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Chronic Rhinosinusitis Diagnosis: Primary and Secondary Care
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Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
tinued analysis of success in additional clinical measures is ongoing. CONCLUSION: The implementation of a formal synoptic report at our institution translated to a higher level of adherence to reporting of critical pathologic features that impact outcomes for patients with oral cavity cancer. It is incumbent upon us to continue to develop ways to track these features and measure adherence to quality measures locally and via national cancer registries. Benchmarking Low-Volume Center Head and Neck Surgery Outcome Alexander Vlantis, FCS(SA)ORL (presenter); Wendy F Bower; Siu-Kwan Ng, FHKAM; Eddy W Y Wong, MB, ChB; C Andrew van Hasselt OBJECTIVE: To determine if 1) Low-volume surgery negatively impacts the outcomes of head and neck patients and 2) Benchmarking the outcomes from low-volume surgical services matches those from high-volume services. METHOD: Outcome data registries were prospectively completed for audit purposes for 203 consecutive patients undergoing a surgical head and neck procedure between October 2005 and August 2009 at a low-volume but high intensity and complexity academic tertiary referral center. Intra- and postoperative complications were identified, data evaluated and the morbidity and mortality rates compared with rates from highvolume centers or surgical specialty group data. Morbidity was benchmarked against international levels to evaluate quality of outcomes. RESULTS: Head and neck procedures were grouped into oral cavity, non-oral cavity and thyroid procedures. Morbidity of any severity was reported in 74%, 56% and 25% respectively of oral cavity, non-oral cavity and thyroid patients. One patient required a return to the operating room postoperatively. The most common complications were fistula (16%) and fever (12%) for oral cavity patients, fever (11%) and dysphagia (10%) for non-oral cavity patients and swallowing difficulty (2%) and non-laryngeal nerve damage (2%) for thyroid patients. The incidence of the major thyroid surgery complications of vocal cord paralysis, non-resolving vocal cord palsy and hypocalcemia were 8%, 2% and 33% respectively. CONCLUSION: This prospective study demonstrated that low-volume surgery does not negatively impact the surgical outcomes of head and neck patients, and that meaningful surgical outcomes from low-volume centers can be measured and benchmarked. Carotid Stenosis after Cervical Radiotherapy Marco de Vincentiis, MD (presenter); Andrea Gallo, MD, PhD; Caterina Marinelli, MD; Gian Franco Macri, MD; Antonio Greco, MD
OBJECTIVE: The aim of our study was to evaluate the prevalence of carotid stenosis in patients with head and neck malignant tumors treated with radiotherapy. METHOD: In our study we included 137 patients with head and neck cancers treated during a period of about 5 years. The larynx was the most common affected site of primary tumor. Only 93 patients were alive at the moment of our observation. A group of 39 patients underwent neck radiation. A control group of 54 patients were not treated with radiotherapy. All patients undergoing radiotherapy received a local dose of 50-70 Gy for 6 weeks. An echo Doppler scan of the carotid arteries was performed in all patients with estimation of common and internal carotid artery Intimal Medial Thickness (IMT). Stenosis grading was divided into low (0-30%), moderate (31-49%) and severe (more than 50%). In addition, we considered hematochimic and flogistic parameters. Statistic evaluation was performed with Chi-square test. RESULTS: We found that severe carotid stenosis was higher (41%) in patients who had undergone radiotherapy than in the control group (16.6 %) (P ⫽ 0.008). The echo Doppler examination demonstrated that the most commonly affected site was the internal carotid artery, just past the carotid fork. CONCLUSION: A pre-operative carotid artery echo Doppler allows to detect asymptomatic atherosclerotic lesions with no actinic action relation. A post-operative study is also very important