Cheryl C. Nocon

Immunoglobulin E-mediated food allergies among adults with allergic rhinitis

OBJECTIVE: To compare the prevalence of food allergy for peanut, shrimp, and milk in adults with allergic rhinitis and to determine predictive values of these allergens and total immunoglobulin E (IgE) to detect food allergies. STUDY DESIGN: Cross-sectional study. SETTING: University of Chicago Medical Center, Chicago, Illinois. SUBJECTS AND METHODS: We retrospectively analyzed in vitro enzyme-linked immunosorbent assays of adults with rhinitis. Subjects were tested for nine inhalants and three foods (peanut, shrimp, milk) and total IgE. Subjects with food allergy history were tested with additional foods. The sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of the allergens and total IgE to detect food allergies were calculated. RESULTS: A total of 283 subjects received in vitro tests. Fortyone percent tested negative and 59 percent tested positive for inhalants. The prevalence of subjects with a positive peanut or shrimp allergy in the inhalant-positive population was significantly greater than subjects with milk allergy (23.4% peanut [P = 0.008], 22.2% shrimp [P = 0.001], and 13.2% milk [P = 0.008], P = 0.001). For subjects with food allergy history, peanut had the best SP (100.0%), SE (28.1%), PPV (100.0%), and NPV (64.6%) in detecting allergies to other foods. In patients positive for the initial panel (inhalants and peanut), the SP, SE, PPV, and NPV of elevated total IgE was 71.4, 72.4, 77.8, and 65.2 percent, respectively. CONCLUSION: Peanut and shrimp were the most common foods encountered in adults with allergic rhinitis. Peanut was best in predicting other food allergies. Total IgE levels with inhalants plus peanut provided the optimal combination of SE, SP, PPV, and NPV. In vitro testing may be important to identify and prevent anaphylaxis to foods in adults.

Emergency airway management: Training and experience of chief residents in otolaryngology and anesthesiology†‡§

Resident training in emergency airway management is not well described. We quantified training and exposure to airway emergencies among graduating Otolaryngology–Head and Neck Surgery and Anesthesiology residents.

Assessment of adjuvant therapy in resected head and neck cancer with high-risk features

OBJECTIVES Subgroup analysis from two randomized trials showed a survival benefit for adjuvant chemoradiation (CRT) over radiation alone (RT) in patients with extracapsular spread (ECS) of involved lymph nodes and/or positive margins (PM) in resected head and neck cancer (HNSCC). However, results were not analyzed separately for patients with ECS or PM and were not stratified by tumor subsite/HPV status. We therefore sought to determine whether adjuvant CRT is associated with a survival benefit, separately among patients with ECS or PM and stratified by subsite/HPV status. METHODS Using the National Cancer Database (NCDB), we identified 6948 patients diagnosed with HNSCC between 2010 and 13 who underwent surgical resection and had either ECS or PM. The impact of adjuvant therapy on OS from surgery was evaluated using Cox proportional hazards regression adjusting for clinical and demographic factors. RESULTS Adjuvant CRT was associated with a significant survival benefit over RT alone among patients with ECS (aHR 0.83, 95%CI 0.71-0.97) but not among those with PM (aHR 0.89, 95%CI 0.77-1.04). In patients with HPV-negative tumors, CRT was associated with a benefit over RT alone in the setting of ECS (aHR 0.83, 95%CI 0.70-0.98) but not PM (aHR 0.91, 95%CI 0.78-1.06). However, in patients with HPV-positive oropharynx tumors, CRT was not associated with a benefit over RT in ECS (aHR 0.94, 95%CI 0.47-1.88) but appeared beneficial in PM (aHR 0.54, 95%CI 0.32-0.90). CONCLUSIONS CRT appears beneficial over RT in ECS among patients with HPV-negative tumors, and beneficial in PM among patients with HPV-positive tumors.

