JAMA otolaryngology-- head & neck surgery最新文献

Importance: The benefit of adenoidectomy on otologic outcomes after tympanostomy tube (TT) insertion is unclear. Results from prior work are challenging to interpret due to small sample sizes, heterogeneous study designs, and varying outcome measures.

Objective: To evaluate the association between adenoidectomy and otologic outcomes using a US population-level sample of children who received TTs, producing generalizable results for widespread clinical application.

Design, setting, and participants: A matched cohort study was conducted using claims data from the Merative MarketScan Research Databases. The study included 601 848 children who received TTs between January 1, 2007, and December 31, 2021. Children who received adenoidectomy and TTs simultaneously (Ad+TT) were identified irrespective of the number of prior TTs. Control participants who received TTs without adenoidectomy were matched based on sex, age at the time of the procedure, and the number of prior TT procedures.

Exposures: Adenoidectomy without tonsillectomy was the primary exposure.

Main outcomes and measures: The primary outcomes were repeat TT insertion and subsequent oral antibiotic prescriptions after TT insertions. Multivariable logistic regression was used to quantify the effects of adenoidectomy and covariates on each outcome. Stratified analyses were performed in children younger than 4 years and 4 years or older.

Results: Overall, 601 848 children (median [IQR] age, 2 [1-4] years; range, 0-11 years; 351 078 [58.3%] male) who received TTs were identified. The Ad+TT cohort included 201 932 children, with an equal number in the matched cohort. In children younger than 4 years, Ad+TT was common and was associated with lower odds of subsequent oral antibiotics (odds ratio [OR], 0.59; 95% CI, 0.58-0.60) but higher odds of repeat TT insertions (OR, 1.24; 95% CI, 1.22-1.27). In children 4 years or older, Ad+TT was associated with lower odds of repeat TT insertions (OR, 0.78; 95% CI, 0.75-0.81) and subsequent oral antibiotics (OR, 0.63; 95% CI, 0.62-0.65).

Conclusions and relevance: This study found that in children younger than 4 years, Ad+TT was commonly performed and may have had a secondary benefit of reducing subsequent oral antibiotic courses; however, it was not associated with a reduction in the risks of repeat TT insertions. In children 4 years or older, Ad+TT was associated with a reduction in the risk of repeat TT insertions and subsequent oral antibiotics. Given these findings, Ad+TT may be offered in children 4 years or older to improve otologic outcomes.

Importance: Frozen section (FS) analysis of sentinel nodes offers potential on-table diagnosis and treatment for occult metastasis in oral squamous cell cancer. Systematic analysis of FS during sentinel node biopsy has not been illuminated in the literature.

Objective: To systematically review pooled data from studies using FS analysis in evaluating sentinel nodes in patients with cT1-T2 N0 oral squamous cell cancer.

Data sources: An academic librarian led the search of CENTRAL, CINAHL, Cochrane Database of Systematic Reviews, Embase, and MEDLINE for studies published in English between January 2000 and January 2023.

Study selection: Two authors independently screened cohort studies, case series, and randomized clinical trials, in which FS analysis was used to evaluate sentinel nodes in patients with cT1-T2 N0 oral squamous cell cancer.

Data extraction and synthesis: Data were extracted by 2 reviewers. Reporting quality was estimated using the Diagnostic Precision Study Quality Assessment Tool. Data analysis was performed between April and July 2023, and the meta-analysis was completed using the bivariate random-effects model.

Main outcomes and measures: The primary outcome was the pooled sensitivity of FS sentinel node analysis. Secondary outcomes included evaluation of the FS technique, rate of occult metastasis, false-negative rate, and survival.

Results: Seventeen articles with 878 patients met the eligibility criteria. Although protocols varied, confirmatory serial step sectioning was performed in all studies. Occult metastasis was found in 263 of 878 patients (30%), and FS analysis identified 173 cases (65.8%). Following serial sectioning, an additional 90 positive results were identified, leading to 47 patients undergoing staged completion neck dissection. The pooled sensitivity of FS was 0.71 (95% CI, 0.60-0.80), the diagnostic odds ratio was 110, and the false-negative rate was 34.2%. The Cochrane Q value was 15.62 (df = 16; P = .48) and τ2 = 0.36.

Conclusion and relevance: In this systematic review and meta-analysis, evaluated studies showed various techniques, in which pooled sensitivity reached 0.71, providing a benchmark for comparison to other 1-stop approaches. Due to the high false-negative rate of approximately one-third of patients, intraoperative FS must always be supplemented by serial sectioning. On-table diagnosis remains a key objective for sentinel node biopsy, and FS detection may be improved by standardizing protocols.

Importance: How rates of thyroid cancer diagnosis were affected by the emergence of COVID-19 variants during the 2020 to 2021 era of the pandemic has not been described.

Objective: To estimate the total number of undiagnosed cases of thyroid cancer, by histologic type, during the first 2 years of the COVID-19 pandemic (2020 and 2021) by comparing observed to expected incidence and to test for changes in size of cancer at incidence during the same period compared to prior years.

Design, setting, and participants: This longitudinal study analyzed trends in thyroid cancer diagnoses from 2016 to 2021 among US adults using data from the Surveillance, Epidemiology, and End Results 22 (SEER-22) program database. Data analyses were performed in April to May 2024.

Main outcomes and measures: Age-adjusted incidence rate per 100 000 US adults, changes in incidence, estimated number of undiagnosed cases, and mean cancer size.

