Evaluation of opioid prescription patterns among patients undergoing thyroid surgery.

BACKGROUND: There is variability in opioid prescription patterns among surgeons performing thyroidectomy. Thus, the aim of this study is to evaluate opioid prescription rates and opioid use among hemithyroidectomy (HT) and total thyroidectomy (TT) patients. DESIGN/METHOD: An electronic postoperative survey was distributed to assess opiate use among patients undergoing HT/TT. Groups were compared using t-tests, chi-square tests, and analysis of variance. RESULTS: A total of 142 opiate naïve patients were included, of which 75 (52.8%) underwent HT and 67 (47.1%) underwent TT. The mean number of tablets prescribed was 21.3 (HT = 22.1, TT = 20.4; P = 0.3), with a mean of 14.1 tablets unused after surgery (HT = 13.2 tablets, TT = 15.0 tablets; P = 0.44). The mean morphine milligram equivalent (MME) prescribed was 150.1 mg (HT = 159.0 mg, TT = 140.2 mg; P = 0.3), with a mean of 98.2 MME unused after surgery (HT = 93.7 mg, TT = 103.2 mg; P = 0.6). CONCLUSIONS: Opioids are overprescribed after thyroid surgery. Avoidance of overprescribing is vital in mitigating the current opioid crisis.

Prognostic Impact of Metastatic Site and Pattern in Patients with Metastatic Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: Investigate the relationship between site and pattern of distant metastasis (DM) and overall survival (OS) in a multi-institutional cohort of patients with DM head and neck cancer (HNC). STUDY DESIGN: Retrospective review. METHODS: 283 patients treated at 4 academic centers in the Midwest HNC Consortium between 2000 and 2015 were retrospectively reviewed. Disease patterns were divided between solitary metastatic versus polymetastatic (≥2 sites) disease. Survival functions for clinically relevant variables were estimated using Kaplan-Meier and Cox proportional hazards models. RESULTS: Median OS for all patients was 9.0 months (95% confidence interval [CI]: 7.4-10.6). Lung (n = 220, 77.7%) was the most common site of DM, followed by bone (n = 90, 31.8%), mediastinal lymph nodes (n = 55, 19.4%), liver (n = 41, 14.5%), and brain (n = 17, 6.0%). Bone metastases were independently associated with the worst prognosis (hazard ratio [HR] = 1.6, 95% CI: 1.3-2.1). On univariate analysis, brain metastases were associated with improved prognosis (HR = 0.5, 95% CI: 0.3-0.9), although this was not statistically significant on the multivariate analysis. Polymetastatic disease was present in the majority of patients (n = 230, 81.3%) and was associated with a worse prognosis compared to solitary metastatic disease (HR = 1.4, 95% CI: 1.0-2.0). CONCLUSION: Our large, multi-institutional review indicates that both the metastatic pattern and site of DM impact OS. Polymetastatic disease and bone metastasis are associated with worse prognosis, independent of treatment received. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1838-E1846, 2021.

Cost and operative time estimation itemized by component procedures of endoscopic sinus surgery.

BACKGROUND: Endoscopic sinus surgery (ESS) is a variable combination of individual procedures. Cost estimates for ESS as a single entity have wide variation, likely influenced by variation in procedures performed. We sought to identify operative time, supply costs, and total procedure cost specific to the component procedure combinations comprising ESS. METHODS: Bilateral ESS cases at 13 Intermountain Healthcare facilities (2008 to 2016) were identified from a database with corresponding cost and time data. Procedure details were obtained by chart review. Least-squares (LS) means of cost (in 2016 US dollars) and time for specific procedures were obtained by multivariable gamma regression models. RESULTS: Among 1477 bilateral ESS cases with 19 different procedure combinations, operative time ranged from 59.5 (95% confidence interval [CI], 48.6-73.0) minutes for total ethmoid to 147.1 (95% CI, 126.4-171.2) minutes for full ESS with maxillary and sphenoid tissue removal. Sphenoidotomy had lowest total and supply costs (in US dollars) of $2112 (95% CI, $1672-$2667) and $636 (95% CI, $389-$1040), respectively. Total cost was highest for full ESS with maxillary tissue removal at $4640 (95% CI, $4115-$5232). Supply cost was highest for full ESS with maxillary and sphenoid tissue removal at $2191 (95% CI, $1649-$2909). CONCLUSION: Operative time and costs for ESS vary depending on the procedures performed, demonstrating the importance of procedure specificity in assessment of ESS time, cost, and, ultimately, value. These procedure-specific estimates of cost enable nonbinary valuation of ESS, appropriate for the multitude of procedure options intended to optimize individual outcomes.

A Surgical Mouse Model for Advancing Laryngeal Nerve Regeneration Strategies.

