External laryngotracheal trauma: Incidence, airway control, and outcomes in a large Canadian center.

OBJECTIVES/HYPOTHESIS: Laryngotracheal trauma encompasses a subset of relatively uncommon yet life-threatening injuries requiring prompt intervention to prevent short- and long-term aerodigestive tract sequelae. Minimal literature exists regarding laryngotracheal injuries on a population level, particularly among Canadian centers. STUDY DESIGN: Case series. METHODS: Regional health databases containing in-patient admissions, emergency department visits, and trauma service activations using International Classification of Diseases (ICD) diagnostic codes were queried to identify all laryngotracheal injuries diagnosed from April 1, 1995, to December 31, 2011. Health records and diagnostic imaging were evaluated for mechanism, injuries, airway management, and long-term aerodigestive function. RESULTS: Eighty-nine patients met inclusion criteria, equating to 1/1042 admissions and 1/2478 emergency presentations. Nineteen percent of injuries were severe (Schaefer-Fuhrman score ≥ 4). Airway intervention was performed at presentation in 65% of patients, with 13.5% necessitating emergent surgical airway; 52% underwent investigative or interventional airway surgery. Nine patients (16%) had long-term moderate or severe dysphonia; 14.5% had dysphagia. Odds ratio for death and long-term dysphonia among severe compared to minor laryngotracheal injuries were 7.1 (95% CI = 1.4-35.4) and 17.2 (95% CI = 3.3-91.1), respectively. Several factors were identified that predicted airway management and outcomes. CONCLUSION: Traumatic laryngotracheal injuries are more common than previously reported, due to increased recognition. Many can be managed nonoperatively; however, cases require individual evaluation with judicious airway management and intervention to minimize aerodigestive sequelae. Severe injuries are associated with death and dysphonia but not with dysphagia. LEVEL OF EVIDENCE: 4.

Cost-effectiveness analysis of a postoperative clinical care pathway in head and neck surgery with microvascular reconstruction.

BACKGROUND: The objective of this study is to evaluate the cost-effectiveness of a postoperative clinical care pathway for patients undergoing major head and neck oncologic surgery with microvascular reconstruction. METHODS: This is a comparative trial of a prospective treatment group managed on a postoperative clinical care pathway and a historical group managed prior to pathway implementation. Effectiveness outcomes evaluated were total hospital days, return to OR, readmission to ICU and rate of pulmonary complications. Costing perspective was from the government payer. RESULTS: 118 patients were included in the study. All outcomes demonstrated that the postoperative pathway group was both more effective and less costly, and is therefore a dominant clinical intervention. The overall mean pre- and post-pathway costs are $22,733 and $16,564 per patient, respectively. The incremental cost reduction associated with the postoperative pathway was $6,169 per patient. CONCLUSION: Implementing the postoperative clinical care pathway in patients undergoing head and neck oncologic surgery with reconstruction resulted in improved clinical outcomes and reduced costs.

Radiologic reporting for paranasal sinus computed tomography: a multi-institutional review of content and consistency.

OBJECTIVES/HYPOTHESIS: To optimize clinical care, radiologic reporting should consistently include clinically pertinent information. The purpose of this study was to: 1) determine the current satisfaction of otolaryngologists with paranasal sinus computed tomography (CT) radiologic reporting and 2) evaluate the comprehensiveness of paranasal sinus CT radiologic reporting. STUDY DESIGN: Two parts: 1) A national survey of all practicing otolaryngologists in Canada and 2) a retrospective review of paranasal sinus CT scan radiologic reporting. METHODS: A national survey of all Canadian otolaryngologists was conducted in September 2011. Questions were focused on eliciting the current satisfaction with sinus CT radiologic reporting. At two major centers (Alberta Health Services-Calgary Zone and the Ottawa Hospital), all sinus CT scans performed over a 2-year period were identified (9,739), and 100 from each center were randomly selected for analysis. The radiology reports were scrutinized to determine if seven critical and 11 noncritical items were mentioned. RESULTS: Many (22%) otolaryngologists are dissatisfied with current sinus CT radiologic reporting, and the majority (67%) would like more clinically useful information. All predefined sinus CT items were inconsistently reported. Anterior ethmoid artery anatomy, ethmoid skull base integrity, and sphenoethmoidal cell were the most infrequently reported critical items. CONCLUSIONS: This study has demonstrated that important information is inconsistently reported for sinus CT, and most otolaryngologists would like to see more clinically relevant content in radiology reports. Optimizing the reporting of sinus CT scans will improve communication between the radiologist and other clinicians managing patients with sinonasal disease. LEVEL OF EVIDENCE: 2b.

The utility of the harmonic scalpel in selective neck dissection: a prospective, randomized trial.

OBJECTIVES: To determine the impact of the harmonic scalpel on intraoperative blood loss and operative time in selective neck dissection (SND) (levels I-IV) for head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN: Prospective randomized controlled trial. SETTING: A single, tertiary care institution (Foothills Medical Centre) in Calgary, Alberta, Canada. SUBJECTS: A total of 31 patients (36 neck dissections) were prospectively enrolled between January 2009 and March 2010. METHODS: Patients were randomized to receive a neck dissection with either the harmonic scalpel or the traditional technique of using electrocautery and sharp dissection. The study included adult patients older than age 18 years diagnosed with HNSCC and who required an SND (levels I-IV). Study exclusion criteria included previous treatment for head and neck cancer and all patients unwilling or unable to provide informed consent. Primary clinical outcomes were intraoperative blood loss and operative time. Secondary outcomes included intraoperative complications and surgical drain output. RESULTS: Intraoperative blood loss was significantly lower in the harmonic scalpel group compared to the traditional group (158 vs 61 mL, P = .02). There was no difference in operative time (81 minutes harmonic vs 85 minutes traditional) or total drain output (at both 48 hours and 1 week) between the groups. There were no intraoperative complications reported in either group. CONCLUSIONS: Results from this study suggest that the harmonic scalpel can reduce blood loss during SND for HNSCC. The harmonic scalpel had no impact on operative time, postoperative drain output, or complication rate.

