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Despite fire prevention protocols and perioperative staff training, surgical fires continue to cause patient harm, disability, and death.We identified surgical fires that were reported to the Food and Drug Administration's Manufacturer and User Facility Device Experience database between 2000 and 2020 that resulted in patient or surgical personnel harm. Quantitative and descriptive content analyses were performed on free-text responses to identify contributing factors of surgical fire patient and personnel harm events.We identified 565 surgical fire events resulting in patient or surgical personnel harm over a 20-year study period (median 25 events/year; range, 8-53). Surgical fires were significantly more likely to occur during upper aerodigestive tract (unadjusted odds ratio 15.96; 95% confidence interval, 11.93-21.34) and head and neck (unadjusted odds ratio 5.47; confidence interval 4.14-7.22) procedures compared with abdomen and pelvis procedures. Upper aerodigestive tract and head and neck procedures had the highest incidence of life-threatening injury (41% and 21%, respectively). An electrosurgical device was the ignition source in 82% of events. Content analysis revealed 7 common categories identified as root causes of surgical fires: preparation of surgical site (n = 55, 29%); device malfunction (n = 51, 26%), surgical accident (n = 47, 24%), medical judgement (n = 44 reports, 23%), equipment care and handling (n = 18, 9%), patient factors (n = 10, 5%), and communication (n = 3, 2%).Surgical fires resulting in harm to patient and surgical personnel continue to occur. The common themes identified in this study will prepare and empower surgeons and surgical personnel to prevent surgical fires in the future.

Between August 2016 and July 2018, three states classified gabapentin as a Schedule V drug and nine states implemented prescription drug monitoring program (PDMP) regulation for gabapentin. It is highly unusual for states to take drug regulation into their own hands. The impact of these changes on gabapentin prescribing is unclear.To determine the effect of state-imposed regulation on gabapentin prescribing for Medicare Part D enrollees from 2013 to 2018.Population-based difference-in-difference(DID) analysis study utilizing the Medicare Part D Prescriber Public Use File.All eligible Medicare Part D prescribers excluding those outside of the fifty states and the District of Columbia were included in our analysis. Prescriber data and key sociodemographic variables were organized by state and year. States with a gabapentin schedule change or PDMP regulation enacted before 2019 were included in the intervention group. For the Schedule V DID analysis, a control group of the ten highest opioid-prescribing states was used.States with gabapentin schedule changes or PDMP regulation before January 1, 2019, were included and compared to control states that did not implement these policies.Total days' supply of gabapentin per enrollee per year was the primary outcome variable.The mean total days' supply of gabapentin per enrollee increased 41% from 19.71 to 27.81 total days' supply per enrollee per year between 2013 and 2018. After adjustment, Schedule V gabapentin regulation resulted in a reduction of 8.37 total days of gabapentin prescribed per enrollee (95% confidence interval of - 10.34 to - 6.39). In contrast, PDMP regulation resulted in a reduction of 1.01 total days of gabapentin prescribed per enrollee (95% confidence interval of - 1.74 to - 0.29).Classifying gabapentin as a Schedule V drug results in substantial reduction in total days prescribed whereas PDMP regulation results in modest reduction.

Survival outcomes are generally better for human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC) than other forms of head and neck cancer. However, less is known about oncologic outcomes, late adverse events, and gastrostomy tube dependence associated with salvage surgery after the failure of definitive chemoradiation in patients with HPV+ OPSCC.A secondary analysis of the Radiation Therapy Oncology Group 1016 randomized trial, which compared radiotherapy plus cetuximab to radiotherapy plus cisplatin in patients with HPV+ OPSCC, was performed. The oncologic and adverse event outcomes for patients who underwent salvage surgery were examined.Among the 805 patients who were assigned to treatment and were eligible for analysis, 198 developed treatment failure. Salvage surgery was required for 61 patients (7.6%), with 33 patients undergoing salvage surgery after locoregional failure (LRF) and 28 patients undergoing salvage neck dissection within the 20 weeks after treatment. Patients with LRF who underwent salvage surgery experienced improved overall survival in comparison with patients with LRF who did not undergo surgery (45% vs. 17% at 5 years after treatment; hazard ratio, 0.41; 95% confidence interval [CI], 0.23-0.74). Surgical salvage after LRF was associated with similar frequencies of late grade 3/4 dysphagia in comparison with LRF without surgery (24% [95% CI, 13%-41%] vs. 20% [95% CI, 12%-32%]; p = .64) and with similar gastrostomy tube dependence at 2 years (29% [95% CI, 15%-49%] vs. 13% [95% CI, 5%-28%]; p = .12).Salvage surgery in patients with HPV+ OPSCC is associated with favorable survival and adverse event outcomes.

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.The guideline development group made

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of ‘complex’ patients as they undergo surgical procedures.