One-hour PTH after thyroidectomy predicts symptomatic hypocalcemia

BACKGROUND A major morbidity after total thyroidectomy is hypocalcemia. Although many clinical factors and laboratory studies have been correlated with both biochemical and symptomatic hypocalcemia, the ideal use and timing of these tests remain unclear. We hypothesize 1-h (PACU) parathyroid hormone (PTH) will identify patients at risk for symptomatic hypocalcemia. METHODS This prospective study evaluated 196 patients undergoing total thyroidectomy. Serum calcium and PTH levels were measured 1 h after surgery and on postoperative day 1 (POD1). Performance of a central compartment lymph node dissection, parathyroid autotransplantation, indication for procedure, pathology, and presence of parathyroid tissue in the pathology specimen were recorded. RESULTS Of 196 patients, nine (4.6%) developed symptomatic hypocalcemia. Thirty four (17.3%) had a 1-h PACU PTH ≤10 pg/dL, whereas 31 (15.8%) had a POD1 PTH of ≤10. Five (56%) of the nine symptomatic patients underwent central compartment lymph node dissection, four (44%) had parathyroid autotransplantation, and four (44%) had a PACU PTH ≤10. PACU and POD1 PTH levels were correlated (R(2) = 0.682). Multivariate regression identified central compartment dissection, autotransplantation, and PACU or POD1 PTH correlated with symptomatic hypocalcemia. PACU PTH, POD1 PTH, PACU Ca, malignant final pathology, and age ≤45 y correlated with biochemical hypocalcemia. CONCLUSIONS A 1-h postoperative PACU PTH is equivalent to POD1 PTH in predicting the development of symptomatic hypocalcemia. Biochemical hypocalcemia was not predictive of symptoms in the immediate postoperative period. Lymph node dissection and parathyroid autotransplantation correlated with symptomatic hypocalcemia and improve the sensitivity of biochemical screening alone.

Acute Rhinosinusitis in Children

Acute rhinosinusitis in children is a common disorder that is characterized by some or all of the following symptoms: fever, rhinorrhea, nasal congestion, cough, postnasal drainage, and facial pain/headache. It often starts as an upper respiratory tract infection that is complicated by a bacterial infection in which the symptoms worsen, persist, or are particularly severe. The accurate diagnosis of acute rhinosinusitis is challenging because of the overlap of symptoms with other common diseases, heavy reliance on subjective reporting of symptoms by the parents, and difficulties related to the physical examination of the child. Antibiotics are the mainstay of treatment. There is no strong evidence for the use of ancillary therapy. Orbital and intracranial complications may occur and are best treated early and aggressively. This article reviews the diagnosis, pathophysiology, bacteriology, treatment, and complications of acute rhinosinusitis in children.

Quality of neck dissection operative reports

PURPOSE The operative report is the official documentation of an operation and a key form of surgical communication. The objective of this study is to assess completeness of operative reports for neck dissections. METHODS This is a retrospective review of narrative operative reports for neck dissections for head and neck squamous cell carcinoma. Forty-nine operative reports were provided by ten surgeons from seven academic institutions. Operative report completeness was expressed as a percentage of variables from a standardized checklist created by an expert panel. RESULTS For level 1 dissections, most reports identified critical structures, such as the marginal mandibular nerve (84%) and the submandibular gland (84%). Of the cases that involved submandibular gland excision, reports were deficient in identification of the lingual nerve (74%), hypoglossal nerve (58%) and submandibular duct (22%). For neck dissections involving levels 2, 3 and 4, most described identifying spinal accessory nerve (92%) and internal jugular vein (98%), whereas fewer described identification of carotid artery or vagus nerve (67%), ansa cervicalis (31%), or cervical rootlets (48%). For level 5 dissections, only 75% of reports reported identification of spinal accessory nerve. Sixty percent of reports provided some description of the removed lymph nodes, but there was no consistency in terminology or definitions. Overall completeness of all NORs was 64% (40%-79%, SD 9%). CONCLUSIONS There is heterogeneity and incompleteness in neck dissection operative reports across surgeons and institutions, despite being a crucial record of head and neck cancer treatment.

Racial disparities in the choice of definitive treatment for squamous cell carcinoma of the oral cavity

Definitive surgery is recommended for oral cavity squamous cell carcinoma (SCC). The purpose of this study was to present our assessment of the disparities in treatment selection for oral cavity SCC.

Association of Facility Volume With Positive Margin Rate in the Surgical Treatment of Head and Neck Cancer

Importance The achievement of complete tumor resection with tumor-free margins is one of the main principles of oncologic surgery for head and neck squamous cell carcinoma (HNSCC). The negative prognostic influence of a positive margin (PM) across all head and neck subsites has been well established. National guidelines recommend the use of adjuvant chemoradiation therapy (CRT) in the setting of PM. Objective To determine the incidence of PM in HNSCC across multiple subsites, as well as the factors associated with its occurrence. Design, Setting, and Participants This retrospective cohort study used the National Cancer Database to identify patients diagnosed with HNSCC between 2010 and 2014 and who underwent surgical resection (n = 28 840). Main Outcomes and Measures Predictors of PM rate and likelihood to receive adjuvant CRT. Results Among the 28 840 patients included in this study, 19 727 (68.4 %) were men, and the average age was 62.4 years (range, 40 to ≥90 years). In univariable analysis, a lower PM rate was associated with higher facility volume (26.3% for the lowest volume quartile, 16.5% for the middle 2 quartiles, and 10.8% for the highest volume quartile) and treatment at academic vs nonacademic facilities (14.0% vs 22.7%). In multivariate analysis, those treated at higher-volume facilities remained significantly less likely to have PM (adjusted odds ratio, 0.85; 95% CI, 0.83-0.88). The trend of decreasing PM rate with increasing facility volume was observed in both academic (aOR, 0.88 per 10-case volume increase [95% CI, 0.85-0.91]) and nonacademic (aOR, 0.73 per 10-case volume increase [95% CI, 0.68-0.80]) facilities. There was no association between facility volume and patient likelihood of receiving adjuvant CRT in the setting of PM (compared with CCPs: aOR, 0.98 per 10-case volume increase [95% CI, 0.84-1.14] for CCCPs; and aOR, 1.24 [95% CI, 0.99-1.55] for INCPs). Conclusions and Relevance These findings suggest that high-volume facilities are associated with lower rates of PM in the surgical treatment of HNSCC in both academic and nonacademic settings. Facility volume for head and neck oncologic surgeries may be considered a benchmark for quality of care.

