Assessing social vulnerabilities of salivary gland cancer care, prognosis, and treatment in the United States.

BACKGROUND: Salivary gland cancers (SGC)-social determinants of health (SDoH) investigations are limited by narrow scopes of SGC-types and SDoH. This Social Vulnerability Index (SVI)-study hypothesized that socioeconomic status (SES) most contributed to SDoH-associated SGC-disparities. METHODS: Retrospective cohort of 24 775 SGCs assessed SES, minority-language status (ML), household composition (HH), housing-transportation (HT), and composite-SDoH measured by the SVI via regressions with surveillance and survival length, late-staging presentation, and treatment (surgery, radio-, chemotherapy) receipt. RESULTS: Increasing social vulnerability showed decreases in surveillance/survival; increased odds of advanced-presenting-stage (OR: 1.12, 95% CI: 1.07, 1.17), chemotherapy receipt (OR: 1.13, 95% CI: 1.03, 1.23); decreased odds of primary surgery (0.89, 0.84, 0.94), radiotherapy (0.91, 0.85, 0.97, p = 0.003) for SGCs. Trends were differentially correlated with SES, ML, HH, and HT-vulnerabilities. CONCLUSIONS: Through quantifying SDoH-derived SGC-disparities, the SVI can guide targeted initiatives against SDoH that elicit the most detrimental associations for specific sociodemographics.

Assessment of social vulnerability impact in care and prognosis of sinonasal cancers in the United States.

KEY POINTS: Social determinants of health interactively influence sinonasal cancer care and prognosis. Housing-transportation and socioeconomic status showed the largest associations with disparities. The social vulnerability index can reveal the social determinants of sinonasal cancers.

Outcomes in Pediatric Thyroidectomy: Results From a Multinational, Multi-institutional Database.

OBJECTIVE: Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism. STUDY DESIGN: Retrospective multi-institutional cohort study. SETTING: Tertiary care pediatric hospital systems throughout North America. METHODS: Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models. RESULTS: In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism. CONCLUSION: These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.

Comparison of Pediatric Otolaryngology clinical and operative case volume among surgical specialties in the COVID-19 pandemic.

OBJECTIVES: To report changes in clinical and surgical volume impacting a Pediatric Otolaryngology division one year prior to and following the onset of the COVID-19 pandemic in comparison to five other pediatric surgical subspecialties. METHODS: The number of clinical visits and surgical cases per month for six pediatric surgical specialties (Otolaryngology, Orthopedic Surgery, Urology, Neurosurgery, Plastic Surgery, and General Surgery) for 12 months prior to the pandemic and 12 months following the onset of the pandemic was collected. Poisson regression analysis was performed for the number of visits and cases per season adjusting for specialty, season, staffing changes, and the pandemic to determine adjusted rate ratios (aRR) post-pandemic for the surgical fields compared to Otolaryngology. RESULTS: A percentage decrease in median visits per paired month (-15.63%, IQR = -23.01, -1.66) and operative cases (-19.86%, IQR = -29.39, -10.17) was seen for Pediatric Otolaryngology. Regression analysis showed a significant negative effect on the number of visits (aRR = 0.74, 95% CI = 0.70-0.77) and cases (aRR = 0.65, 95% CI = 0.60-0.71) due to the pandemic. While many of the other specialties had predicted reductions in volume (notably Orthopedics), they all experienced significant predicted increases in productivity following the pandemic compared to Otolaryngology. CONCLUSIONS: These findings suggest that Pediatric Otolaryngology is particularly vulnerable to this change in clinical pattern, which could be due to a decline in community infections from mask wearing and social distancing, and may result in a longer-term volume deficit when compared to other pediatric surgical subspecialties.

Age based evaluation of nut aspiration risk.

OBJECTIVE: To identify an age at which initiation of whole nut into the pediatric diet could be considered safe, by evaluating the age distribution of children undergoing bronchoscopy with removal of nut or seed material from the airway. METHOD: A retrospective chart review over a ten-year period identifying children age 0-18 that have undergone bronchoscopy with retrieval of airway foreign bodies. A statistical analysis of demographic data was carried out to identify age distribution of aspiration events. RESULTS: Sixty-four cases of foreign body aspiration were identified, of which 43 (67%) were of organic origin, specifically nuts. A Fisher's exact test was carried out on the cumulative percentage of organic foreign body aspirations to identify the age distribution of nut aspiration events. A statistically significant decrease in organic foreign body aspirations occurred at approximately 36 months of age (p = 0.004). CONCLUSION: Foreign body aspiration is a leading cause of accidental injury or death in children. Nut and other small organic foreign bodies account for a significant portion of accidental aspiration events, however, no guidelines exist regarding appropriate age of whole nut introduction into the diet. Our study suggests that 90% of pediatric nut aspiration events occur under the age of 36 months. We suggest supervised introduction of whole nuts between the ages of 3 and 4 years. Official guidelines regarding this should be considered by professional pediatric societies. LEVEL OF EVIDENCE: 4.