ImportanceClear surgical margins reduce the risk of local recurrence, improve survival, and determine decision-making with regard to adjuvant treatment of squamous cell carcinoma of the head and neck (SCCHN). However, the definitions of clear, close, or positive surgical margins vary in both the literature and in practice.ObjectiveTo examine whether the association between surgical margin distance and survival varies by primary tumor site.Design, Setting, and ParticipantsThis was a secondary analysis of a multi-institutional, multinational randomized clinical trial. The trial enrolled patients from January 22, 2007, to March 29, 2013, with stage II to IVA resected SCCHN with extranodal extension (ENE) or positive margins (InterventionsPatients received adjuvant chemoradiotherapy plus either placebo or lapatinib.Main Outcomes and MeasuresOverall survival (OS) was calculated to examine association with surgical margin distance, primary site, and survival, with stratification by ENE status.ResultsAmong 688 patients enrolled in the trial, 630 patients with known ENE and margin status were included. Exact patient ages were not made available; 523 (83%) patients were male, and 415 (66%) patients were White. Patients with 1 high-risk feature (positive margins or ENE) had significantly better OS vs 2 high-risk features (hazard ratio [HR], 0.65; 95% CI, 0.49-0.87), although most other results were not statistically significant. For example, in the cohort with ENE-negative disease, multivariable adjusted analysis showed nonsignificant improvements with shorter surgical margin distance (1- to 5-mm margins), and no association with OS was found in the cohort with ENE-positive status (either >5 mm margins or 1-5 mm margins). The association between survival and margin distance varied based on primary site, human papillomavirus (HPV) status, and ENE status. For example, HPV-positive status was associated with a significant and clinically meaningful increase in survival (adjusted HR, 0.33; 95% CI, 0.11-0.97). The improvement was greatest, although not significantly so, in patients with ENE- and HPV-negative oropharynx (OP), hypopharynx (HP), and larynx cancer (HR, 0.57; 95% CI, 0.30-1.10). No survival benefit was seen in ENE-negative oral cavity cancer (HR, 0.89; 95% CI, 0.45-1.77), nor was an association observed between margins and OS in HPV-positive OP cancer.Conclusions and RelevanceIn this secondary analysis of a randomized clinical trial, the presence of high-risk features (extranodal extension, positive margins, or both) was associated with worse survival; longer survival was observed with greater surgical margin distance among patients with oral cavity tumors and human papillomavirus–negative tumors of the OP, larynx, or HP. No other significant differences were found. These findings support variable interpretation of surgical margin distance based on the primary site and HPV status.Trial RegistrationClinicalTrials.gov Identifier: NCT00424255

Initial primary head and neck cancer (IPHNC) is associated with second primary lung cancer (SPLC). We studied this association in a population with a high proportion of African American (AA) patients.Patients with IPHNC and SPLC treated between 2000 and 2017 were reviewed for demographic, disease, and treatment-related characteristics and compared to age-and-stage-matched controls without SPLC. Logistic and Cox regression models were used to analyze the relationship of these characteristics with the development of SPLC and overall survival (OS).Eighty-seven patients and controls were compared respectively. AA race was associated with a significantly higher risk of developing SPLC (OR 2.92, 95% CI 1.35-6.66). After correcting for immortal time bias, patients with SPLC had a significantly lower OS when compared with controls (HR 0.248, 95% CI 0.170-0.362).We show that AA race is associated with an increased risk of SPLC after IPHNC; reasons of this increased risk warrant further investigation.

To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology-HeadNeck Surgery (AAO-HNS) clinical practice guideline (CPG), "Opioid Prescribing for Analgesia After Common Otolaryngology Operations," presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib.National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT.AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials.NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects.The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.

The COVID‐19 pandemic has profoundly disrupted head and neck cancer (HNC) care delivery in ways that will likely persist long term. As we scan the horizon, this crisis has the potential to amplify preexisting racial/ethnic disparities for patients with HNC. Potential drivers of disparate HNC survival resulting from the pandemic include (a) differential access to telemedicine, timely diagnosis, and treatment; (b) implicit bias in initiatives to triage, prioritize, and schedule HNC‐directed therapy; and (c) the marked changes in employment, health insurance, and dependent care. We present four strategies to mitigate these disparities: (a) collect detailed data on access to care by race/ethnicity, income, education, and community; (b) raise awareness of HNC disparities; (c) engage stakeholders in developing culturally appropriate solutions; and (d) ensure that surgical prioritization protocols minimize risk of racial/ethnic bias. Collectively, these measures address social determinants of health and the moral imperative to provide equitable, high‐quality HNC care.

Acute Upper Airway Obstruction Acute upper airway obstruction has varied causes with distinct pathophysiological features. High-flow oxygen remains the basis for management, but improvements in equ...

To evaluate the incidence of head and neck cancers (HNC) in high-risk current and/or former smokers with screening low-dose computed tomography (LDCT) chest versus chest x-ray (CXR).Second analysis of randomized clinical trial.We performed a secondary analysis examining the incidence of HNC in the National Lung Screening Trial. This was a randomized trial comparing LDCT versus CXR screening for lung cancer detection in high-risk individuals (30 pack-year smokers who currently smoke or quit within the last 15 years, aged 55-74). We compared the incidence of HNC in participants screened with LDCT versus CXR. We performed subgroup analyses in participants with mucosal HNC (oral cavity, oropharynx, larynx, hypopharynx, nasal/sinus cavity, or nasopharynx) or nonmucosal HNC (thyroid or salivary gland) and examined survival in the two screening arms.This trial enrolled 53,452 participants with a median follow-up of 6.2 years after randomization. The incidence of HNC was 111.8 cases per 100,000 person-years in the LDCT group versus 87.1 cases per 100,000 person-years in the CXR group (rate ratio 1.30, 95% confidence interval [CI] 1.05-1.61). There were 11.7 deaths from HNC per 100,000 person-years in the LDCT group and 12.9 deaths per 100,000 person-years in the CXR group (hazard ratio 0.80, 95% CI 0.42-1.52).Participants screened with LDCT had a modestly higher incidence of HNC. As uptake and adherence of lung cancer screening guidelines improve, clinicians should recognize that incidental findings from screening may lead to increased detection of HNC.3 Laryngoscope, 132:1609-1614, 2022.

