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OBJECTIVE: To assess differences in obstructive sleep apnea (OSA)-related health parameters between residents of low income/low access (LILA) census tracts-food deserts-and non-LILA residents STUDY DESIGN: Retrospective review. SETTING: Single institution serving a large region in Southern California from 2017 to 2023. METHODS: Census tracts are defined as LILA if a significant proportion of residents live below the poverty threshold and far from healthy food vendors. Adults newly diagnosed with OSA on polysomnography were included. Food access status was determined by searching patient addresses in the US Department of Agriculture Food Access Research Atlas. Baseline and 1-year follow-up body mass index (BMI) and vitals were collected and compared based on food access and other demographic variables. RESULTS: A total of 379 patients in the LILA+ group and 2281 patients in the LILA- group met inclusion criteria. BMI was higher in the LILA group (36.6 ± 9.4 vs 35.2 ± 8.9; P = .006). The effect of food access was most significant in certain demographic groups: patients aged < 65, males, Asian/Pacific Islanders, Hispanics, and patients with Medicaid coverage all had a higher BMI when in the LILA+ group compared to the LILA- group. When considering insurance, LILA+ patients with Medicaid coverage had a significantly higher BMI than LILA- patients with non-Medicaid coverage (40.4 ± 10.3 vs 34.2 ± 8.4, P < .001. Blood pressure, heart rate, and apnea-hypopnea index were also significantly higher in LILA+/Medicaid group. BMI change across all demographic groups was minimal at 1-year follow-up. CONCLUSION: Living in a LILA census tract may result in worse OSA-related health parameters. When accounting for insurance status, the effects are even more profound. Intensive counseling on the importance of weight management should begin at the diagnosis of OSA.
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Objectives: Recurrence and survival in early T-stage oral tongue squamous cell carcinoma (OTSCC) may be impacted by histopathologic risk factors. This study aims to examine which of these factors predict long-term outcomes of T1 and T2 OTSCC. Methods: A retrospective review of T1 and T2 OTSCC patients treated with surgery at a single tertiary care center was conducted. Multivariate regression and Kaplan-Meier survival plots were used to identify predictors of recurrence and compare disease-free survival respectively. Results: 100 consecutive patients were studied. Of these, 51 were staged pT1, 49 pT2, 69 pN0, 10 pN1, and 21 pN2. Multivariate regression analysis revealed that >4 nodes was the strongest predictor of overall recurrence [odds ratio 1.68 (1.23-2.28), p = 0.001], while >4 nodes [odds ratio 1.14 (1.09-1.85), p = 0.008] and pT2 [odds ratio 1.15 (1.01-1.30), p = 0.033] were predictors of local recurrence (R2 = 0.112). Five-year disease-free survival was not significantly impacted by any risk factors except for the number of positive nodes-86% for ≤4 nodes vs. 20% for >4 nodes (p < 0.001)-and pathologic T-stage-90% for pT1 vs. 75% for pT2 (p = 0.035) regardless of adjuvant radiation and/or chemotherapy use. Conclusions: Patients who underwent adjuvant radiation and/or chemotherapy had similar survival to those who did not despite having worse overall tumor prognostic factors. Adding adjuvant therapy may equalize some high-risk histopathologic factors. In the highest risk patients-specifically those with pathologic >4 nodes and pT2 staging-adjuvant therapy should be considered.
