria, but archived tissue was available only for 83 (31 primaries, 52 metastases). The majority of primary tumors demonstrated grade 1 PD-L1 staining, while grade 2 staining was more likely for metastases. Neither high- nor low-grade PD-L1 expression correlated with any clinicopathologic variable for primary tumors. However, for metastases, high-grade staining was significantly associated with regional recurrence (15 of 19, P = .02). TILs were present for 65% of primary tumors and 90% of regional metastases but did not correlate with any clinicopathologic variables. CONCLUSION: Diffuse expression of PD-L1 in this study highlights the possibility of using immunotherapy in the form of programmed death 1/PD-L1 blockade to improve treatment for this devastating disease. However, further studies are needed to clarify the significance of PD-L1 expression and TIL positivity for locally advanced or regionally metastatic cHNSCC.

Renal ultrasound abnormalities in children with syndromic and non-syndromic microtia.

OBJECTIVE: Renal abnormalities are commonly considered in the work up of pediatric patients with external ear malformations. However, there is little consensus regarding an appropriate renal screening protocol for patients with microtia. We sought to characterize renal abnormalities detected on ultrasonography in pediatric patients with microtia. METHODS: We conducted a retrospective cohort study of pediatric patients diagnosed with microtia who underwent renal ultrasound from 1991 to 2014 at a single tertiary academic institution. Renal ultrasound reports and medical records were reviewed to assess for renal abnormalities and to determine whether patients required specialist follow-up or interventions. Audiograms and otolaryngology notes were used to determine patterns of hearing loss. The following additional information was recorded from the electronic medical records: patient sex, microtia grade (I-IV), microtia laterality, and known associated syndromes. Characteristics were compared between those who did and did not have renal ultrasound findings using Fisher's exact test. Univariate logistic regression analysis was performed to determine factors associated with renal ultrasound findings. RESULTS: The majority of patients in this cohort were syndromic (n = 51, 64%) with grade III microtia (n = 46, 58%) and conductive hearing loss (n = 58, 72%). Syndromic children with microtia demonstrated a higher crude rate of renal ultrasound abnormalities (22%) than children with isolated microtia (7%). Of these patients, 69% required specialist follow-up. Univariate logistic regression analysis did not identify predictors that were significantly associated with renal ultrasound findings. CONCLUSION: Fairly high rates of abnormalities in syndromic and non-syndromic patients may warrant screening renal ultrasound in all patients with microtia, especially given the high percentage of findings requiring renal follow-up. A prospective study to formally evaluate screening efficacy is needed.

Node-positive cutaneous squamous cell carcinoma of the head and neck: Survival, high-risk features, and adjuvant chemoradiotherapy outcomes.

BACKGROUND: Data lacks to guide treatment of regionally metastatic cutaneous head and neck squamous cell carcinoma (HNSCC). METHODS: We conducted a retrospective review of 80 patients treated for regionally metastatic cutaneous HNSCC. The effect of various clinicopathologic variables on overall survival (OS) was investigated, in addition to outcomes by treatment modality. RESULTS: On multivariate regression, cutaneous primary >2 cm (p = .03) and extracapsular spread (ECS; p = .01) were significantly associated with decreased OS. Location of regional metastasis (neck vs parotid vs both) had no effect on OS (p = .2), nor did the presence of a cutaneous primary at the time of presentation (p = .9). The 3-year survival was 43%, 52%, and 49% for surgery alone, adjuvant radiation, and adjuvant chemoradiation, respectively. Fifty-one percent of patients had a recurrence of their disease. CONCLUSION: Regionally metastatic cutaneous HNSCC is an aggressive disease associated with high recurrence rates. Patients with tumors >2 cm and ECS have poorer OS despite adjuvant therapy. © 2017 Wiley Periodicals, Inc. Head Neck 39: 881-885, 2017.

Postoperative Complications in Pediatric Tonsillectomy and Adenoidectomy in Ambulatory vs Inpatient Settings.