Aspiration pneumonia is a potentially preventable, aggressive type of pneumonia. Little is understood on the burden in mortality from aspiration pneumonia. Our objectives were to first examine the burden of mortality from aspiration pneumonia in the United States and second investigate comorbidities associated with aspiration pneumonia to understand risk factors. We conducted a case-control study of individuals who died of aspiration pneumonia matched to those who died of other causes. We analyzed all deaths in the United States using the Multiple Cause of Death Dataset from 1999 to 2017. Cases were matched with controls based on age, sex, and race. We calculated age-adjusted mortality rates, annual percentage changes in aspiration pneumonia mortality, and matched odds ratio comparisons. We identified a total of 1,112,944 deaths related to aspiration pneumonia from 1999 to 2017 or an average of 58,576 per year (age-adjusted mortality rate, 21.85 per 100,000 population; 95% confidence interval (CI) 21.78-21.92). Aspiration pneumonia was reported as the underlying cause of death in 334,712 deaths or an average of 17,616 deaths per year (30.1% of the total aspiration pneumonia-associated deaths). Individuals 75 years old or older accounted for 76.0% of aspiration pneumonia deaths and the age adjusted rate ratio was 161.0 (CI 160.5-161.5). Neurologic, upper gastrointestinal, and pulmonary conditions as well as conditions associated with sedative substances were more often associated with aspiration pneumonia-associated deaths. Aspiration pneumonia is the underlying cause or a cofactor in tens of thousands of deaths each year in the United States. Aspiration pneumonia-associated deaths are highly prevalent with advanced age and are associated with neurologic, upper gastrointestinal and pulmonary conditions.

This cohort study uses Medicare Part D data to examine whether there is an association between the implementation of state limits on opioid prescription duration and changes in prescribing.

We examined the impact of treatment modality on gastrostomy tube dependence and patient-reported outcomes in human papillomavirus-associated oropharyngeal cancer (HPV-OPSCC). We performed systematic review and meta-analysis of functional outcomes 1-3 years after treatment. Twenty-three studies were included, reporting on 3127 patients treated for HPV-OPSCC. Gastrostomy tube dependence failed to show statistically significant difference between surgery with adjuvant therapy and chemoradiotherapy with cisplatin at 12 months (8.3% [95% CI: 3.1-15.9] vs. 4.2% [1.1-9.2], p = 0.37) and 24-36 months (10.5% [95% CI: 3.2-21.5] vs. 3.3% [2.0-4.9], p = 0.06). Surgery with adjuvant therapy was associated with worse University of Washington Quality of Life (UW-QOL) Swallowing (84 [95% CI: 80-88] vs. 89 [87-90], p = 0.03) and UW-QOL Overall scores (76 [95% CI: 72-80] vs. 84 [81-86], p = 0.001) compared to chemoradiotherapy with cisplatin at 12 months. Surgery with adjuvant therapy was associated with worse performance on certain measures of patient-reported swallow and overall function compared to chemoradiotherapy with cisplatin. Further randomized controlled trials are needed to directly compare functional outcomes after treatment for HPV-OPSCC.

Background:There is currently no consensus on the role of pulmonary metastasectomy(PM) for thyroid malignancies. The main objective of this study is therefore to systematically determine if there is any survival benefit to PM and determine good candidates for metastasectomy. Methods: A systematic review of relevant studies was performed, evaluating articles identified using the PubMed, Cochrane and MEDLINE databases according to PRISMA-guidelines. Results:The initial literature search yielded 18 articles of which 7 met inclusion criteria. Only data on thyroid cancers were included in the systematic review. A total of 174 patients who underwent PM were analyzed. The mean age was 54.8(range: 10-90), and 52.5% of patients were female. The overall absolute 5-year survival rate was 67.7% (range: 32.5-84.0%) for patients undergoing PM. The reported post-surgical complication rate overall was 14.4% and two peri-operative deaths were reported. Three papers reported the following as good prognostic factors: Papillary histology, younger age(3 years, R0 resection, systematic lymphadenectomy, thyroglobulin 80% after metastasectomy. Conclusion:This study is the first systematic review evaluating the clinical role of PM for thyroid cancer in the literature to date. PM may offer prolonged survival over traditional therapy for selected patients.

American Society of Clinical Oncology guidelines recommend that the decision to give postoperative radiotherapy (PORT) for pN1 oral cavity squamous cell carcinoma (OCSCC) without other adverse features be based on the adequacy of the neck dissection (18 or ≥18 nodes).We conducted a cohort study of the National Cancer Database examining how PORT affects survival. We stratified analyses by the adequacy of the neck dissection and lymph node (LN) size.Our cohort comprised 1909 patients (898 received PORT). PORT conferred a survival benefit in the overall cohort (adjusted hazard ratio 0.82, 95% CI 0.72-0.94). There was similar benefit in patients receiving inadequate and adequate neck dissections. Patients with10 mm LN metastasis derived greater benefit compared with patients with smaller metastases.In pN1 OCSCC without other adverse features, the size of the LN metastases may predict benefit from PORT, whereas the adequacy of the neck dissection may not.

Head and neck cancers are a heterogeneous collection of malignancies of the upper aerodigestive tract, salivary glands and thyroid. In this Review, we primarily focus on the changing therapeutic landscape of head and neck squamous cell carcinomas (HNSCCs) that can arise in the oral cavity, oropharynx, hypopharynx and larynx. We highlight developments in surgical and non-surgical therapies (mainly involving the combination of radiotherapy and chemotherapy), outlining how these treatments are being used in the current era of widespread testing for the presence of human papillomavirus infection in patients with HNSCC. Finally, we describe the clinical trials that led to the approval of the first immunotherapeutic agents for HNSCC, and discuss the development of strategies to decrease the toxicity of different treatment modalities.