Surgical management of midline cervical cleft.

INTRODUCTION: Midline Cervical Cleft (MCC) is a midline cervical congenital anomaly that manifests as a vertical cutaneous/subcutaneous defect with abnormal dermal elements as well as an underlying fibrous cord that extends from the sternum to the mentum of the mandible, which can lead to "wry neck" and hypoplastic mandible. The goal of surgical correction of MCC is to provide adequate healthy tissue coverage, as well as restore contour of the anterior neck. The primary treatment modality for midline cervical cleft is surgical. We describe a technique involving complete excision of the fibrous cord, and use of double z-plasty flap in order to create a tension-free closure and restore contour to the anterior neck. METHODS: Using a database search method, children with the clinical diagnosis of midline cervical cleft treated between 2006 and 2016 were identified at a pediatric tertiary care center. Chart review was completed to assess for age at surgery, follow up, results, and complications. RESULTS: 12 patients were identified in the Lurie Children's Hospital (LCH) database. 8 patients underwent complete cord excision by the seniorauthor using the double z-plasty (DZ) technique for closure, with no recurrences. 4 patients underwent linear closure by another surgeon, had persistent contracture, and underwent revision using the DZ technique by the senior author, with no recurrence. Average age of surgery was 9.5 months. Most common post op complication was hypertrophic scar (3/12). Recurrence was only seen in the linear closure cases (4/12). CONCLUSIONS: Midline Cervical Cleft is a rare entity with less than 200 cases in the literature. We believe the double z-plasty closure and complete excision of the fibrous cord results in reproducible restoration of neck contour and prevents cord recurrence, and should be considered the standard method for surgical excision of MCC.

Pigmented Melanotic Schwannoma of the Neck: Report of 2 Cases and Review of the Literature.

BACKGROUND:: Melanotic schwannoma is a rare tumor with indeterminate biologic behavior and varying treatment recommendations. METHODS:: We report 2 cases of pigmented melanotic schwannoma of the head and neck and perform literature review. The pathologic and immunohistochemical characteristics of melanotic schwannoma are reviewed. RESULTS:: Two cases of melanotic schwannoma are presented. Both cases underwent surgical resection with one patient receiving adjuvant radiation therapy. CONCLUSIONS:: Melanotic schwannoma is a rare nerve sheath tumor that is frequently mistaken for malignant melanoma. We describe 2 cases of pigmented melanotic schwannoma of the head and neck with different presentations and review the histopathological and immunohistochemical features.

Complications Following Pediatric Tracheotomy.

IMPORTANCE: Pediatric tracheotomy is a complex procedure with significant postoperative complications. Wound-related complications are increasingly reported and can have considerable impact on clinical course and health care costs to tracheotomy-dependent children. OBJECTIVE: The primary objective of this study was to identify the type and rate of complications arising from pediatric tracheotomy. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of medical records of 302 children who underwent tracheotomy between December 1, 2000, and February 28, 2014, at a tertiary care pediatric referral center. Records were reviewed for preoperative diagnoses, gestational age, age at tracheotomy, tracheotomy technique, and incidence of complication. MAIN OUTCOMES AND MEASURES: Main outcome measures included incidence, type, and timing of complications. Secondary measures included medical diagnoses and surgical technique. RESULTS: Of the 302 children who underwent tracheotomy, the median (SD) age at time of tracheotomy was 5 months (64 months) and the range was birth to 21 years. The most frequent diagnosis associated with performance of a tracheotomy was ventilator-associated respiratory failure (61.9%), followed by airway anomaly or underdevelopment (25.2%), such as subglottic or tracheal stenosis, laryngotracheomalacia, or bronchopulmonary dysplasia. The remaining indications for tracheotomy included airway obstruction (11.6% [35 of 302]) and vocal fold dysfunction (1.3% [4 of 302]). No statistical significance was found associated with diagnosis and incidence of complications. Sixty children (19.9%) had a tracheotomy-related complication. Major complications, such as accidental decannulation (1.0% [3 of 302]). There were no deaths associated with tracheotomy. Minor complications, such as peristomal wound breakdown or granuloma (12.9% [39 of 302]) and bleeding from stoma (1.7% [5 of 302]), were more common. Of all complications, 70% (42 of 60) occurred early (≤7 days postoperatively) and 20% (12 of 60) were late (>7 days postoperatively). CONCLUSIONS AND RELEVANCE: Pediatric tracheotomy at our institution is associated with an overall 19.9% incidence of complications. Although the rate of major complications such as accidental decannulation or death is low, rates of peristomal skin breakdown and development of granuloma are more frequently reported and can occur at any point following tracheotomy. Further work is necessary to understand and mitigate wound care issues in post-tracheotomy care.

Cervical Spine Spondylodiscitis After Esophageal Dilation in Patients With a History of Laryngectomy or Pharyngectomy and Pharyngeal Irradiation.