Iatrogenic recurrent laryngeal nerve (RLN) injury is a morbid complication of anterior neck surgical procedures. Existing treatments are predominantly symptomatic, ranging from behavioral therapy to a variety of surgical approaches. Though laryngeal reinnervation strategies often provide muscle tone to the paralyzed vocal fold (VF), which may improve outcomes, there is no clinical intervention that reliably restores true physiologic VF movement. Moreover, existing interventions neglect the full cascade of molecular events that affect the entire neuromuscular pathway after RLN injury, including the intrinsic laryngeal muscles, synaptic connections within the central nervous system, and laryngeal nerve anastomoses. Systematic investigations of this pathway are essential to develop better RLN regenerative strategies. Our aim was to develop a translational mouse model for this purpose, which will permit longitudinal investigations of the pathophysiology of iatrogenic RLN injury and potential therapeutic interventions. C57BL/6J mice were divided into four surgical transection groups (unilateral RLN, n = 10; bilateral RLN, n = 2; unilateral SLN, n = 10; bilateral SLN, n = 10) and a sham surgical group (n = 10). Miniaturized transoral laryngoscopy was used to assess VF mobility over time, and swallowing was assessed using serial videofluoroscopy. Histological assays were conducted 3 months post-surgery for anatomical investigation of the larynx and laryngeal nerves. Eight additional mice underwent unilateral RLN crush injury, half of which received intraoperative vagal nerve stimulation (iVNS). These 8 mice underwent weekly transoral laryngoscopy to investigate VF recovery patterns. Unilateral RLN injury resulted in chronic VF immobility but only acute dysphagia. Bilateral RLN injury caused intraoperative asphyxiation and death. VF mobility was unaffected by SLN transection (unilateral or bilateral), and dysphagia (transient) was evident only after bilateral SLN transection. The sham surgery group retained normal VF mobility and swallow function. Mice that underwent RLN crush injury and iVNS treatment demonstrated accelerated and improved VF recovery. We successfully developed a mouse model of iatrogenic RLN injury with impaired VF mobility and swallowing function that can serve as a clinically relevant platform to develop translational neuroregenerative strategies for RLN injury.

Prescription patterns and opioid usage in sinonasal surgery.

BACKGROUND: Excess opioid use after surgery contributes to opiate misuse and diversion. Understanding opioid prescribing and utilization patterns after sinonasal surgery is critical in designing effective practice protocols. In this study we aim to identify factors associated with variable opioid usage and further delineate optimal prescription patterns for sinonasal surgery. METHODS: All patients undergoing sinonasal surgery within a single health-care system from March 2017 to August 2018 were sent electronic postoperative surveys. Data were collected on the amount of opioid required, pain control, presurgical opiate use, and narcotic disposal. Additional data collected from the electronic medical record included demographics, type of surgery performed, and total amount of opioid prescribed, including refills. RESULTS: Three-hundred sixty four patients were included. A mean number of 25.3 tablets were prescribed per patient, yet the mean taken was just 11.8 tablets. Excess opioids were prescribed 84.9% of the time with a mean excess narcotic in oral morphine equivalents of 152.5. Among patients, 11.8% reported using no opioids, whereas 52.1% used <50% and 36.1% used >50% of their narcotic prescription. Patients used 9.3% of their full prescription and only 2.6% required a refill. The amount used was not associated with complexity of endoscopic sinus surgery, type of opiate prescribed, gender, distance living from hospital, or current opioid usage before surgery (p > 0.05). The addition of septoplasty and/or turbinoplasty was associated with variation in opioid usage (p < 0.001). A total of 76.1% of patients incorrectly discarded/stored excess opiates. CONCLUSION: Opioids are overprescribed after sinonasal surgery. The amount of postoperative opiate prescribed should be greatly reduced and may be based on the specific procedures performed. Improved patient education regarding disposal of excess narcotics may help to curtail future opioid diversion.

Operative time and cost variability for functional endoscopic sinus surgery.

BACKGROUND: Understanding the variation in costs of endoscopic sinus surgery (ESS) is critical to defining value. Current published costs of ESS have not identified potential sources of variation. Our objective was to analyze ESS costs to identify sources of variance that could guide value-improving decisions. METHODS: ESS cases (n = 1739) performed between 2008 and 2016 were identified from a database of 22 rural to tertiary facilities. Cost and time data were extracted from the database. Medical records were reviewed to confirm procedures. Three bilateral groupings were examined (n = 895 cases from 13 facilities): (1) full ESS (all sinuses); (2) intermediate ESS (total ethmoid, maxillary); and (3) anterior ESS (anterior ethmoid, maxillary). Cost and operative time were analyzed using multivariable gamma regression. RESULTS: Median costs for full, intermediate, and anterior ESS were $4281, $3716, and $2549 U.S. dollars (p < 0.001). Median durations were 87, 60, and 58 minutes (p < 0.001). Among patients with no additional procedures, those with full ESS had operative duration, total cost, and supply costs that were 1.37 (95% confidence interval [CI], 1.17 to 1.61), 1.52 (95% CI, 1.32 to 1.75), and 2.40 (95% CI, 1.76 to 3.25) times greater than anterior ESS, respectively (all p < 0.001). Intermediate ESS duration at community urban facilities was 1.87 (95% CI, 1.74 to 2.02) times that of community rural facilities (p < 0.001). CONCLUSION: Duration of surgery, extent of surgery, and location of surgery are sources of significant variation in the cost of ESS. These findings will assist healthcare policy makers, hospitals, and surgeons in optimizing the value of ESS.