The submandibular gland (SMG) is typically included in level I neck dissection specimens despite limited data demonstrating SMG invasion. The main objective of this article is to determine the rate and pathways of SMG invasion by squamous cell carcinoma of the oral cavity and oropharynx.A systematic review of relevant studies was performed, evaluating articles identified via the PubMed, Cochrane, and Medline databases.Descriptive features of primary tumors, primary treatment modalities, the rate and pathway of SMG invasion, and survival outcomes, if present, were reported following the PRISMA guidelines.The initial literature search yielded 273 articles, of which 17 met inclusion criteria. A total of 2306 patients with 2792 SMG resections were analyzed. Fifty-eight resections (2.0%) were revealed to have tumor involvement. Among patients with SMG tumor involvement, the most common invasion pathway was direct SMG invasion by primary tumor (43 of 58, 74.1%). The second-most common mode of SMG invasion was from involved adjacent lymph nodes (10 of 58, 17.2%). Only 3 SMG resections out of 2792 (0.1%) had isolated metastatic parenchyma without evidence of direct tumor invasion or invasion by involved lymph nodes.Given this rarity of SMG involvement, preservation of SMG might be feasible in selected patient population. However, additional studies need to examine the functionality of preserved SMGs among patients who receive postoperative adjuvant radiation therapy.

This cohort study uses data from the Surveillance, Epidemiology, and End Results database to examine the association between changes in Medicaid dental insurance coverage in California between 2009 and 2014 and rates of localized oral cavity cancer diagnoses.

Objectives Human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) is a unique form of head and neck cancer with improved prognosis. We assessed survival for stage I patients with low- or intermediate-risk pathologic features with surgery alone compared with surgery with adjuvant radiation (RT) or chemoradiation (CRT). Materials and methods We identified patients with stage I HPV+ OPSCC (after restaging with 8th edition staging system) treated with surgery alone, adjuvant RT or CRT in the National Cancer Data Base from 2010 to 2013. We compared survival for low-risk patients (≤1 metastatic lymph nodes with no adverse features) and intermediate-risk patients (2-4 metastatic lymph nodes, microscopic extranodal extension (ENE) or lymphovascular invasion). Results We examined 1677 patients with median follow-up of 43.9 months. In the intermediate-risk group, 4-year overall survival was 94.0% with surgery alone, 91.5% with adjuvant RT and 92.0% with adjuvant CRT (p = 0.72). There were similar rates of overall survival in the low-risk group. In multivariable models accounting for clinicopathologic differences the dose of adjuvant RT was not associated with mortality. On Cox proportional hazard modeling, adjuvant RT (HR 0.94; CI 0.43-2.08) or CRT (HR 0.96; CI 0.45-2.11) did not significantly improved survival compared with surgery alone in the intermediate-risk group (reference). Similar results were seen in the low-risk group. The composite number of pathologic risk features significantly improved risk stratification. Conclusion We provide observational evidence that adjuvant RT or CRT does not provide a survival benefit for stage I HPV+ OPSCC with low- or intermediate-risk pathologic features.

Objectives/hypothesis To investigate patterns of tracheostomy-associated death in the United States. Study design Retrospective database review. Methods We used Multiple Cause-of-Death data from the Centers for Disease Control and Prevention to determine cumulative national mortality associated with tracheostomy complications in the United States from 2007 to 2016. Using International Classification of Diseases, Tenth Revision data, we investigated how frequently tracheostomy-related complications were reported in cause of death data. We then compared the characteristics of patients with tracheostomy-related mortality to patients reported to have died of other causes. Results Over the 10-year period studied, we identified 623 tracheostomy-related deaths (537 adults and 86 children) out of 25,587,306 total deaths reported. Although absolute mortality was higher in adults, the reported base rate of tracheostomy complication-associated mortality was tenfold higher in children. Most tracheostomy-related deaths occurred in a hospital facility (74.5% in adults). Deaths associated with tracheostomy complications were significantly more common for African American children (odds ratio [OR]: 2.02, 95% confidence interval [CI]: 1.26-3.24) and adults (OR: 1.59, 95% CI: 1.29-1.96) or in Hispanic adults (OR: 1.42, 95% CI: 1.06-1.89). Deaths related to a tracheostomy complication more commonly occurred on the weekend (OR: 1.24, 95% CI: 1.04-1.49) and in the most recent 2-year period (OR: 1.31, 95% CI: 1.03-1.68). Adults with a bachelor's, master's or doctorate degree were significantly less likely to have mortality associated with a tracheostomy-related complication (OR: 0.54, 95% CI: 0.39-0.75). Conclusions Tracheostomy-related complications were implicated in the deaths of a significant number of individuals. Several demographic groups had increased likelihood of tracheostomy-related mortality. Future research is necessary to develop targeted interventions to decrease harm. Level of evidence NA Laryngoscope, 129:619-626, 2019.

ObjectiveOpioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead...

BACKGROUND The standardization of quality measures has been key in advancing the aims of the National Quality Forum established to improve health outcomes. METHODS The National Cancer Database was used to identify eligible patients. Two quality metrics were evaluated including time to treatment initiation (TTI) and chemotherapy in locoregionally head and neck squamous cell carcinoma (HNSCC). RESULTS TTI was significantly associated with mortality reflected by a hazard ratio (HR) of 1.13 for 60-90 days of TTI (95% CI 1.08-1.17), 1.19 for >90 days of TTI (95% CI 1.13-1.26). Patients with locoregionally advanced HNSCC had an 87% adherence to chemotherapy, which correlated with reduced mortality (HR 0.57; 95% CI 0.55-0.59). Patients treated at high quality centers had a 9% increase in survival (HR 0.91; 95% CI 0.88-0.93). CONCLUSION We identified that both TTI and chemotherapy for locoregionally advanced HNSCC meet criteria for valid quality metrics potentially suitable for national adoption.