Association of a Proactive Swallowing Rehabilitation Program With Feeding Tube Placement in Patients Treated for Pharyngeal Cancer

Importance A proactive speech and language pathology (SLP) program is an important component of the multidisciplinary care of patients with head and neck squamous cell carcinoma (HNSCC). Swallowing rehabilitation can reduce the rate of feeding tube placement, thereby significantly improving quality of life. Objective To evaluate the initiation of a proactive SLP rehabilitation program at a single institution and its association with rates of feeding tube placement and dietary intake in patients with HNSCC. Design, Setting, and Participants Cohort study at a tertiary care and referral center for patients with HNSCC serving the northern Chicago region. Patients were treated for squamous cell carcinomas of the hypopharynx, oropharynx, and nasopharynx from 2004 to 2015 with radiation or chemoradiation therapy in the definitive or adjuvant setting. Patients who received less than 5000 cGy radiation or underwent reirradiation were excluded. Interventions A proactive SLP program for patients with HNSCC was initiated in 2011. Study cohorts were divided into 2 groups: 2004 through 2010 and 2011 through 2015. Main Outcomes and Measures Primary outcome variables were SLP referral placement and timing of the referral. Secondary outcomes were feeding tube placement and ability to tolerate any oral intake. Results A total of 254 patients met inclusion criteria (135 before and 119 after implementation of SLP program; median age, 60 years [range, 14-94 years]; 77% male). With the initiation of a proactive SLP program, pretreatment evaluations increased from 29 (21.5%) to 70 (58.8%; risk ratio [RR], 2.74; 95% CI, 1.92-3.91), and rate of referral overall at any time increased from 60.0% to 79.8% (RR, 1.33; 95% CI, 1.13-1.57). Feeding tube placement rates decreased from 45.9% (n = 62) to 29.4% (n = 35; RR, 0.64; 95% CI, 0.46-0.89). Among patients receiving a swallow evaluation, feeding tube requirements were less frequent for those receiving a pretreatment evaluation (31 of 99 [31%]) than for those referred during (11 of 18 [61%]) or after (38 of 59 [64%]) treatment. The rate of tolerating any oral intake at the end of treatment improved from 71.1% (n = 96) in the preimplementation period to 82.4% (n = 98; RR, 1.16; 95% CI, 1.01-1.33). Conclusions and Relevance A proactive SLP program can be successfully established as part of the multidisciplinary care of patients with HNSCC and improve patient quality of life.

Factors Affecting Delays to Surgery for Oral Tongue Carcinoma in the National Cancer Data Base

Objectives: Surgery is the definitive treatment for oral tongue squamous cell carcinoma (OSCC). Studies have described correlates of delayed diagnosis. However, little is known about treatment delays after diagnosis. This study investigates time intervals from diagnosis to surgery for OSCC using the National Cancer Data Base (NCDB). Methods: The NCDB was queried for OSCC patients initially treated with surgery in 1998 through 2009. Patients were dichotomized based on time to surgery relative to the median. Chi-square and multivariable logistic regression models were used for statistical analyses. Results: A total of 14,270 patients were identified. The median age was 60 years (range, 18-90 years). For all stages, the median time from diagnosis to surgery was 27 days (SD = 42). Factors that predicted a longer interval to surgery included: advanced stage (28 days), Hispanic ethnicity (29 days), lack of health insurance (29 days), treatment at an academic/research facility (29 days), residence >75 miles from the hospital (31 days), treatment in the Middle (29 days) and South Atlantic (28 days) states, and having a referral to a different treating center (30 days). The strongest predictors of time delay were having a referral (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.83-2.13, P < .001) and geographic location (Middle Atlantic: OR 1.83, 95% CI 1.57-2.14, P < .001). Conclusions: There is significant variation in the time from diagnosis to surgery for patients with OSCC. Several patient, geographic, and facility factors predict treatment delays. These findings can be used as a benchmark for quality of care and to guide further investigation into whether timing disparities affect outcomes.