IMPORTANCE: A large-scale review is needed to characterize the rates of airway, respiratory, and cardiovascular complications after pediatric tonsillectomy and adenoidectomy (T&A) for inpatient and ambulatory cohorts. OBJECTIVE: To identify risk factors for postoperative complications stratified by age and operative facility type among children undergoing T&A. DESIGN, SETTING, AND PARTICIPANTS: This retrospective review included 115,214 children undergoing T&A in hospitals, hospital-based facilities (HBF), and free-standing facilities (FSF) in California from January 1, 2005, to December 31, 2010. The analysis used the State of California Office of Statewide Health Planning and Development private inpatient data and Emergency Department and Ambulatory Surgery public data. Inpatient (n = 18,622) and ambulatory (n = 96,592) cohorts were identified by codes from the International Classification of Diseases, Ninth Revision, and Current Procedural Terminology. Data were collected from September 2011 to March 2012 and analyzed from March through May 2012. MAIN OUTCOMES AND MEASURES: Rates of airway, respiratory, and cardiovascular complications. RESULTS: A total of 18,622 inpatients (51% male; 49% female; mean age, 5.4 [range, 0-17] years) and 96,592 ambulatory patients (37% male; 35% female; 28%, masked; mean age, 7.6 [range, 0-17] years) underwent analysis. The ratio of ambulatory to inpatient procedures was 5:1. Inpatients demonstrated more comorbidities (≤8, compared with ≤4 for HBF and ≤3 for FSF patients) and, in general, their complication rates were 2 to 5 times higher (seen in 1% to 12% of patients) than those in HBFs (0.2% to 5%), and more than 10 times higher than those in the FSFs (0% to 0.38%), with rates varying markedly by age range and facility type. Tonsillectomy and adenoidectomy was associated with increased risk for all complication types in both settings, reaching an odds ratio of 8.5 (95% CI, 6.6-11.1) for respiratory complications in the ambulatory setting. Inpatients aged 0 to 9 years experienced higher rates of airway and respiratory complications, peaking at an odds ratio of 7.5 (95% CI, 3.1-18.2) for airway complications in the group aged 0 to 11 months. CONCLUSIONS AND RELEVANCE: Large numbers of pediatric patients undergo T&A in ambulatory settings despite higher rates of complications in younger patients and patients with more comorbidities. Fortunately, a high percentage of these patients has been appropriately triaged to the inpatient setting. Further research is needed to elucidate the subgroups that warrant postoperative hospitalization.

Patterns and Predictors of Sensorineural Hearing Loss in Children With Congenital Diaphragmatic Hernia.

Importance: Although congenital diaphragmatic hernia (CDH) may be associated with sensorineural hearing loss (SNHL), to our knowledge, no studies have yet identified the pattern of this hearing loss or definitive independent risk factors that may place this population at higher risk. Objective: To characterize the type and degree or SNHL in CDH survivors and better characterize perinatal risk factors. Design, Setting, and Participants: This was a retrospective cohort study of CDH survivors who had a pure-tone audiogram available for review followed at a multidisciplinary clinic. Interventions: Treatment for CDH at birth. Main Outcomes and Measures: Audiograms were used to calculate pure-tone average (PTA) for the most severely affected side and classify SNHL as normal (<20 dB), mild (20-39 dB), moderate (>40-59 dB), severe (≥60 dB), or profound (≥80 dB). Clinically significant SNHL was defined as a PTA of at least 40 dB. Perinatal data evaluated included demographics, characteristics of CDH and neonatal respiratory course, peak total and direct bilirubin levels, exposure to ototoxic drugs, need for supplemental oxygen at discharge, and results of newborn hearing screen. Univariate analysis was conducted to examine the relationship between these variables and (1) any SNHL or (2) significant SNHL. Results: Fifty patients were included. Audiograms were performed at age 2.7 ± 2.3 years (range, 0.5-10.7 years). Of the 50 patients, 28 (56%) had any SNHL and 9 of the 28 (32%) had significant SNHL (PTA ≥ 40 dB). Any SNHL was not significantly different (P = .42) by newborn hearing screen results: 5 of 7 children (71%) who failed the screening were classified as having any SNHL, and 20 of 40 children (50%) who passed were classified as having any SNHL. While no variables were significantly associated with any SNHL, multiple significant associations were found with significant SNHL: extracorporeal membrane oxygenation support (P = .02), nonprimary CDH repair (P = .01), prolonged ventilation (≥14 days) (P = .001), and high neonatal furosemide exposure (P = .03). Conclusions and Relevance: Sensorineural hearing loss is prevalent among children with CDH. As would be expected, significant SNHL (PTA ≥ 40 dB) in this cohort was associated with markers of more severe CDH with a more complicated neonatal hospital course. Overall close follow-up for hearing and speech development, including routine audiology testing, is indicated in children with CDH.