Objective Despite the implementation of advanced health care safety systems including checklists, preventable perioperative sentinel events continue to occur and cause patient harm, disability, and death. We report on findings relating to otolaryngology practices with surgical safety checklists, the scope of intraoperative sentinel events, and institutional and personal response to these events. Study Design Survey study. Setting Anonymous online survey of otolaryngologists. Methods Members of the American Academy of Otolaryngology–Head and Neck Surgery were asked about intraoperative sentinel events, surgical safety checklist practices, fire safety, and the response to patient safety events. Results In total, 543 otolaryngologists responded to the survey (response rate 4.9% = 543/11,188). The use of surgical safety checklists was reported by 511 (98.6%) respondents. At least 1 patient safety event in the past 10 years was reported by 131 (25.2%) respondents; medication errors were the most commonly reported (66 [12.7%] respondents). Wrong site/patient/procedure events were reported by 38 (7.3%) respondents, retained surgical items by 33 (6.4%), and operating room fire by 18 (3.5%). Although 414 (79.9%) respondents felt that time-outs before the case have been the single most impactful checklist component to prevent serious patient safety events, several respondents also voiced frustrations with the administrative burden. Conclusion Surgical safety checklists are widely used in otolaryngology and are generally acknowledged as the most effective intervention to reduce patient safety events; nonetheless, intraoperative sentinel events do continue to occur. Understanding the scope, causes, and response to these events may help to prioritize resources to guide quality improvement initiatives in surgical safety practices.

Objective: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. Data Sources: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. Review Methods: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. Conclusions: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. Implications for Practice: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.

OBJECTIVES/HYPOTHESIS To assess the causative factors that contribute to racial disparities in head and neck squamous cell carcinoma (HNSCC) and establish the role of hospital factors in racial disparities. STUDY DESIGN Retrospective database analysis. METHODS Patients with surgically treated HNSCC were identified using the National Cancer Database (2004-2014). Logistic and proportional-hazard regression models were used to characterize the factors that contribute to racial disparities. Differences in quality of care received were compared among black and white patients using previously validated metrics. RESULTS We identified 69,186 eligible patients. Black patients had a 48% higher mortality than white patients (HR 1.48; 95% confidence interval [CI], 1.41-1.54). Black patients had a lower mean quality score (67.6%; 95% CI, 66.8%-69.4%) compared with white patients (71.2%: 95% CI, 71.0%-71.4%) for five quality metrics. After adjusting for differences in patient, oncologic, and hospital factors we were able to explain 60% of the excess mortality for black patients. Oncologic factors at presentation accounted for 57.7% of observed mortality differences, whereas hospital characteristics and quality of care accounted for 11.5%. After adjusting for these factors, black patients still had a 19% higher mortality (HR 1.19; 95% CI, 1.14-1.24). CONCLUSIONS Oncologic factors at presentation are a major contributor to racial disparities in outcomes for HNSCC. Hospital factors, such as quality, volume, and safety-net status, constitute a minor factor in the mortality difference. Resolving existing disparities will require detecting head and neck cancer at an earlier stage and improving the quality of care for black patients. LEVEL OF EVIDENCE 3. Laryngoscope, 131:1053-1059, 2021.

OBJECTIVE. In the chronic phase of COVID-19 pandemic, questions have arisen regarding care of patients with tracheostomy and downstream management. This review addresses gaps in the literature regarding post-tracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy. DATA SOURCES. PubMed, Cochrane Library, Scopus, Google Scholar, Institutional guidance documents REVIEW METHODS. Literature through June 2020 on care of tracheostomy patients was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations. CONCLUSIONS. Best practices in caring for patients after tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol generating procedures; minimizing exposure risks to healthcare workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendation for personal protective equipment (PPE), equipment, care protocols, and personnel. IMPLICATIONS FOR PRACTICE. Management of patients with tracheostomy in COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

In the last 30 years, pain control in the United States has undergone several evolutions impacting the care of surgical patients. More recently, safe pain control has been a subject of quality improvement efforts by otolaryngologists focusing on minimizing opioid consumption. This article discusses the rising overprescription of opioids, influenced by legislation and governmental agencies, and the steps taken to correct and reform policies to decrease the amount of opioids prescribed. Lastly, specific institutional examples of quality improvement protocols implemented to help decrease opioid consumption and prescription are discussed.

Objective The incidence of lymph node metastases (LNM) in squamous cell carcinoma of the lip is modest (8%), making it challenging to identify patients that may benefit from elective pathologic staging evaluation of the neck. We evaluated predictors of LNM in patients with lip cancer in order to potentially refine selection of patients for pathologic staging evaluation of the neck. Study design Retrospective cohort study. Subjects Clinically N0 patients with squamous cell carcinoma of the lip that underwent definitive surgical resection and pathologic evaluation of lymph node metastases in the National Cancer Data Base from 2006 to 2013. Methods Multivariable binomial logistic-regression was used to assess the relationship between occult pathologic lymph node metastasis and potential preoperative predictors including; patient demographics, T-stage, location, and pathologic details. Results Among 786 patients the overall rate of LNM was 12.1%. Patients were more likely to have LNM with T2 (odds ratio (OR) 2.05; (95% confidence interval (CI) 1.19–3.54) or T3–4 (OR 2.36; CI 1.32–4.22) moderately differentiated (OR 2.65; CI 1.30–5.38) or poorly differentiated (OR 4.37; CI 1.97–9.71), or involvement of the mucosal surface (OR 1.82; CI 1.09–3.03). We created a prediction model based on proportional odd ratios from multivariant binomial logistic-regression analysis from statistically significant factors; incorporating T2–4, moderate/poorly differentiated, or mucosal site. Conclusion Our prediction model found that patients with two or more risk factors were the best candidates for elective pathologic nodal evaluation.

