Predictors of Quality-of-Life Improvements Following Global Head and Neck Surgery Trips to Underserved Regions.

OBJECTIVES/HYPOTHESIS: To conduct longitudinal postoperative follow-up and discern health-related quality-of-life (HR-QoL) changes using a validated questionnaire among patients undergoing head and neck surgeries during a short-term, global surgical trip in a resource-limited setting. To identify clinicodemographic predictors of post-operative HR-QoL improvements in this setting. STUDY DESIGN: Retrospective observational study with prospective follow-up. METHODS: Patients undergoing surgery at Moi Teaching and Referral Hospital in Eldoret, Kenya through the authors' short-term surgical trip (STST) between 2016 and 2019 were asked to complete preoperative Short Form-36 (SF-36) HR-QoL questionnaires, and postoperative SF-36 questionnaires during subsequent follow-up. Preoperative and postoperative SF-36 domain scores, and two composite scores (mental component summary [MCS] and physical component summary [PCS]) were compared. Linear regression models were fit to identify clinicodemographic factors predictors of general health (GH), MCS, and PCS scores. RESULTS: Among the 26 participating patients, significant improvements were seen in post-operative GH (mean change = 19.8) and MCS (mean change = 11.2) scores. Lower pre-operative GH, MCS, and PCS scores were predictive of greater improvement in the corresponding post-operative scores. Longer time to follow-up was associated with greater improvement in GH score. Mean follow-up interval was 23.1 months (SD = 1.8 months). CONCLUSIONS: Utilizing the SF-36 questionnaire, we found that patients' perception of their general and psychosocial health improved after undergoing head and neck surgeries through a global STST. This study provides important, preliminary evidence that that elective surgeries performed in low-resource settings convey substantial benefit to patient QoL. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2006-2010, 2021.

African Head and Neck Society Clinical Practice guidelines for thyroid nodules and cancer in developing countries and limited resource settings.

BACKGROUND: International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources. METHODS: Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined. RESULTS: Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines. CONCLUSIONS: Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources.

Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube.

OBJECTIVE: To develop a clinical consensus statement on the use of balloon dilation of the eustachian tube (BDET). METHODS: An expert panel of otolaryngologists was assembled with nominated representatives of general otolaryngology and relevant subspecialty societies. The target population was adults 18 years or older who are candidates for BDET because of obstructive eustachian tube dysfunction (OETD) in 1 or both ears for 3 months or longer that significantly affects quality of life or functional health status. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus. RESULTS: After 3 iterative Delphi method surveys, 28 statements met the predefined criteria for consensus, while 28 statements did not. The clinical statements were grouped into 3 categories for the purposes of presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes. CONCLUSION: This panel reached consensus on several statements that clarify diagnosis and perioperative management of OETD. Lack of consensus on other statements likely reflects knowledge gaps regarding the role of BDET in managing OETD. Expert panel consensus may provide helpful information for the otolaryngologist considering the use of BDET for the management of patients with OETD.

Otolaryngology in Low-Resource Settings: Practical and Ethical Considerations.

Providing otolaryngology care in low-resource settings requires careful preparation to ensure good outcomes. The level of care that can be provided is dictated by available resources and the supplementary equipment, supplies, and personnel brought in. Other challenges include personal health and safety risks as well as cultural and language differences. Studying outcomes will inform future missions. Educating and developing ongoing partnerships with local physicians can lead to sustained improvements in the local health care system.

Impact of Humanitarian Experiences on Otolaryngology Trainees: A Follow-up Study of Travel Grant Recipients.

In this study, we seek (1) to determine the impact of humanitarian experiences on otolaryngology trainee recipients of the American Academy of Otolaryngology-Head and Neck Surgery Foundation humanitarian travel grant (2001-2015); (2) to better understand trainee and trip characteristics, as well as motivations and attitudes toward future volunteerism; and (3) and to identify potential barriers to participation. An anonymous 30-question survey was distributed to 207 individuals, and 52 (25.1%) responded. Respondents viewed the trip as very worthwhile (score = 98 of 100), expressed improved cultural understanding (75.0%), and continued participation in humanitarian activities (75.0%). Competency-based evaluation results suggest a positive impact on systems-based practice and professionalism. Respondents commented on the trip's positive value and shared concerns regarding expense. Despite potential barriers, Foundation-supported humanitarian trips during training are perceived as worthwhile; they may enhance cultural understanding and interest in future humanitarian efforts; and they may positively affect competency-based metrics. Based on the potential benefits, continued support and formalization of these experiences should be considered.