IMPORTANCE: Dysphagia is a frequently reported sequela of treatment for head and neck cancer and is often managed with esophageal dilation in patients with dysphagia secondary to hypopharyngeal or esophageal stenosis. Reported complications of esophagoscopy with dilation include bleeding, esophageal perforation, and mediastinitis. These, though rare, can lead to substantial morbidity or mortality. In patients who have undergone irradiation, tissue fibrosis and devascularization may contribute to a higher incidence of these complications. OBJECTIVES: To describe the occurrence of cervical spine spondylodiscitis (CSS) following esophageal dilation in patients with a history of laryngectomy or pharyngectomy and irradiation with or without chemotherapy. DESIGN, SETTING, AND PARTICIPANTS: Medical records from a 5-year period (January 1, 2009, through December 31, 2014) in an academic tertiary care center were searched for patients with a history of laryngopharyngeal irradiation and a diagnosis of CSS following esophageal dilation. Four eligible patients were identified. MAIN OUTCOMES AND MEASURES: Recognition and treatment of CSS in the study population. RESULTS: A total of 1221 patients underwent esophageal dilation for any reason. Of these, 247 patients carried a diagnosis of head and neck cancer at the following sites: piriform sinus, larynx, hypopharynx, epiglottis, oropharynx, base of the tongue, and tonsil. Of these, 4 patients with a diagnosis of CSS following esophageal dilation were included in this assessment. Prompt diagnosis and multidisciplinary management of CSS with intravenous antibiotics as well as spinal surgical debridement and stabilization led to recovery of full ability to take food by mouth in 3 of the 4 included patients. One patient remained dependent on the feeding tube. CONCLUSION AND RELEVANCE: In patients with a history of laryngopharyngeal irradiation and esophageal dilation, complaints of neck pain or upper extremity weakness should trigger immediate evaluation for CSS; if present, prompt therapy is essential for prevention of substantial morbidity and mortality.

Postoperative nonsteroidal anti-inflammatory drugs and risk of bleeding in pediatric intracapsular tonsillectomy.

OBJECTIVES: In light of current FDA guidelines on opioid use in children, we sought to determine the risk of post-tonsillectomy hemorrhage (PTH) in children who received ibuprofen with acetaminophen versus those who received narcotic with acetaminophen for postoperative pain control. METHODS: This was an IRB-approved retrospective chart review of patients at a tertiary-care pediatric center. The medical records of 449 children who received acetaminophen and ibuprofen following intracapsular tonsillectomy with or without adenoidectomy were reviewed (NSAID group) and compared with medical records of 1731 children who underwent intracapsular tonsillectomy and received acetaminophen with codeine or hydrocodone with acetaminophen postoperatively (narcotic group). Main outcome measure was the incidence of PTH requiring return to the operating room. Secondary outcome measures included incidence of primary PTH, secondary PTH, and postoperative evaluation in the emergency department or readmission for pain and/or dehydration. RESULTS: Incidence of PTH requiring return to the operating room was higher in the NSAID group (1.6%) compared with the narcotic group (0.5%), P=0.01. Incidence of primary PTH was significantly higher in the NSAID group (2%) versus the narcotic group (0.12%), P<0.0001. Incidence of secondary PTH was 3.8% in the NSAID group and 1.1% in the narcotic group (P<0.0001). CONCLUSION: Use of ibuprofen after intracapsular tonsillectomy in children is associated with statistically significant increase in PTH requiring return to the operating room, as well as an increase in overall rates of both primary and secondary PTH. Ibuprofen provides pain control that is at least equivalent to narcotic and is not associated with respiratory depression. Further study of ibuprofen use in the post-tonsillectomy patient is warranted.

Orbital Involvement by NUT Midline Carcinoma.

A 32-year-old female presented with a sino-orbital lesion that proved to be a NUT midline carcinoma. This is only the third case of orbital involvement by this aggressive lesion. The clinical, radiographic, and histopathologic features of NUT midline carcinoma are discussed, as well as its management options.

Neonatal parotid gland enlargement: Is it suppurative parotitis? A case report.

BACKGROUND: Acute suppurative parotitis (ASP) is a rare finding in the neonate. It is commonly caused by S. aureus but other bacterial isolates may be emerging. Effective treatment includes prompt diagnosis, parenteral antibiotics and supportive measures such as rehydration and bimanual gland massage. CASE REPORT: This case report describes an extremely premature female infant with a complicated post-natal course who presented with unilateral swelling of the parotid region. Diagnostic workup revealed purulent exudate from Stensen's duct and ultrasound findings consistent with parotitis. Culture of the exudate showed growth of Staphylococcus aureus and Enterococcus species. The patient responded well to a ten-day antibiotic course and supportive measures. CONCLUSIONS: ASP, though rare, should be considered in the differential diagnosis of a neonatal parotid swelling since early and prompt diagnosis prevents morbidity and complications.