Background Sentinel lymph node biopsy (SLNB) is widely used for Merkel cell carcinoma (MCC), however in SLNB positive MCC the role of completion lymph node dissection (CLND) with or without adjuvant radiation therapy is unclear. Objective Our goal was to determine the impact of CLND and adjuvant radiation therapy on survival in SLNB positive MCC. Materials and methods We examined 447 patients with MCC with a positive SLNB in the National Cancer Data Base from 2012 to 2015. We compared patients who underwent CLND versus observation with or without adjuvant radiation. Results Compared with CLND and adjuvant radiation (reference) treatment with observation (HR 3.54, CI 1.36–9.18) or CLND alone (HR 2.54, CI 1.03–6.27) were associated with worse overall survival after adjusting for clinicopathologic differences. In contrast treatment with adjuvant radiation alone without CLND was not associated with worse overall survival (HR 1.70, CI 0.74–3.92) compared with CLND and adjuvant radiation (reference). Conclusions In SLNB positive MCC, CLND alone is associated with worse survival compared with treatment with adjuvant radiation or both CLND and adjuvant radiation.

To evaluate the impact of oral cancer screening if applied to the United States (US) population or various high-risk populations in the US.We modeled the effects of applying an oral cancer screening program to the US population assuming a similar mortality reduction as seen in the randomized Kerala trial. We combined data on the incidence of oral cancer in the Surveillance, End Results, and Epidemiology database, data on the relative risk in various high-risk groups from the Prostate, Lung, Cervical, and Ovarian screening trial, and the National Lung Screening Trial and data on the prevalence of cigarette use from the National Health Interview Survey.When extrapolating to the US population we predict the number needed to screen to prevent one oral cancer death (NNS) = 9,845 in all individuals aged 35 + . Screening efficiency would increase if applied to higher-risk populations. If oral cancer screening were applied to male ≥ 60 pack-year current smokers or former smokers who have quit within 15 years aged 50-79 we predict a 4.6% reduction in oral cancer mortality with an NNS = 1,485.Targeted screening of individuals at high risk for oral cancer has the potential to maximize the efficiency of screening and meaningfully impact oral cancer mortality. We suggest a future screening trial in high-risk individuals be considered to clarify the role of oral cancer screening in the US.

OBJECTIVES Sentinel lymph node biopsy (SLNB) has been shown to be an accurate technique for staging the neck in early-stage oral cavity squamous cell carcinoma (OCSCC) and has been incorporated in treatment guidelines as an option instead of elective neck dissection (END). However, utilization of SLNB in the United States remains unclear, and existing prospective studies did not directly compare survival between SLNB and END. METHODS We conducted a retrospective cohort study of patients with stage I to II OCSCC (cT1-2cN0cM0) who underwent staging of the neck in the National Cancer Data Base from 2012 to 2015. We compared the practice patterns and outcomes of patients who underwent SLNB versus END. RESULTS We identified 8,328 eligible patients with a median follow-up of 35.4 months. SLNB was used for 240 patients, or 2.9% of stage I to II OCSCC. Completion neck dissection was avoided in 63.8% of patients undergoing SLNB. SLNB was associated with reduced perioperative morbidity, with median length of hospital stay of 1.0 days versus 3.0 days after END (P

Patient safety and quality improvement (PS/QI) initiatives have rapidly proliferated through all fields of healthcare including otolaryngology. Harnessing these initiatives provides an opportunity to systematically evaluate and disseminate best practices and to evaluate their effect in improving value for patients. New data registries and disease-specific quality improvement collaboratives provide opportunities for otolaryngologists to use data to enhance quality. We describe PS/QI measures that enhance value by improving quality and controlling costs. These include data registries that allow “big data” approaches, the benefits of multidisciplinary teams and care coordination, subspecialty-specific initiatives, use of M&M conference as a launchpad for PS/QI activity, and barriers to implementation of PS/QI strategies. As changes in healthcare continue to accelerate, otolaryngologists who embrace opportunities to optimize value in their respective subspecialties will see improved outcomes for their patients and will reap the benefits of thriving, fulfilling clinical practices.

Pain is common among patients with cancer, stemming from both malignancy and side effects of treatment. The extent to which pain persists after treatment has received little attention. We examined the prevalence, predictors, and impact on quality of life (QOL) caused by pain among survivors of head and neck cancer.Cohort study.Tertiary head and neck cancer survivorship clinic.We identified survivors of head and neck cancer ≥1 year after diagnosis and examined the prevalence and risk factors for development of pain. Pain and QOL were assessed with multiple QOL instruments. Ordinal regression modeling examined predictors of pain in survivors.We identified 175 patients at a median of 6.6 years after diagnosis. Among survivors, 45.1% reported pain, and 11.5% reported severe pain. Among patients with current pain, 46% reported low overall QOL versus only 12% of those without pain ( P.001). On multivariable analysis after adjustment for age, sex, and stage of disease, pain was associated with trimodality treatment (odds ratio [OR], 3.55; 95% CI, 1.06-12.77). Multivariable analysis of QOL issues revealed that pain was associated with major depression (OR, 3.91; 95% CI, 1.68-9.11), anxiety (OR, 4.22; 95% CI, 2.28-7.81), poor recreation (OR, 3.31; 95% CI, 1.70-6.48), and low overall QOL (OR, 2.20; 95% CI, 1.12-4.34).Years after head and neck cancer treatment, pain remains a significant problem and is associated with worse QOL. Future efforts should focus on preventing pain from treatment and comprehensive management.