Training, practice, and referral patterns in rhinologic surgery: survey of otolaryngologists.

OBJECTIVES: Rhinology, which encompasses clinical and surgical treatment of the nasal cavity and paranasal sinuses, is a growing subspecialty with advances in the surgical, clinical, and research realms. The advancement of this subspecialty and its impact on the practice of otolaryngology, in both academic and nonacademic institutions, is not yet understood. METHODS: A novel survey created by our research team was mailed out to 150 randomly selected otolaryngology staff and 8 fellowship-trained rhinologists throughout Canada asking questions related to demographics, training, referral patterns, technique, and adequacy of training. RESULTS: One hundred respondents completed the survey, yielding a response rate of 63%. The average age of rhinologists who responded (38 years) was younger than those who were nonrhinologists (50 years). Compared with fellowship-trained rhinologists, nonrhinologists felt less comfortable with cerebrospinal leak repairs, skull base surgery, frontal sinus surgery, paranasal sinus neoplasm removal, and sphenopalatine artery ligation. CONCLUSIONS: Rhinology is a distinct subspecialty with new fellowship opportunities combined with advances in surgical technique, clinical treatments, and research opportunities. There are procedures that can be performed by both rhinologists and nonrhinologists; however, there is a subset of procedures that nonrhinologists do not feel comfortable performing. These procedures should be referred to fellowship-trained rhinologists who practice out of academic centres.

Complementary and alternative medicine use among general surgery, hepatobiliary surgery and surgical oncology patients.

BACKGROUND: The use of complementary and alternative medicine (CAM) is becoming more common, particularly among cancer patients. We sought to define the frequency of CAM use among general surgery, hepatobiliary and surgical oncology patients and to define some of the determinants of CAM use in patients with benign and malignant disease. METHODS: We asked all patients attending the clinics of 3 hepatobiliary/surgical oncology surgeons from 2002 to 2005 to voluntarily respond on first and subsequent visits to a questionnaire related to the use of CAM. We randomly selected patients for review. RESULTS: We reviewed a total of 490 surveys from 357 patients. Overall CAM use was 27%. There was significantly more CAM use among cancer (34%) versus noncancer patients (21%; p = 0.008), and the use of CAM was more common in patients with unresectable cancer (51%) than resectable cancer (22%; p < 0.001). There was no significant difference in use between men and women. There did not appear to be a change in CAM use with progression of cancer. The most common CAM was herbs or supplements (58% of all users), which were most frequently used by patients with malignant disease. Among the 27 herbs reported to be ingested, 10 are associated with bleeding and hepatotoxicity, as described in the literature. CONCLUSION: Prospective studies evaluating surgical outcomes related to CAM use are needed.

Evaluation of meta-analyses in the otolaryngological literature.

OBJECTIVE: To evaluate the quality of meta-analyses written on otolaryngological topics and define areas that can be improved upon in future studies. DATA SOURCES: MEDLINE (PubMed) and EMBASE databases were searched. The Cochrane database of systematic reviews was excluded, because these meta-analyses have already been critically evaluated and found to be of high quality. REVIEW METHODS: A systematic review of otolaryngological meta-analyses published between 1997 and 2006 (10 years) was performed in duplicate and independently by two authors. The search included 16 common otolaryngological terms. Inclusion criteria were meta-analytic methodology, otolaryngological topic, and at least one author from a department of otolaryngology. Fifty-one articles fulfilled eligibility criteria. In duplicate and independently, two reviewers assessed the quality of eligible meta-analyses using a validated 10-item index called the Overview Quality Assessment Questionnaire. Using the methods of Spearman, correlation coefficients are reported for associations examined between covariates and the Overall Score Quality. RESULTS: The majority of studies had methodologic flaws (mean score 3.9, scale of 1-7). Variables predicting higher-quality meta-analyses were publication in journals with higher impact factors (P = 0.0007) and authors who previously published meta-analyses (P = 0.0001). Using and reporting about a validity assessment tool needs to be improved upon in future studies. CONCLUSION: The quality of meta-analyses on otolaryngological topics is moderate. Future meta-analyses can be improved upon by following evidence-based guidelines for the reporting of meta-analyses, which include the use of a validity assessment tool, and consulting with an author familiar with meta-analysis methodology.

Does surgeon fatigue influence outcomes after anterior resection for rectal cancer?

BACKGROUND: The long work hours in surgery may contribute to medical errors and impact patient outcomes. To date, there are no studies investigating outcomes related to fatigue in general surgery. METHODS: All patients undergoing anterior resection between 1994 and 2005 at 2 university hospitals were identified. Cases were categorized as fatigued or nonfatigued and then compared with respect to complications and cancer recurrence. RESULTS: Two hundred seventy patients underwent anterior resection during the study period. Of these, 22 were performed when the surgeon was fatigued. The fatigued and nonfatigued groups had similar preoperative characteristics. The rates of intraoperative complications (fatigued 14%, rested 18%, P = .58), major postoperative complications (fatigued 9%, rested 15%, P = .68), long-term complications (fatigued 31%, rested 31%, P = .9), and local cancer recurrence rates (fatigued 0%, rested 7%, P = .2) were not significantly different between the 2 groups. CONCLUSIONS: Surgeon fatigue did not influence outcomes after anterior resection for rectal cancer.