Thyroid Surgery in a Resource-Limited Setting.

Objective The present study reviews a series of patients who underwent thyroid surgery in Eldoret, Kenya, to demonstrate the feasibility of conducting long-term (>1 year) outcomes research in a resource-limited setting, impact on the quality of life of the recipient population, and inform future humanitarian collaborations. Study Design Case series with chart review. Setting Tertiary public referral hospital in Eldoret, Kenya. Subjects and Methods Twenty-one patients were enrolled during the study period. A retrospective chart review was performed for all adult patients who underwent thyroid surgery during humanitarian trips (2010-2015). Patients were contacted by mobile telephone. Medical history and physical examination, including laryngoscopy, were performed, and the SF-36 was administered (a quality-of-life questionnaire). Laboratory measurements of thyroid function and neck ultrasound were obtained. Results The mean follow-up was 33.6 ± 20.2 months after surgery: 37.5% of subtotal thyroidectomy patients and 15.4% of lobectomy patients were hypothyroid postoperatively according to serologic studies. There were no cases of goiter recurrence or malignancy. All patients reported postoperative symptomatic improvement and collectively showed positive pre- and postoperative score differences on the SF-36. Conclusion Although limited by a small sample size and the retrospective nature, our study demonstrates the feasibility of long-term surgical and quality-of-life outcomes research in a resource-limited setting. The low complication rates suggest minimal adverse effects of performing surgery in this context. Despite a considerable rate of postoperative hypothyroidism, it is in accordance with prior studies and emphasizes the need for individualized, longitudinal, and multidisciplinary care. Quality-of-life score improvements suggest benefit to the recipient population.

Midcervical scar satisfaction in thyroidectomy patients.

OBJECTIVES/HYPOTHESIS: Assess long-term patient satisfaction with conventional thyroidectomy scars and the impact of thyroidectomy scars on patient quality of life. STUDY DESIGN: Validated survey administration and retrospective review of clinical and demographic data. METHODS: Patients who underwent conventional thyroidectomy through years 2000 to 2010 were identified and administered the validated Patient Scar Assessment Questionnaire. Mean satisfaction, appearance and scar-consciousness scores were determined. Thirty-seven patients also measured the length of their current scar. Patient demographic and operative data were collected retrospectively from the medical record. Data were analyzed with one-way analysis of variance and independent samples t testing. RESULTS: Sixty of 69 patients perceived the appearance of their scar to be "good" or "excellent." Sixty-three patients (91.3%) were satisfied with all scar outcomes; 67 (97.1%) were satisfied with the overall appearance of their scar. Mean total satisfaction score was 17.3 (<26 indicates a high level of satisfaction). Fifty-six (81.2%) were "not at all" self-conscious of their scar; 65 (94.2%) reported no attempt to hide their scar. Seven patients (10.1%) indicated any likelihood of pursuing scar revision. Females had significantly higher total satisfaction scores, consciousness scores, and satisfaction with appearance scores. The effect of perceived scar length was significant for scar-consciousness, not patient satisfaction. CONCLUSIONS: The majority of patients were satisfied with their thyroidectomy scar appearance. Few patients reported a desire to hide the scar or pursue revision. Women were more likely to be dissatisfied than men. Length may play a role in scar consciousness. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:1247-1252, 2017.

The impact of obesity on adult tracheostomy complication rate.