OBJECTIVE For the first time in 30 years, the eighth edition of the American Joint Committee on Cancer (AJCC) Staging Manual offers major changes in the staging of oral cavity cancer. We evaluated the predictive ability of the new staging system for oral cavity cancer to validate these changes and hypothesized that the new system would improve prognostic accuracy. METHODS We conducted a retrospective cohort study of patients with oral cavity squamous cell carcinoma in the National Cancer Data Base from 2009 to 2013 and applied the seventh and eighth edition staging AJCC staging systems to all patients. Stage-specific overall survival was calculated using the Kaplan-Meier method and concordance indices to measure the system's prognostic accuracy. RESULTS We identified 39,361 patients with a median follow-up of 27.1 months (range 0.1-80.4 months). In the seventh edition, there were 43.0%, 15.0%, 10.6%, and 25.7% of patients with pathologic stage I, II, III, and IV disease, respectively. After restaging based on eighth edition pathological guidelines, 10.0% of patients were upstaged (38.1%, 18.1%, 14.2%, and 25.2%, respectively, with stage I, II, III, and IV disease, respectively). The survival concordance index improved from the seventh to eighth edition for pathological staging (concordance index 0.699 and 0.704, respectively) and for clinical staging (concordance index 0.714 and 0.715, respectively). CONCLUSION We provide validation of the new AJCC staging system for oral cavity cancer. Eighth edition AJCC staging guidelines upstage a substantial number of patients with greater depth of invasion or extranodal extension. This resulted in slightly improved prognostication. LEVEL OF EVIDENCE 2c. Laryngoscope, 128:2351-2360, 2018.

Objectives/hypothesis Fellowship is the capstone of academic training and serves as preparation for an academic career. Fellows are expected to educate medical students and residents during and long after fellowship. However, little time is typically spent teaching fellows to become effective educators. We investigate a formal curriculum addressing teaching skills among fellows in otolaryngology-head and neck surgery (OHNS). Study design E-mail survey. Methods We developed and implemented an educational program called Teach the Teacher to build skills as educators for fellows in OHNS. We conducted a survey of fellows from 2014 to 2017 in OHNS who participated in the course. The survey evaluated demographics, teaching experiences, and teaching limitations structured as yes/no and Likert-style questions (1 = strongly disagree, 5 = strongly agree). Results Thirty fellows were surveyed with a response rate was 80%. Fellowship was rated highly as an experience that will make fellows a better academic educator (mean ± standard deviation: 4.54 ± 0.64). The most important components of teaching during fellowship were role modeling (4.67 ± 0.62), followed by teaching psychomotor skills in the operating room (4.29 ± 0.89), diagnostic reasoning (4.25 ± 0.66), and evidence-based medicine (4.25 ± 0.83). The Teach the Teacher course specifically was rated as a helpful experience (4.00 ± 0.90). The primary limitations to developing teaching skills during fellowship identified were lack of time, patient safety, and inexperience with hospital culture. Conclusions Fellowship is a key time to improve skills as academic educators. Fellows value formal efforts to teach academic skills. Level of evidence NA. Laryngoscope, 128:2034-2048, 2018.

Objective The aim of this report is to present a cohesive evidence-based approach to reducing venous thromboembolism (VTE) in otolaryngology-head and neck surgery. VTE prevention includes deep venous thrombosis and pulmonary embolism. Despite national efforts in VTE prevention, guidelines do not exist for otolaryngology-head and neck surgery in the United States. Data Sources PubMed/MEDLINE. Review Methods A comprehensive review of literature pertaining to VTE in otolaryngology-head and neck surgery was performed, identifying data on incidence of thrombotic complications and the outcomes of regimens for thromboprophylaxis. Data were then synthesized and compared with other surgical specialties. Conclusions We identified 29 articles: 1 prospective cohort study and 28 retrospective studies. The overall prevalence of VTE in otolaryngology appears lower than that of most other surgical specialties. The Caprini system allows effective individualized risk stratification for VTE prevention in otolaryngology. Mechanical and chemoprophylaxis ("dual thromboprophylaxis") is recommended for patients with a Caprini score ≥7 or patients with a Caprini score of 5 or 6 who undergo major head and neck surgery, when prolonged hospital stay is anticipated or mobility is limited. For patients with a Caprini score of 5 or 6, we recommend dual thromboprophylaxis or mechanical prophylaxis alone. Patients with a Caprini score ≤4 should receive mechanical prophylaxis alone. Implications for Practice Otolaryngologists should consider an individualized and risk-stratified plan for perioperative thromboprophylaxis in every patient. The risk of bleeding must be weighed against the risk of VTE when deciding on chemoprophylaxis.

Objective The United States is facing an epidemic of opioid addiction. Deaths from opioid overdose have quadrupled in the past 15 years and now surpass annual deaths during the height of the human immunodeficiency virus epidemic. There is a link between opioid prescriptions after surgery, opioid misuse, opioid diversion, and use of other drugs of abuse. As surgeons, otolaryngologists contribute to this crisis. Our objective is to outline the risk of abuse from opioids in the management of acute postoperative pain in otolaryngology-head and neck surgery (OHNS) and strategies to avoid misuse. Data Sources PubMed/MEDLINE. Review Methods We conducted a review of the literature on the rate of opioid abuse after surgery, methods of safe opioid use, and strategies to minimize the dangers of opioids. Conclusions Otolaryngologists have a responsibility to treat pain. This begins preoperatively by discussing perioperative pain control and developing a personalized pain control plan. Patients should be aware that opioids carry significant risks of adverse events and abuse. Perioperative use of multimodal nonopioid agents enables pain control and avoidance of opioids in many otolaryngologic cases. When this approach is inadequate, opioids should be used in short duration under close surveillance. Institutional standards for opioid prescribing after common procedures can minimize misuse. Implications for Practice Otolaryngologists need to acknowledge the potential harm that opioids cause. It is essential that we evaluate our practices to ensure that opioids are used responsibly. Furthermore, opioid stewardship should become a priority in otolaryngology.

