 |
|
Benchmarks for Mortality, Morbidity, and Length of Stay for Head and Neck Surgical Procedures
Neil Bhattacharyya, MD;
Marvin P. Fried, MD
Arch Otolaryngol Head Neck Surg. 2001;127:127-132.
ABSTRACT
| |
Objective To determine benchmarks and factors that influence morbidity, mortality,
and length of stay (LOS) for head and neck surgical procedures.
Methods A specific database for head and neck surgical procedures was extracted
from the National Hospital Data Survey database for 1995 through 1997. Records
of inpatient admissions for patients undergoing head and neck surgery were
examined to determine demographics, incidence of medical complications, mortality,
and LOS. Data were statistically examined for the influence of medical complications
on mortality and LOS.
Results A total of 3932 patients underwent head and neck procedures. The overall
medical morbidity and mortality rates were 5.65% and 2.98%, respectively.
The presence of a major medical complication increased the odds of death by
5.65 (P<.001). Postoperative pneumonia was the
most common medical complication (3.26%) and was associated with a mortality
rate of 10.94% (odds ratio for mortality, 4.4). Acute myocardial infarction
and stroke were rare (combined incidence, 1.86%) and were not statistically
associated with increased mortality. Procedures that involved the esophagus
carried the highest mortality rate (8.38%). The overall mean LOS was 6.15
days. This increased to 17.7 days when a major medical complication occurred
(P<.001). Increasing age was associated with increased
rates of medical complications and mortality (P<.001).
Conclusions Medical complications in patients undergoing head and neck surgical
procedures are associated with increased mortality rates and longer LOS. Mortality
rates in head and neck surgery are low but may be improved by preventing medical
complications.
INTRODUCTION
AS PART of the ongoing trend toward ambulatory surgery, many otolaryngology
procedures have shifted from the inpatient arena to the outpatient setting.
The remaining procedures performed in the inpatient setting, therefore, tend
to reflect more difficult or extensive procedures or a more ill patient population.
Many of the procedures performed in the realm of head and neck oncology qualify
on both fronts. Most patients with head and neck tumors present in the later
decades of life and have risk factors for cardiopulmonary or vascular disease,
usually in the setting of tobacco and/or alcohol use. This places them at
higher risk for anesthesia, surgery, and postoperative complications. Preoperative
counseling for these patients should include a discussion of such potential
complications, and accurate counseling requires knowledge of the incidence
and relative risks for such events. Several published reports1, 2, 3, 4, 5
have examined the incidence of various comorbidities and postoperative complications
for patients with head and neck tumors. However, most of these studies are
conducted within a single academic medical center and focus on specific patient
populations or a select few complications. To determine reliable benchmarks,
a large database of head and neck surgical procedures would need to be examined,
sampling a wide range of institutions, thereby eliminating institutional and
selection biases.
The National Hospital Discharge Survey (NHDS) is an annual survey conducted
by the National Center for Health Care Statistics, which is a public agency
charged with tracking health care utilization on a yearly basis across the
United States. From the aggregate group of all US hospitals, representative
institutions are randomly selected to provide data for the NHDS. A sample
of discharge records from this national sample of nonfederal hospitals from
all 50 states and the District of Columbia are reviewed, and data are collected
both manually and electronically by trained staff members. The sample contains
representative proportions of inpatient hospital admissions spanning all services,
diagnoses, hospital sizes, and geographic locations. Community hospitals,
teaching hospitals, and tertiary care centers are all sampled. Patients undergoing
ambulatory surgery are excluded. The data collected include age, sex, ethnic
background, geographic region, length of stay (LOS), discharge status, and
up to 7 diagnoses and 4 procedures. Procedures and diagnoses are coded according
to the system of the International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM).6 This data set has been frequently used to determine
benchmarks for incidence of disease, rates of surgery, and annual trends.
In addition, it has been used to investigate mortality and morbidity in both
surgical and medical patient populations.7, 8, 9
In the present study, the NHDS data were adapted to encompass a standard battery
of head and neck surgical procedures to determine benchmarks for morbidity,
mortality, and LOS in head and neck surgery.
METHODS
The NHDS databases for each of the years 1995 through 1997 were combined
into a composite database, consisting of more than 750 000 non-newborn
inpatient admissions. A list of head and neck surgical procedure codes was
compiled that directly reflected the head and neck procedures section of the
American Board of Otolaryngology's operative log, which is completed by each
graduating otolaryngology resident. The 1997 version of the operative log
was used. From the NHDS database, cases were extracted by matching any 1 of
4 procedure codes for each patient to any of the head and neck surgical procedure
codes derived from the operative log. This formed a database in which each
patient had at least 1 head and neck surgical procedure during their admission.
A second more selective database was constructed in which the primary procedure
was a head and neck surgical procedure. Further data processing and statistical
analyses were conducted for each of these 2 databases.
The data were examined using the SPSS statistical package system (SPSS
Inc, Chicago, Ill). From the ICD-9-CM diagnosis codes,
categorical variables that reflected the following comorbid medical complications
were constructed: pulmonary embolism, acute myocardial infarction, acute cerebrovascular
accident, pneumonia, and acute renal failure. The term complication used herein refers to one of these "medical" morbidities
incurred during the admission. The morbidity rate refers to the rate of occurrence
of 1 or more of these complications in the population.