since we can attempt medical therapy with antiinflammatory drugs in line with the modern concept of atherosclerosis as a focal arteritis. Chronic Rhinosinusitis Diagnosis: Primary and Secondary Care Constantine Stamatoglou, MBBS (presenter); Suresh Yadlapalli, MS, MRCS, DOHNS; Navdeep Upile, MBBS, MRCS; Nazir Bhat, MD, MRCS OBJECTIVE: The European Position Paper on Rhinosinusitis and Nasal Polyps 2007 (EPOS 2007) sets out a clear set of evidence-based guidelines regarding the management of chronic rhinosinusitis. We audited the referrals to and subsequent management of rhinosinusitis in a secondary care centre in relation to these guidelines. METHOD: A prospective audit, comparing validity of referral to secondary care and subsequent diagnosis, investigation and management, as compared to the standards set out by the EPOS 2007 paper. RESULTS: There appeared to be poor uptake of the guidelines in general practice. This was improved in secondary care, however severity was rarely noted as per guidelines. CONCLUSION: We discuss referrals falling outside of EPOS criteria, and highlight the need for further uptake of these protocols within primary care, including the possibility of local training sessions. Diagnosis in secondary care was more accurate, but objective measures of severity such as visual analogue
scales were not used routinely, and there was some variation according to specialist preference. Clinical Care Pathway: Improving Free Flap Patient Outcomes Brian Harmych, MD (presenter); Gordon Sun, MD; Meredith Tabangin, MPH; Jareen Meinzen-Derr, PhD; Yash Patil, MD OBJECTIVE: Determine whether utilization of a clinical care pathway/computerized order set (CCP/COS) results in decreased hospital length of stay (LOS), expenditures, and unplanned surgery for complications in patients undergoing head and neck microvascular free flap reconstruction (FFR). METHOD: A retrospective review of 130 patients undergoing FFR from March 2007 to June 2009 was conducted. Unplanned operation rate, disposition, overall hospital length of stay (LOS) and cost, plus LOS and cost variance, were reported. Chi-square testing, Wilcoxon’s ranked sum test, Fisher’s exact test, and a logistic regression model were utilized for statistical analysis. RESULTS: 133 FFR procedures were performed by the senior author, 86 of which were performed prior to CCP/COS implementation. Patient median age was 58 years. 108/133 (81%) of all surgeries were performed following squamous cell carcinoma resection. The unplanned operation rate of 34% decreased to 15% after CCP/COS institution (P ⫽ 0.019). Discharge with home health care (HHC) declined from 74% to 45% (P ⫽ 0.0006), while skilled nursing facility (SNF) utilization increased from 21% to 45% (P ⫽ 0.016). Mean LOS decreased from 9.5 to 8.7 days after CCP/COS implementation (P ⫽ 0.59), with a significant difference in LOS variance (P ⫽ 0.0009). There was no difference in median hospital costs (P ⫽ 0.39) or cost variance (P ⫽ 0.65) after CCP/COS implementation. CONCLUSION: Preliminary data on CCP/COS implementation in head and neck FFR patients suggest that improved patient outcomes could be achieved without a significant change in overall median hospital costs. Endoscopic Repair of CSF Leaks Using Turbinate Grafts Danilo Sguillar, MD (presenter); Antonio Carlos Cedin, MD; Ana Paula Bezerra, MD OBJECTIVE: To analyze the results of surgical treatment of CSF leaks having different etiologies by endoscopic endonasal surgery using mucosa from inferior/middle turbinates. METHOD: Thirteen patients were analyzed in a retrospective study. They were operated on by a endoscopic endonasal approach using the mucosa of the turbinates which were fash-