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OBJECTIVE: To determine the prevalence of occult contralateral nodal metastasis in tonsillar squamous cell carcinoma (TSCC) in patients who have undergone bilateral neck dissection. DATA SOURCE: A systematic review of English articles identified from PubMed, Embase, and Web of Science databases. REVIEW METHODS: Search terms included "oropharynx," "carcinoma," "lymph node," and "neck dissection." Two reviewers independently screened abstracts, reviewed full texts, and extracted data from all studies that presented the prevalence of contralateral occult nodal metastasis in TSCC. RESULTS: The overall prevalence of occult contralateral nodal metastasis was 10%. The prevalence was 8% for cT1/T2 tumors, 19% for cT3/T4, 1% for N0 in the ipsilateral neck, and 12% for N+. Occult contralateral lymph nodes were most frequently found in neck level II (81%) and level III (19%). No metastatic nodes were found in level I. CONCLUSION: Elective neck dissection of the contralateral neck in TSCC is controversial due the historic morbidity caused by the surgery. A widely accepted recommendation suggests performing an elective neck dissection when the prevalence of occult metastasis is between 15% and 20%. The results of this study suggest that elective contralateral neck dissection will identify occult positivity in 19% of patients with T3/T4 tonsil cancer. In T1/T2 or N0 tumors, the diagnostic yield would be considerably lower at 8% and 1%, respectively. Contralateral nodal sampling could be considered based on patient preference after adequate counseling on the risks/benefits of occult nodal detection. More research is needed on other nodal features to formulate treatment guidelines. Laryngoscope, 2024.
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Objective: To characterize presentation, disease course, and treatment of idiopathic subglottic stenosis (iSGS) in non-Caucasian women and compare this cohort to the predominantly female, Caucasian patient cohorts identified in the literature. Study Design: Retrospective review. Results are compared to systematic review of demographics. Setting: Multiple California institutions from 2008 to 2021. Methods: Patients with intubation within 2 years of disease or who met exclusion criteria listed in prior publications were excluded. A systematic review of iSGS patient demographics was also completed for comparison. Results: Of 421 patients with iSGS, 58 self-identified as non-Caucasian women, with 50 ultimately included. Mean age of onset was 45.1 years old (95% confidence interval [CI], 41.5-48.8), and mean age at diagnosis was 47.2 years (95% CI, 43.6-50.7). Mean Charlson comorbidity index was 1.06 (n = 49, 95% CI, 0.69-1.44). At diagnosis, Cotton-Meyer severity scores (documented in n = 45) were Cotton-Myer (CM) I (28.9%), CM II (40%), and CM III (31.1%). Mean age at first endoscopic surgery was 47.7 (95% CI, 44.2-51.3) years. 64% experienced disease recurrence with a median of 11 months between their first and second surgery. Our systematic review identified 60 studies that reported demographic features in patients with iSGS. 95% of pooled patients were Caucasian, while other demographic features were similar to the current cohort. Conclusion: The non-Caucasian population, almost 14% of this Californian cohort, does not differ from the majority Caucasian population detailed in contemporary literature. This cohort supports the presence of some racial and ethnic heterogeneity in this disease population.
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OBJECTIVE: To qualitatively describe variation in morphology of the genial tubercle and quantify the spatial relationship between the tubercle and genioglossus muscle. STUDY DESIGN: Case series. SETTING: Cadaver dissection. METHODS: Segmental sections of the mandible, with muscular attachments intact, were harvested from 18 fresh cadaver heads. Three-dimensional laser scans, with a resolution of 0.025 mm, were taken of each specimen with muscle attached and repeated after muscle removal. The genioglossus muscular attachment was measured relation to bony landmarks. RESULTS: The morphology of the genial tubercle varied, with anywhere from 1 large spine to 4 individual spines. However, all specimens had a distinguishable superior portion of the tubercle, where the genioglossus attached, and an inferior portion, where the geniohyoid attached. The height of the superior tubercle (ST) was 6.1 mm (95% confidence inerval [CI]: 5.7-6.5). The height of the genioglossus muscle above the peak amplitude of the ST was 4.3 mm (3.8-4.9), but only 2.5 mm (2.0-3.0) below. On average, 64.4% (58.6-70.2) of the height of the genioglossus muscle attachment was above the peak. Overall, 19.5% (14.1-25.0) of the muscle surface area extended beyond the boundaries of the tubercle. CONCLUSION: The genioglossus muscle attachment originates from the superior genial tubercle, which has a variable topography and amplitude. However, the muscle is not centered on the spines-more of the muscular fibers attach above the spine as compared to below. This new data may explain the genioglossus advancement "miss rate"-failure to advance muscle on initial osteotomy-of 39-78% reported in the literature.