OBJECTIVES/HYPOTHESIS: Prospectively compare tracheostomy-related complications in obese patients with complications in nonobese patients. STUDY DESIGN: Prospective cohort study. METHODS: Adult patients undergoing tracheostomy were studied. Patients who had a prior tracheostomy were excluded. Complications were classified as intraoperative, early (within the first 2 weeks), or late. RESULTS: A total of 151 patients met inclusion/exclusion criteria. Fifty-five percent of obese patients experienced at least one tracheostomy-related complication; 19.5% of the control group had a complication. Mean procedure duration for patients with body mass index < 30 was 24.74 minutes and for obese patients was 46.17 minutes. There was a statistically significant effect of body mass index on complication rate (P < .0001) and on procedure duration (P < .0001). The relationships between body mass index and intraoperative complications (P = .027) and early postoperative complications (P = .001) were significant. CONCLUSIONS: The tracheostomy-related complication rate is significantly higher for obese patients, especially for body mass index ≥ 35, especially in the intraoperative and early postoperative time periods. Procedure duration is significantly longer in obese patients.

Laryngeal melanosis.

OBJECTIVE: Laryngeal melanosis (LM) is an unusual condition. Little is known about its clinical significance. To learn more about this unusual disorder, we prospectively gathered data on a series of patients with LM and compared the data with the summarized findings from the cases currently available in the literature. STUDY DESIGN: Case series with planned data collection. SETTING: Two hundred fifty-five-bed urban indigent care hospital located on a university medical center campus. Subjects and Methods Demographics, history, examination findings, and concurrent head and neck disorders were prospectively recorded for all patients with LM who presented to our institution between 2005 and 2012. RESULTS: Eighteen patients with laryngeal melanosis were enrolled. All patients are African American, and all have a history of chronic tobacco use. The most common presenting symptom was dysphonia, and examination most often revealed flat, pigmented lesions of the larynx. Nine patients (50%) had concomitant squamous cell carcinoma of the upper aerodigestive tract. There are 19 previous cases of laryngeal melanosis reported by 12 different authors, with a concomitant carcinoma rate of 26%. Our patients are similar in age and are all African American, with a greater percentage of women and greater rate of concomitant carcinoma. Our study represents the single largest case series of laryngeal melanosis and is more complete given the prospective nature of the data collection. CONCLUSION: Laryngeal melanosis is an unusual disorder that is associated with chronic tobacco use. Clinicians should be aware of the association between laryngeal melanosis and squamous cell carcinoma and perform a thorough evaluation for concomitant carcinoma.

An experimental model to investigate initial tracheal anastomosis strength.

OBJECTIVES/HYPOTHESIS: Early anastomotic dehiscence is a devastating complication of segmental tracheal resection. Although wound healing, patient comorbidities, and anastomotic tension are all influential factors, there is a paucity of information available on initial tracheal stability after various tracheal anastomosis techniques in human tissue. STUDY DESIGN: Prospective cadaver study. METHODS: We present a novel, inexpensive pulley-based system to apply symmetric tension on the trachea in a longitudinal direction to the point of anastomotic dehiscence. The validity of this mechanism was confirmed with trials using incrementally increasing quantities of the same suture type. Twenty-four trials were then performed on 12 cadaver tracheas (six fresh and six preserved) to compare anastomotic strength with two commonly used suture materials (3-0 polyglactin [Vicryl] vs. 3-0 polydioxanone [PDS]). RESULTS: Validation studies demonstrated that the force increased appropriately with an increasing number of sutures tested. In the tracheal anastomoses, tracheal suture pull-through was the most common mechanism of dehiscence, regardless of suture type. No significant difference in anastomotic stability was detected between the fresh versus preserved cadaver tracheas. The mean anastomotic strength was slightly greater for Vicryl (179.9 N) when compared to PDS (161.5 N), but the difference did not reach significance (P = .207). CONCLUSIONS: We introduce an inexpensive tool for measuring initial tracheal anastomosis stability with human cadavers, which demonstrated no difference in the tracheal pull-through strength of Vicryl and PDS.

Multiple phosphaturic mesenchymal tumors associated with oncogenic osteomalacia: case report and review of the literature.

Oncogenic osteomalacia is a rare paraneoplastic syndrome that occurs secondary to tumor development in a variety of locations. Only about 140 cases have been reported in the literature. The most common causal tumor is phosphaturic mesenchymal tumor (PMT), a histologically benign lesion. The two most common sites of PMT are the lower extremities and the head/neck. We report the case of a 33-year-old woman with oncogenic osteomalacia who was diagnosed with two PMTs; the first arose in the tibia, and the second occurred 2 years later in the maxillary sinus. To the best of our knowledge, this is the first reported case of multiple PMTs. Despite resection of both tumors, the patient's signs and symptoms did not resolve, suggesting either incomplete tumor removal or the presence of another undetected tumor. We discuss the diagnosis of oncogenic osteomalacia, its associated biochemical abnormalities, and its histopathology.