P143 ioned preserving the periosteum of the mucosal graft. They were positioned by the overlay technique with the periosteum facing the dural defect and fixed with fibrin glue. Layers of oxidized cellulose polymer were positioned over the graft in order to stabilize it. RESULTS: Twelve patients had successful results (93%). One of them had a new CSF leak at another site (n-11) and another, had a recurrence at the same site (n-2). These latter were repaired successfully by the same technique. The etiology and location differed according to each patient. CONCLUSION: CSF leaks can be treated endoscopically in a satisfactory manner, with minimal morbidity and mortality. Turbinate mucosal grafts fixed with fibrin glue have been effective for closing these defects with low rates of recurrence in long-term follow-ups. Implementation of an Airway Care Team: Effect on Outcomes Kathy Short RRT, RN (presenter); Bonnie Brown, AS; Davila Carter, BS W CRT; Miriam Yoder; Marion Couch, MD, PhD OBJECTIVE: 1) Establish a reproducible protocol to improve patient safety by providing comprehensive and efficient discharge teaching of tracheostomy care to adult patients with new tracheostomies. 2) Determine whether an Airway Care Team (ACT) results in quality improvement by measuring the following outcomes: readmissions, deaths due to tracheotomy related complications, and patient satisfaction. METHOD: The study was conducted at a tertiary care academic center from July 1, 2004, to December 31, 2009. The retrospective portion of the study consisted of chart reviews for adult patients who underwent tracheotomy, while prospectively subjects met with the ACT. If standardized criteria developed specifically for the ACT were met, the patient was discharged. The prospective portion of the study utilized a preand post-treatment survey questionnaire. Statistical analysis was performed by two-tailed t-test. The study was approved by our IRB. RESULTS: Preliminary data show readmission rates due to tracheotomy related complications were significantly lower after the ACT was implemented (p⬍0.05). Post teaching survey results revealed that 15 of 17 (88.2%) (p⬍0.0001) new tracheotomy patients strongly agreed that they understood the care needed for a tracheostomy. 15 of 17 patients (88.2%) (p⬍0.0001) strongly agreed that they felt well prepared to go home, and were prepared in the event of a tracheostomy related emergency. And 94% strongly agreed that they were satisfied with the protocol and ACT. CONCLUSION: We propose a simple and reproducible model to advance quality improvement and improve safety of adult patients with new tracheotomies.
POSTERS
Poster Presentations
Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
tinued analysis of success in additional clinical measures is ongoing. CONCLUSION: The implementation of a formal synoptic report at our institution translated to a higher level of adherence to reporting of critical pathologic features that impact outcomes for patients with oral cavity cancer. It is incumbent upon us to continue to develop ways to track these features and measure adherence to quality measures locally and via national cancer registries. Benchmarking Low-Volume Center Head and Neck Surgery Outcome Alexander Vlantis, FCS(SA)ORL (presenter); Wendy F Bower; Siu-Kwan Ng, FHKAM; Eddy W Y Wong, MB, ChB; C Andrew van Hasselt OBJECTIVE: To determine if 1) Low-volume surgery negatively impacts the outcomes of head and neck patients and 2) Benchmarking the outcomes from low-volume surgical services matches those from high-volume services. METHOD: Outcome data registries were prospectively completed for audit purposes for 203 consecutive patients undergoing a surgical head and neck procedure between October 2005 and August 2009 at a low-volume but high intensity and complexity academic tertiary referral center. Intra- and postoperative complications were identified, data evaluated and the morbidity and mortality rates compared with rates from highvolume centers or surgical specialty group data. Morbidity was benchmarked against international levels to evaluate quality of outcomes. RESULTS: Head and neck procedures were grouped into oral cavity, non-oral cavity and thyroid procedures. Morbidity of any severity was reported in 74%, 56% and 25% respectively of oral cavity, non-oral cavity and thyroid patients. One patient required a return to the operating room postoperatively. The most common complications were fistula (16%) and fever (12%) for oral cavity patients, fever (11%) and dysphagia (10%) for non-oral cavity patients and swallowing difficulty (2%) and non-laryngeal nerve damage (2%) for thyroid patients. The incidence of the major thyroid surgery complications of vocal cord paralysis, non-resolving vocal cord palsy and hypocalcemia were 8%, 2% and 33% respectively. CONCLUSION: This prospective study demonstrated that low-volume surgery does not negatively impact the surgical outcomes of head and neck patients, and that meaningful surgical outcomes from low-volume centers can be measured and benchmarked. Carotid Stenosis after Cervical Radiotherapy Marco de Vincentiis, MD (presenter); Andrea Gallo, MD, PhD; Caterina Marinelli, MD; Gian Franco Macri, MD; Antonio Greco, MD