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Objective: To determine the effect of smoking history on the risk of developing obstructive eustachian tube dysfunction (OETD). Study Design: Cross-sectional review. Setting: National database. Methods: Data from the National Health and Nutrition Examination Survey (1999 to present) was analyzed. OETD was defined as middle ear pressure less than -100 decapascals (daPa). Nonsmokers, current smokers, with tympanometry data were analyzed. Patients under the age of 18, with myringotomy tubes, or with a sinus problem/earache/cold in the past 24 hours were excluded. The relative risks (RRs) for developing OETD were calculated for nonsmokers versus smokers and those with greater versus less than 10, 20, and 30 pack years (py). Results: A total of 9472 patients met inclusion criteria (54.1% female, 75.9% non-Hispanic, mean age 43, 20.3% smokers). The RR of having OETD for smokers versus nonsmokers was 1.75 [95% confidence interval, CI: 1.45-2.11]. The RR of having OETD for patients with a 10+ py was 1.97 [95% CI 1.57-2.47], 20+ py was 2.29 [95% CI 1.76-2.95], and 30 py or greater was 2.08 [95% CI 1.49-2.90]. Conclusion: In this study, smoking roughly doubled the risk of developing OETD, as represented by a single measurement of negative middle ear pressure less than -100 daPa. The definition of OETD used in this study was limited, as it did not include symptomology, and more work is needed to examine additional covariates. However, these results may guide future research to better counsel and screen patients for OETD.
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The complex structure, chemical composition, and biomechanical properties of craniofacial cartilaginous structures make them challenging to reconstruct. Autologous grafts have limited tissue availability and can cause significant donor-site morbidity, homologous grafts often require immunosuppression, and alloplastic grafts may have high rates of infection or displacement. Furthermore, all these grafting techniques require a high level of surgical skill to ensure that the reconstruction matches the original structure. Current research indicates that additive manufacturing shows promise in overcoming these limitations. Autologous stem cells have been developed into cartilage when exposed to the appropriate growth factors and culture conditions, such as mechanical stress and oxygen deprivation. Additive manufacturing allows for increased precision when engineering scaffolds for stem cell cultures. Fine control over the porosity and structure of a material ensures adequate cell adhesion and fit between the graft and the defect. Several recent tissue engineering studies have focused on the trachea, nose, and ear, as these structures are often damaged by congenital conditions, trauma, and malignancy. This article reviews the limitations of current reconstructive techniques and the new developments in additive manufacturing for tracheal, nasal, and auricular cartilages.
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OBJECTIVE: To enhance understanding in patterns of discordance between clinical and pathological T and N staging in multiple sites of head and neck squamous cell cancer. METHODS: A retrospective cohort of 580 newly diagnosed and surgically treated head and neck squamous cell carcinoma patients from a single institution over a 10-year period are presented. Clinical and pathologic staging are compared. RESULTS: Notably, 33% of cases had staging discordance. Overall Cohen's kappa agreement was κ = 0.55 (moderate agreement). Highly discordant site stages with κ < 0.45 included: T2 oral cavity, T2 oropharynx, T3 larynx, and N1 lymph node. T2-4 oral cavity cancers were often overstaged, and more than one-third of T3 larynx cancers were understaged. Highly concordant site stages with κ>0.65 included: T1 larynx, T4 oropharynx, N0 lymph node, and N3 lymph node. CONCLUSION: There exists a quantifiable and, in certain sites, clinically relevant pattern of discordance between clinical and pathologic staging. Tumor board multidisciplinary evaluation can highlight these discrepancies and aide in limiting effects on treatment decisions. However, discordant staging can affect the interpretation and application of prognostication, treatment, and data accuracy. Further investigation is warranted to improve clinical staging accuracy in areas of highest discordance. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.
