Beyond good intentions and patient perceptions: competing definitions of effective communication in head and neck cancer care at the end of life.

Effective communication between dying cancer patients and their health care providers about prognosis and treatment options ensures informed decision making at the end of life. This study analyzed data from interviews with end-stage head and neck cancer patients and their health care providers about communication competence and approaches to communicating about end-of-life issues. Patients rated their oncologists as competent and comfortable discussing end-of-life issues, although few reported discussing specific aspects of end-of-life care. Oncologists viewed giving prognostic information as a process rather than a singular event, and preferred answering patients' questions as opposed to guiding the discussion. These data reveal subtle disconnects in communication suggesting that patients' and health care providers' information needs are not being met.

Alcoholism, depression, and abnormal cognition in head and neck cancer: a pilot study.

OBJECTIVE: To determine prevalence of alcohol abuse and dependency, depression, and cognitive impairment in presurgical head and neck cancer patients. STUDY DESIGN: Standardized testing by diagnostic interview was used to determine major depression and alcoholism. Mattis Dementia Rating Scale examined cognitive ability preoperatively. Twenty-four patients with advanced head and neck cancer participated. SETTING: University hospital. RESULTS: A total of 63.6% met criteria for alcohol abuse and 62 percent for alcohol dependence; 26.1 % of patients met criteria for major depression. Testing in multiple subsets of cognitive function demonstrated measurable deficits in both alcohol dependents and abusers. All deficits were significant when compared with population norms. CONCLUSIONS: Findings suggest that prevalence of alcohol abuse, major depression, and cognitive impairment is common in head and neck cancer patients preoperatively. Early diagnosis and management of these disorders should be considered in care of the head and neck cancer patient.

Aerodigestive tract invasion by well-differentiated thyroid carcinoma: diagnosis, management, prognosis, and biology.

OBJECTIVES/HYPOTHESIS: 1) To describe the clinical entity invasive well-differentiated thyroid carcinoma (IWDTC), 2) to determine prognostic factors for survival in patients with IWDTC, 3) to describe and compare types of surgical resection to determine treatment efficacy, 4) to offer a staging system and surgical algorithm for management of patients with IWDTC, 5) to examine alterations in expression of E-cadherin and beta-catenin adhesion molecules in three groups of thyroid tissue and propose a cellular mechanism for invasion of the aerodigestive tract. STUDY DESIGN: Basic science: quantification of expression of E-cadherin and beta-catenin in three groups of thyroid tissue. Clinical: retrospective review of patients with IWDTC surgically treated and followed over a 45-year time period. METHODS: Basic science: immunohistochemical staining was used with antibodies against E-cadherin and beta-catenin in three groups of tissue: group 1, normal control thyroid tissue (n = 10); group 2, conventional papillary thyroid carcinoma (n = 20); group 3, IWDTC (n = 12). Intensity scores were given on the basis of protocol. One-way analysis of variance (ANOVA) was used to evaluate differences between groups. Post hoc ANOVA testing was completed. P < .05 was significant. Clinical: patients were divided into three surgical groups within the laryngotracheal subset: group 1, complete resection of gross disease (n = 34); group 2, shave excision (n = 75); group 3, incomplete excision (n = 15). Cox regression analysis was used to determine significance of prognostic factors. Kaplan-Meier plots were used to evaluate survival. P < .05 was significant. RESULTS: Basic science: a significant difference between the three thyroid tissue groups for E-cadherin expression was demonstrated on one-way ANOVA testing. When controls were compared with either experimental group in post hoc ANOVA testing, differences between all groups were demonstrated (P < .001). For beta-catenin, the intensities of the three groups were not different by one-way ANOVA testing. Similar nonsignificant results were found on post hoc ANOVA testing. Clinical: there was a statistically significant difference in survival for patients with and without involvement of any portion of the endolarynx or trachea (P < .01). There was a significant difference among all three surgical groups when compared (P < .001). When complete and shave groups were compared with gross residual group there was a significant decrease in survival in incomplete resection group (P < .01). Cox regression analysis demonstrated invasion of larynx and trachea were significant prognostic factors for poor outcome. The type of initial resection was significant on multivariate analysis. Removal of all gross disease is a major factor for survival. CONCLUSIONS: Basic science: there is a decrease in membrane expression of E-cadherin in IWDTC, and loss of this tumor suppressor adhesion molecule may contribute to the invasive nature of well-differentiated thyroid carcinomas. Clinical: laryngotracheal invasion is a significant independent prognostic factor for survival. Patients undergoing shave excision had similar survival when compared with those undergoing radical tumor resection if gross tumor did not remain. Gross intraluminal tumor should be resected completely. Shave excision is adequate for minimal invasion not involving the intraluminal surfaces of the aerodigestive tract.

Medical student selection of otolaryngology-head and neck surgery as a specialty: influences and attitudes.

OBJECTIVES: 1) To determine factors students perceive as influential in decision to pursue otolaryngology; 2) to determine perception of importance of factors used for resident selection and individual student commitment to the match; and 3) to identify exposure to various subspecialties within otolaryngology. DESIGN: Population survey. METHODS: A survey was administered to students applying for otolaryngology between 2000 and 2003 at a single institution. RESULTS: Ninety-six students were interviewed. Seventy-eight percent believed that the main factor influencing their decision to pursue otolaryngology was their exposure to the residents. Board scores and one-on-one interviews were important factors in selection of interviewees and ranking process. Interestingly, over 20% of students believed that the match should not be early because they wanted more time to commit to ENT. CONCLUSIONS: These data underscore the importance that residents have in directing future students to our specialty. Results of the match survey may indicate an attrition rate within residency programs that may be avoided if ENT were part of the "regular" match.

Laryngotracheal injury after percutaneous dilational tracheostomy in cadaver specimens.

OBJECTIVE: To evaluate the stoma and surrounding insertion site for common laryngotracheal injury patterns after percutaneous dilational tracheostomy that may contribute to clinically significant tracheal stenosis. STUDY DESIGN: Preliminary prospective cadaver study. METHODS: A preliminary prospective cadaver study was performed in which percutaneous dilational tracheostomy (Ciaglia Blue Rhino kit) was placed in six fixed cadaveric specimens. Laryngotracheal segments were harvested. Two independent evaluators graded cadaver features and characteristic injuries in laryngotracheal specimens the tracheal site of stoma placement was identified. Cadaver features evaluated included gender, obesity, and ease of landmark identification. Mucosal and cartilage injuries were evaluated on a scale of 0 to 4, with 4 representing severe comminuted injuries beyond the intended stoma site. RESULTS: Accurate prediction of tracheal placement was achieved in only three (50%) of the specimens. In the remaining cadavers, one stoma site was placed higher than intended (16%) and two sites were lower than intended (33%). Mucosal injury was most severe at the anterior internal surface of the trachea with all specimens sustaining tears beyond one tracheal ring (mean mucosal injury score, 3.5). Cartilaginous injury was severe in five of six specimens (83%) that sustained multiple comminuted injuries to two or more adjacent rings (mean cartilage injury score, 3.34). Cricoid comminutions and a posterior membranous tracheal wall injury were each found in one specimen. CONCLUSIONS: Laryngotracheal injuries found after percutaneous dilational tracheostomy in the study indicated that severe damage to mucosa and cartilage surrounding the intended stoma site occurs at the time of placement. These injuries may contribute to clinically significant tracheal stenosis preventing decannulation in patients undergoing percutaneous dilational tracheostomy. Two case studies that support this hypothesis are also presented.