OBJECTIVE: The aim of our study was to evaluate the prevalence of carotid stenosis in patients with head and neck malignant tumors treated with radiotherapy. METHOD: In our study we included 137 patients with head and neck cancers treated during a period of about 5 years. The larynx was the most common affected site of primary tumor. Only 93 patients were alive at the moment of our observation. A group of 39 patients underwent neck radiation. A control group of 54 patients were not treated with radiotherapy. All patients undergoing radiotherapy received a local dose of 50-70 Gy for 6 weeks. An echo Doppler scan of the carotid arteries was performed in all patients with estimation of common and internal carotid artery Intimal Medial Thickness (IMT). Stenosis grading was divided into low (0-30%), moderate (31-49%) and severe (more than 50%). In addition, we considered hematochimic and flogistic parameters. Statistic evaluation was performed with Chi-square test. RESULTS: We found that severe carotid stenosis was higher (41%) in patients who had undergone radiotherapy than in the control group (16.6 %) (P ⫽ 0.008). The echo Doppler examination demonstrated that the most commonly affected site was the internal carotid artery, just past the carotid fork. CONCLUSION: A pre-operative carotid artery echo Doppler allows to detect asymptomatic atherosclerotic lesions with no actinic action relation. A post-operative study is also very important since we can attempt medical therapy with antiinflammatory drugs in line with the modern concept of atherosclerosis as a focal arteritis. Chronic Rhinosinusitis Diagnosis: Primary and Secondary Care Constantine Stamatoglou, MBBS (presenter); Suresh Yadlapalli, MS, MRCS, DOHNS; Navdeep Upile, MBBS, MRCS; Nazir Bhat, MD, MRCS OBJECTIVE: The European Position Paper on Rhinosinusitis and Nasal Polyps 2007 (EPOS 2007) sets out a clear set of evidence-based guidelines regarding the management of chronic rhinosinusitis. We audited the referrals to and subsequent management of rhinosinusitis in a secondary care centre in relation to these guidelines. METHOD: A prospective audit, comparing validity of referral to secondary care and subsequent diagnosis, investigation and management, as compared to the standards set out by the EPOS 2007 paper. RESULTS: There appeared to be poor uptake of the guidelines in general practice. This was improved in secondary care, however severity was rarely noted as per guidelines. CONCLUSION: We discuss referrals falling outside of EPOS criteria, and highlight the need for further uptake of these protocols within primary care, including the possibility of local training sessions. Diagnosis in secondary care was more accurate, but objective measures of severity such as visual analogue
scales were not used routinely, and there was some variation according to specialist preference. Clinical Care Pathway: Improving Free Flap Patient Outcomes Brian Harmych, MD (presenter); Gordon Sun, MD; Meredith Tabangin, MPH; Jareen Meinzen-Derr, PhD; Yash Patil, MD OBJECTIVE: Determine whether utilization of a clinical care pathway/computerized order set (CCP/COS) results in decreased hospital length of stay (LOS), expenditures, and unplanned surgery for complications in patients undergoing head and neck microvascular free flap reconstruction (FFR). METHOD: A retrospective review of 130 patients undergoing FFR from March 2007 to June 2009 was conducted. Unplanned operation rate, disposition, overall hospital length of stay (LOS) and cost, plus LOS and cost variance, were reported. Chi-square testing, Wilcoxon’s ranked sum test, Fisher’s exact test, and a logistic regression model were utilized for statistical analysis. RESULTS: 133 FFR procedures were performed by the senior author, 86 of which were performed prior to CCP/COS implementation. Patient median age was 58 years. 