Venous malformations of the temporal bone are a common feature in CHARGE syndrome.

OBJECTIVES/HYPOTHESIS: CHARGE (Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth and/or development, Genital and/or urinary abnormalities, and Ear abnormalities and/or deafness) syndrome is a genetic disorder with prominent otolaryngologic features including choanal atresia and inner ear malformations. Recent experience with venous malformations during cochlear implant surgery prompted this study to define the spectrum of venous abnormalities in CHARGE and their surgical implications in otology. STUDY DESIGN: Retrospective review of medical and radiologic records from databases of patients with CHARGE syndrome from three tertiary care academic medical centers. METHODS: Eighteen patients with CHARGE for whom temporal bone CT scans were available were included in the review. RESULTS: Venous anomalies of the temporal bone were present in 10 of 18 (56%) patients. The most common were large emissary veins (n = 5). In two of these cases, these veins were associated with an ipsilateral a hypoplastic sigmoid sinus or jugular foramen. Other abnormalities included an aberrant petrosal sinus, venous lakes in proximity to the lateral venous sinus, condylar canal veins, and jugular bulb abnormalities, including a high riding bulb obscuring the round window niche and a dehiscent jugular bulb. In four of six patients undergoing cochlear implantation, the course of the aberrant vessel necessitated a change in the surgical approach, either during mastoidectomy or placement of the cochleostomy. CONCLUSIONS: Temporal bone venous abnormalities are a common feature in CHARGE syndrome. The pattern of venous abnormality suggests that there is a failure of the sigmoid sinus/jugular bulb to fully develop, resulting in persistence of emissary veins. Recognition of these abnormal venous structures during otologic surgery is critical to avoiding potentially catastrophic bleeding.

Non-audiofacial morbidity after Gamma Knife surgery for vestibular schwannoma.

OBJECT: While many studies have been published outlining morbidity following radiosurgical treatment of vestibular schwannomas, significant interpractitioner and institutional variability still exists. For this reason, the authors conducted a systematic review of the literature for non-audiofacial-related morbidity after the treatment of vestibular schwannoma with radiosurgery. METHODS: The authors performed a comprehensive search of the English-language literature to identify studies that published outcome data of patients undergoing radiosurgery treatment for vestibular schwannomas. In total, 254 articles were found that described more than 50,000 patients and were analyzed for satisfying the authors' inclusion criteria. Patients from these studies were then separated into 2 cohorts based on the marginal dose of radiation: < or = 13 Gy and > 13 Gy. All tumors included in this study were < 25 mm in their largest diameter. RESULTS: A total of 63 articles met the criteria of the established search protocol, which combined for a total of 5631 patients. Patients receiving > 13 Gy were significantly more likely to develop trigeminal nerve neuropathy than those receiving < 13 Gy (p < 0.001). While we found no relationship between radiation dose and the rate of developing hydrocephalus (0.6% for both cohorts), patients with hydrocephalus who received doses > 13 Gy appeared to have a higher rate of symptomatic hydrocephalus requiring shunt treatment (96% [> 13 Gy] vs 56% [< or = 13 Gy], p < 0.001). The rates of vertigo or balance disturbance (1.1% [> 13 Gy] vs 1.8% [< or = 13 Gy], p = 0.001) and tinnitus (0.1% [> 13 Gy] vs 0.7% [< or = 13 Gy], p = 0.001) were significantly higher in the lower dose cohort than those in the higher dose cohort. CONCLUSIONS: The results of our review of the literature provide a systematic summary of the published rates of nonaudiofacial morbidity following radiosurgery for vestibular schwannoma.