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Background: The nasal septum supports the structure of the nose and is frequently manipulated during septorhinoplasty. Objective: To compare measurements of thickness and compressive Young's modulus (YM) between different regions of nasal septa from human anatomic specimens. Study Design: Case series. Methods: Cartilaginous septa from human anatomic specimens were dissected. Septum thickness was measured at 24 points with regular intervals using a digital caliper. Compressive YM was determined at 14 regions using a force gauge. Two-tailed student's t-tests were used to compare the average thickness and YM between different regions. Results: Septa from 40 human anatomic specimens were included, with age ranging from 50 to 89. Fifty percent of specimens were female. The mean (standard deviation) thickness of the septum was 1.75 (0.76) mm. The mean YM was 2.38 (1.29) MPa. The septum was thickest near the maxillary crest (3.09 [1.17] mm) and the keystone area (2.52 [0.91] mm) and thinnest near the anterior septal angle (1.29 [0.58] mm). The septum was most stiff posteriorly (2.90 [1.32] MPa) and least stiff anteriorly (1.80 [1.15] MPa). Conclusion: The nasal septum is thickest posteriorly, inferiorly, and along its bony edges. The septum is stiffest posteriorly, ventrally, and along its bony edges.
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The cartilaginous nasal septum is integral to the overall structure of the nose. Developing our an-atomic understanding of the septum will improve the planning and techniques of septal surgeries. While the basic dimensions of the septum have previously been described, the average shape in the sagittal plane has yet to be established. Furthermore, determining the average shape allows for the creation of a mean three-dimensional (3D) septum model. To better understand the average septal shape, we dissected septums from 40 fresh human cadavers. Thickness was measured across pre-defined points on each specimen. Image processing in Photoshop was used to superimpose lateral photographs of the septums to determine the average shape. The average shape was then combined with thickness data to develop a 3D model. This model may be utilized in finite elemental analyses, creating theoretical results about septal properties that are more translatable to real-world clinical practice. Our 3D septum also has numerous applications for 3D printing. Realistic models can be created for educational or surgical planning purposes. In the future, our model could also serve as the basis for 3D-printed scaffolds to aid in tissue regeneration to reconstruct septal defects. The model can be viewed at the NIH 3D model repository (3DPX ID: 020598, Title: 3D Nasal Septum).
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OBJECTIVE: Comparing outcomes of periprosthetic distal femur fractures treated with open reduction and internal fixation (ORIF) versus distal femoral replacement (DFR). SETTING: Three major academic hospitals within one metropolitan area. DESIGN: Retrospective. PATIENTS/PARTICIPANTS: Three hundred seventy patients >64 years old with periprosthetic distal femur fractures were identified and 115 were included (65 ORIF vs. 50 DFR). INTERVENTION: ORIF with locked plating versus DFR. MAIN OUTCOME MEASUREMENT: One-year mortality, ambulatory status at 1 year, reoperations, and hospital readmissions. RESULTS: No differences were observed between ORIF and DFR cohorts regarding demographics or medical history, including Charleston Comorbidity Index. DFR was associated with longer hospital stay (6.09 days ORIF vs. 9.08 days DFR, P < 0.001) and more frequent blood transfusion (12.3% ORIF vs. 44.0% DFR, P < 0.001). Logistic regression analysis using propensity score matching (PSM) demonstrated no statistically significant difference in reoperation, hospital readmission, ambulatory status at 1 year, or 1-year mortality between the 2 cohorts. Finally, applying Bayesian model averaging using PSM to identify risk factors for 1-year mortality demonstrated that increasing age, length of index hospital stay, and 90-day hospital readmission were significantly associated with 1-year mortality, regardless of type of surgical treatment. CONCLUSION: Rehospitalization, reoperation, ambulatory status, and 1-year mortality are no different between ORIF and DFR in the treatment of geriatric periprosthetic distal femur fractures when PSM is applied to mitigate selection bias. Further study is warranted to elucidate functional outcomes, long-term sequelae, and costs of care related to these treatment options to better guide treatment planning. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.