108/133 (81%) of all surgeries were performed following squamous cell carcinoma resection. The unplanned operation rate of 34% decreased to 15% after CCP/COS institution (P ⫽ 0.019). Discharge with home health care (HHC) declined from 74% to 45% (P ⫽ 0.0006), while skilled nursing facility (SNF) utilization increased from 21% to 45% (P ⫽ 0.016). Mean LOS decreased from 9.5 to 8.7 days after CCP/COS implementation (P ⫽ 0.59), with a significant difference in LOS variance (P ⫽ 0.0009). There was no difference in median hospital costs (P ⫽ 0.39) or cost variance (P ⫽ 0.65) after CCP/COS implementation. CONCLUSION: Preliminary data on CCP/COS implementation in head and neck FFR patients suggest that improved patient outcomes could be achieved without a significant change in overall median hospital costs. Endoscopic Repair of CSF Leaks Using Turbinate Grafts Danilo Sguillar, MD (presenter); Antonio Carlos Cedin, MD; Ana Paula Bezerra, MD OBJECTIVE: To analyze the results of surgical treatment of CSF leaks having different etiologies by endoscopic endonasal surgery using mucosa from inferior/middle turbinates. METHOD: Thirteen patients were analyzed in a retrospective study. They were operated on by a endoscopic endonasal approach using the mucosa of the turbinates which were fash-
P143 ioned preserving the periosteum of the mucosal graft. They were positioned by the overlay technique with the periosteum facing the dural defect and fixed with fibrin glue. Layers of oxidized cellulose polymer were positioned over the graft in order to stabilize it. RESULTS: Twelve patients had successful results (93%). One of them had a new CSF leak at another site (n-11) and another, had a recurrence at the same site (n-2). These latter were repaired successfully by the same technique. The etiology and location differed according to each patient. CONCLUSION: CSF leaks can be treated endoscopically in a satisfactory manner, with minimal morbidity and mortality. Turbinate mucosal grafts fixed with fibrin glue have been effective for closing these defects with low rates of recurrence in long-term follow-ups. Implementation of an Airway Care Team: Effect on Outcomes Kathy Short RRT, RN (presenter); Bonnie Brown, AS; Davila Carter, BS W CRT; Miriam Yoder; Marion Couch, MD, PhD OBJECTIVE: 1) Establish a reproducible protocol to improve patient safety by providing comprehensive and efficient discharge teaching of tracheostomy care to adult patients with new tracheostomies. 2) Determine whether an Airway Care Team (ACT) results in quality improvement by measuring the following outcomes: readmissions, deaths due to tracheotomy related complications, and patient satisfaction. METHOD: The study was conducted at a tertiary care academic center from July 1, 2004, to December 31, 2009. The retrospective portion of the study consisted of chart reviews for adult patients who underwent tracheotomy, while prospectively subjects met with the ACT. If standardized criteria developed specifically for the ACT were met, the patient was discharged. The prospective portion of the study utilized a preand post-treatment survey questionnaire. Statistical analysis was performed by two-tailed t-test. The study was approved by our IRB. RESULTS: Preliminary data show readmission rates due to tracheotomy related complications were significantly lower after the ACT was implemented (p⬍0.05). Post teaching survey results revealed that 15 of 17 (88.2%) (p⬍0.0001) new tracheotomy patients strongly agreed that they understood the care needed for a tracheostomy. 15 of 17 patients (88.2%) (p⬍0.0001) strongly agreed that they felt well prepared to go home, and were prepared in the event of a tracheostomy related emergency. And 94% strongly agreed that they were satisfied with the protocol and ACT. CONCLUSION: We propose a simple and reproducible model to advance quality improvement and improve safety of adult patients with new tracheotomies.
POSTERS
Poster Presentations