Results: Absolute rates of overall thyroid cancer incidence in the first quarter of 2016 and of 2019 were 21.0 and 18.8 per 100 000, respectively. From 2020 through 2021, the quarterly rates were 17.3, 11.1, 17.2, 17.9, 17.4, 19.0, 17.1, and 17.3 per 100 000, respectively. The observed incidence of thyroid cancers decreased by 11% for papillary cancers 2 cm or smaller (risk ratio [RR], 0.89; 95% CI, 0.83-0.95), 14% for papillary cancers larger than 2 cm (RR, 0.86; 95% CI, 0.79-0.93), 8% for follicular cancers (RR, 0.92; 95% CI, 0.82-0.92), 10% for medullary cancers (RR, 0.90; 95% CI, 0.78-1.04), and 15% for anaplastic cancers (RR, 0.85; 95% CI, 0.68-1.07) from March 2020 to December 2021. Oncocytic cancers declined in incidence early in the pandemic, but rates returned to baseline or above through 2021 (RR, 1.15; 95% CI, 0.97-1.37). Extrapolated to the general US population, the total estimated number of thyroid cancer cases not diagnosed (expected minus observed) from March 2020 to December 2021 was approximately 10 200: 5400 papillary cancers 2 cm or smaller (95% CI, 2380-8530), 3700 papillary cancers larger than 2 cm (95% CI, 1660-5810), 600 follicular cancers (95% CI, -260 to 1550), 300 medullary cancers (95% CI, -110 to 720), and 190 anaplastic cancers (95% CI, -75 to 530). Mean size at diagnosis did not change significantly between 2016 and 2021 for any histologic type.

Conclusions and relevance: This longitudinal study found that by the end of 2021, many thyroid cancers remained undiagnosed. These were predominantly small papillary cancers but also affected all histologic types except oncocytic. These deficits in diagnosis could produce a temporary increase in the rate of patients presenting with larger or more advanced stage cancers in the future, and consequently, temporary increases in population morbidity and mortality.

Background: Transoral robotic surgery (TORS) or transoral laser microsurgery (TLM) offer excellent oncological outcomes for oropharyngeal squamous cell carcinoma caused by human papillomavirus (HPV) infection. TORS may offer greater margin clearance around tumors than TLM.

Objective: To determine whether the differing energy sources used and surgical technique of TORS or TLM is associated with postoperative early swallowing function, feeding tube use, and specific factors related to quality of life.

Design, setting, and participants: This prespecified cohort study was performed within the Postoperative Adjuvant Treatment for HPV-Positive Tumours (PATHOS) randomized clinical trial at 40 centers in the UK, Germany, France, the US, and Australia between November 1, 2015, and August 31, 2023. PATHOS trial participants with HPV-positive oropharyngeal carcinoma of stages T1 to T3 and N0 to N2b M0 (TNM7) who underwent TLM or TORS were eligible. Of 989 consecutively recruited patients on the PATHOS trial, 508 were eligible for this substudy.

Exposures: The exposure of interest was TORS or TLM.

Main outcomes and measures: Preplanned outcome measures included nasogastric tube insertion rates within 4 weeks after surgery, length of in-hospital stay following surgery, specific scales from the MD Anderson Dysphagia Inventory (MDADI), 35-item European Organization for Research and Treatment of Cancer Head and Neck Questionnaire (H&N35), and 30-item Quality of Life Questionnaire (QLQ C30), water swallow test results, and videofluoroscopy scores.

Results: Of the 508 patients included in the analysis (390 [76.8%] male; median age, 58.3 [IQR, 52.8-63.6] years), 195 had TLM and 313 had TORS. Nasogastric tube insertion rates were higher after TORS than TLM (85 of 189 [45.0%] vs 10 of 126 [7.9%]; adjusted odds ratio [OR], 4.41 [95% CI, 1.01-19.32]). Mean scores favored TLM with small effect sizes in all MDADI domains and the H&N35 swallowing item at 4 weeks after surgery; between-group difference for the MDADI composite score was -4.89 (95% CI, -8.27 to -1.50); for the MDADI physical functioning score, -6.37 (95% CI, -10.15 to -2.59); for the MDADI global score, -10.02 (95% CI, -16.50 to -3.54); and for H&N35 swallowing score, 7.24 (95% CI, 2.17-12.30). No other measures showed evidence of clinically meaningful differences.

Conclusions and relevance: In this cohort study, functional outcomes were moderately less impaired 4 weeks following TLM compared with TORS. Once the longer-term outcomes for these patients are known, these findings could aid the design and use of future head and neck-specific surgical robots.

Trial registration: ClinicalTrials.gov Identifier: NCT02215265.

Importance: Cannabis use has experienced substantial growth. Many patients treated by otolaryngologists are using cannabis in various forms, often without the knowledge of the treating surgeon. These cannabinoid substances have various systemic effects, and it is critical for otolaryngologists to recognize how cannabis use may contribute to a patient's care.

Observations: Cannabis use has effects that contribute to every phase of a surgeon's care. Preoperative counseling for tapering use may prevent increased rates of adverse effects. Care with anesthesia must be observed due to increased rates of myocardial ischemia, higher tolerance to standard doses, and prolonged sedation. Although results of studies are mixed, there may be an association with cannabis use and postoperative pain, nausea, and vomiting. Postoperative wound healing may be improved through the use of topical cannabinoids. Significant drug-drug interactions exist with cannabis, most notably with several common anticoagulant medications. Care should be exercised when managing medications for people who use cannabis. While many people who use cannabis consume it infrequently, a substantial population has developed cannabis use disorder, which is associated with increased morbidity and mortality postoperatively. Screening for cannabis use disorder is important and can be done through short screening tools.

Conclusions and relevance: Patients who use cannabis may require special attention regarding preoperative counseling and workup, intraoperative anesthesia, postoperative pain management, nausea, wound healing, and drug-drug interactions. As patient use continues to increase, otolaryngologists will find an increasing need to remain up to date on how cannabis use contributes to patient care.