Objective To compare rates of morbidity and mortality in patients treated by otolaryngologists who undergo interhospital transfers vs those who do not and to quantify conditions requiring interhospital transfers in this population. Study Design Cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods We identified patients requiring surgery by otolaryngologists in the National Surgical Quality Improvement Program database from 2006 to 2013. We compared patients who were transferred from an outside institution to those admitted from home. Multivariate regression was used to adjust for patient characteristics, comorbidities, and case mix. The primary outcome was overall morbidity and mortality within 30 days of surgery. Results We identified 60,498 patients; 488 (0.8%) were transferred from another institution. Operations that were more common in the transferred group were incision and drainage (24.0% vs 1.2%), facial trauma repair (9.0% vs 3.1%), and oropharyngeal hemorrhage control (3.9% vs 0.4%). External transfer patients had significantly longer hospital stays (44.1% vs 4.4% >7 days, P < .05). On unadjusted analysis, transferred patients had a significantly higher rate of morbidity and mortality (odds ratio [OR], 11.3; 95% confidence interval [CI], 9.4-13.5). On multivariate analysis, transferred patients had a significantly greater rate of morbidity and mortality (OR, 3.1; 95% CI, 2.4-4.0). Conclusion Transfer from another institution is associated with worse outcomes independent of case mix, demographics, and preoperative comorbidities in acute otolaryngology conditions requiring surgery. Practitioners should be aware of this when caring for transfer patients, and transfer status should be considered when measuring hospital quality.

Background The eighth edition American Joint Committee on Cancer (AJCC) staging manual includes major changes in staging of oropharyngeal cancer (OPC). We evaluated the new staging system in order to validate this shift in classification. Methods We used the National Cancer Database (NCDB) to identify patients with human papillomavirus-associated (HPV-positive) OPC from 2010-2013. We restaged patients using the eighth edition guidelines and compared them with those from the seventh edition. We calculated stage-specific overall survival and concordance indices. Results We identified 15 116 patients with a median follow-up period of 29.1 months. Clinical and pathological staging changed for 93.9% and 91.7% of patients, respectively. Survival concordance indices for both clinical (0.621-0.656) and pathological (0.640-0.663) staging were improved in the eighth edition compared to the seventh edition. Conclusion The eighth edition guidelines have profoundly altered staging of HPV-positive OPC and seem to demonstrate improved survival discrimination.

BACKGROUND The National Quality Forum has endorsed quality-improvement measures for multiple cancer types that are being developed into actionable tools to improve cancer care. No nationally endorsed quality metrics currently exist for head and neck cancer. METHODS The authors identified patients with surgically treated, invasive, head and neck squamous cell carcinoma in the National Cancer Data Base from 2004 to 2014 and compared the rate of adherence to 5 different quality metrics and whether compliance with these quality metrics impacted overall survival. The metrics examined included negative surgical margins, neck dissection lymph node (LN) yield ≥ 18, appropriate adjuvant radiation, appropriate adjuvant chemoradiation, adjuvant therapy within 6 weeks, as well as overall quality. RESULTS In total, 76,853 eligible patients were identified. There was substantial variability in patient-level adherence, which was 80% for negative surgical margins, 73.1% for neck dissection LN yield, 69% for adjuvant radiation, 42.6% for adjuvant chemoradiation, and 44.5% for adjuvant therapy within 6 weeks. Risk-adjusted Cox proportional-hazard models indicated that all metrics were associated with a reduced risk of death: negative margins (hazard ratio [HR] 0.73; 95% confidence interval [CI], 0.71-0.76), LN yield ≥ 18 (HR, 0.93; 95% CI, 0.89-0.96), adjuvant radiation (HR, 0.67; 95% CI, 0.64-0.70), adjuvant chemoradiation (HR, 0.84; 95% CI, 0.79-0.88), and adjuvant therapy ≤6 weeks (HR, 0.92; 95% CI, 0.89-0.96). Patients who received high-quality care had a 19% reduced adjusted hazard of mortality (HR, 0.81; 95% CI, 0.79-0.83). CONCLUSIONS Five head and neck cancer quality metrics were identified that have substantial variability in adherence and meaningfully impact overall survival. These metrics are appropriate candidates for national adoption. Cancer 2017. © 2017 American Cancer Society.

Objective Prior studies have reported widely disparate rates of postoperative stroke, with conflicting analyses of whether neck dissection is an independent risk factor. Study Design Cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2013. Subjects and Methods We compared the 30-day rate of postoperative stroke between patients undergoing complete or modified radical neck dissection and a control cohort composed of those undergoing resections in the oral cavity, oropharynx, larynx, or hypopharynx without neck dissection. Propensity scores and paired statistics were used to compare the groups while adjusting for relevant covariates. Results We identified 9697 patients, including 5827 with neck dissection and 3870 without neck dissection. In the full cohort, the rate of postoperative stroke was greater with neck dissection than without it (0.31% vs 0.11%, P = .052), although the relationship was attenuated by propensity score matching to adjust for comorbidities (0.30% vs 0.13%, P = .18). Among patients with ≥2 risk factors for carotid artery stenosis, neck dissection was associated with an increased rate of postoperative stroke (2.68% with bilateral neck dissection, 0.41% with unilateral neck dissection, and 0.24% without neck dissection, P = .04). The incidence of stroke was strongly associated with 30-day mortality (7.4% vs 0.2%, P < .001). Conclusions Stroke is a rare but highly morbid complication after head and neck surgery. Compared with other head and neck surgery, neck dissection in patients at risk for carotid artery stenosis is associated with an increased risk of postoperative stroke.