Papillary carcinoma arising in median ectopic thyroid tissue: management of the thyroid gland.

Thyroid tissue in an ectopic location is rare, 1 in 100,000 to 300,000 persons, and usually in the lateral neck. Median ectopic thyroid tissue is even more unusual, with the vast majority of cases being lingual thyroid tissue. We present a case of carcinoma arising in median, nonlingual ectopic thyroid tissue along with an analysis of the literature to determine the most appropriate management of the orthotopic thyroid gland.

Cryptococcal meningitis with isolated otologic symptoms.

Sensorineural hearing loss (SNHL) is a known complication of cryptococcal meningitis; however, it is unusual for a patient to present with isolated otologic symptoms. We review the case of a patient who is not immunocompromised and who presented with progressive gait instability and sudden onset of left-sided SNHL followed by progression to bilateral SNHL within a 3-week period. Cryptococcal meningitis was confirmed by lumbar puncture with positive cryptococcus antigen in the cerebrospinal fluid. The patient was treated with systemic antifungals, and the hearing loss persisted. The presented report outlines this patient's unusual presentation and his treatment course and reviews the literature on the otologic manifestations of cryptococcal meningitis.

Extramedullary plasmacytoma of the larynx in an adolescent: a case report and review of the literature.

Extramedullary plasmacytoma is uncommon, accounting for only 3% of all plasma cell neoplasms. Most lesions occur in the head and neck, primarily in the upper aerodigestive tract; only a minority occur in the larynx. Most cases of extramedullary plasmacytoma are seen in older men; presentation in an adolescent is rare. We report the case of a 13-year-old girl who presented with a 2- to 3-month history of progressive dysphonia. Physical examination identified two lesions--a nasopharyngeal mass and a laryngeal mass. Biopsy indicated that the masses were extramedullary plasmacytomas with amyloid deposition. The patient was treated with radiation therapy, and the tumors were eradicated. We also review the literature with respect to the epidemiology and presentation of extramedullary plasmacytoma of the head and neck, specifically those that affect the larynx.

Giant basal cell carcinoma of the forehead with extensive intracranial involvement.

Basal cell carcinoma (BCC) is the most common malignant skin lesion and is frequently curatively treated with local excision. Improper removal or neglect of BCC is a particular problem for head and neck surgeons. We describe a case of a recurrent BCC that aggressively grew from the forehead skin through the skull and into the frontal lobe. We also present a review of the literature. Despite its fairly benign growth pattern, BCC should never be underestimated, and care should be taken not only in the complete primary excision but also in cancer surveillance.

Comparison of posttonsillectomy pain using the ultrasonic scalpel, coblator, and electrocautery.

OBJECTIVE: To compare postoperative tonsillectomy pain between 3 commonly used surgical devices: the Harmonic Ultrasonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH), the Coblator (ArthroCare Corp, Sunnyvale, CA), and electrocautery. STUDY DESIGN AND SETTING: A prospective, randomized trial. One hundred thirty-four patients were randomly assigned to receive a tonsillectomy with 1 of 3 surgical devices. All patients were asked to fill out a postoperative diary. RESULTS: Statistically significant differences in pain scores were revealed between the Coblator and electrocautery (P = 0.02) and between the Coblator and the Ultrasonic Scalpel (P = 0.003), with the Coblator having lower pain scores. Electrocautery and the Ultrasonic Scalpel did not differ significantly from each other. The Coblation method showed a strong trend toward quicker return to normal diet. CONCLUSION: Patients undergoing tonsillectomy with the Coblator device reported less pain over a 10-day period than patients undergoing tonsillectomy with electrocautery or the Ultrasonic Scalpel. Pain after tonsillectomy remains a major issue for our patients. The choice of surgical instrument appears to be one way to reduce this pain. EBM RATING: A-1b.