Descriptive statistics for the patient population were computed. In
addition, statistics for LOS, incidence of morbidities during hospitalization,
discharge status, and mortality were computed for the entire database of head
and neck surgical procedures. Head and neck procedures were subclassified
according to primary surgical site, roughly paralleling the American Joint
Committee on Cancer staging system. Surgical site groupings are listed in Table 1. The incidences of acute morbidities
(complications) listed herein were tabulated. The Pearson  2
statistic was used to determine associations between morbidities and mortality.
Where appropriate, odds ratios for mortality were calculated. Univariate analysis
of variance (ANOVA) was used to determine the influence of type of procedure,
site of procedure, and morbidities on LOS.
|
|
|
|
Table 1. Distribution of Surgical Sites for Head and Neck Procedures
|
|
|
RESULTS
The NHDS database for the combined years 1995 through 1997 was composed
of 780 830 inpatient admissions, excluding newborns. After extraction
according to procedure code, the database for patients who had 1 or more head
and neck procedures during their admission consisted of 3932 admissions (aggregate
group). The more selective database for patients whose primary procedure was
a head and neck intervention resulted in 3039 patients (primary procedure
group). These groups constituted 0.50% and 0.39% of the total NHDS inpatient
admissions, respectively.
AGGREGATE GROUP
A total of 4591 head and neck procedures were performed in 3932 admitted
patients, for an average of 1.17 head and neck procedures per patient. A total
of 77 different head and neck surgical procedures were encountered in the
database. For example, the aggregate group included 570 unilateral thyroid
lobectomies, 352 parathyroidectomies, 96 glossectomies, 126 total laryngectomies,
289 unilateral neck dissections, and 63 mandibulectomies. The distributions
of procedures by surgical site for the aggregate group are depicted in Table 1.
For the aggregate group, the mean age was 51.9 years (SD, 20.47 years).
The male-female ratio was 1:1.28. For the aggregate group, the mortality rate
was 2.98% (117 of 3932 patients). A total of 222 patients incurred a medical
complication for a morbidity rate of 5.65%. A total of 12.16% of patients
who experienced a complication also died, whereas only 2.43% of patients without
a major complication died (P<.001, 2). The distributions of major complications and associated mortality
are displayed in Table 2. The
mean LOS was 6.15 days (SD, 10.39 days) and ranged from 1 to 245 days. The
mean LOS was 5.46 days (SD, 8.96 days) in the absence of a major complication
vs 17.70 days (SD, 20.72 days) when a major complication occurred (P<.001, ANOVA). Similarly, the LOS was 15.42 days (SD, 17.29 days)
when the outcome was death vs 5.87 days (SD, 9.97 days) when the patient was
discharged alive (P<.001, ANOVA). Patients with
a fatal outcome had a higher mean age (60.79 years) than patients without
a fatal outcome (51.65 years, P<.001, ANOVA).
Similarly, increasing age was associated with a higher medical complication
rate (P<.001).
|
|
|
|
Table 2. Mortality and Morbidity Data for Aggregate Group
|
|
|
PRIMARY PROCEDURE GROUP
In the primary procedure group, 3039 patients underwent a primary head
and neck surgical procedure. The distributions of procedures by surgical site
for the primary procedure group are depicted in Table 1. The overall mortality rate for this group was 2.11%. The
major morbidity rate was 3.55%. A total of 12.96% of patients who experienced
a concomitant complication died, whereas 1.71% of patients without a major
complication died (P<.001, 2).
The distributions of major complications and associated mortality for the
primary procedure group are displayed in Table 3. For the primary procedure group, procedures involving the
esophagus carried the highest mortality at 8.4% (P<.001).
The average LOS was 4.79 days (SD, 7.97 days). The LOS was significantly higher
for patients with a major morbidity than for those without (16.19 vs 4.65
days, respectively; P<.001, ANOVA). Similarly,
LOS was increased for patients who died during admission when compared with
those who did not (11.15 vs 4.65 days, respectively; P<.001).
The LOS benchmarks for procedures according to surgical site are listed in Table 4.
|
|
|
|
Table 3. Mortality and Morbidity Data for Primary Procedure Group
|
|
|
|
|
|
|
Table 4. Length-of-Stay Benchmarks for Primary Head and Neck Procedures
by Operative Site
|
|
|
COMMENT
Patients undergoing head and neck oncologic surgical procedures are
different from typical patients undergoing other otolaryngologic procedures.
These patients tend to be older with a history of tobacco and/or alcohol abuse.
These same risk factors that are implicated in the development of head and
neck tumors also impart risk for coronary artery disease, chronic obstructive
pulmonary disease, peripheral vascular disease, and stroke. In addition, the
increasing use of chemotherapy and radiation therapy may contribute to poorer
nutritional status and technically more challenging surgery. Furthermore,
because free flap reconstruction for postoperative defects has become more
prevalent, these procedures tend to be longer and more involved.10, 11
Therefore, critical assessment of perioperative surgical risk must include
consideration of these medical risk factors and their associated potential
complications.
Several published reports have focused on various perioperative complications
from head and neck surgical procedures. These may be divided into local complications,
such as wound infection or fistula formation, and distant complications, such
as myocardial infarction, stroke, or pulmonary embolism. We have chosen to
examine our database to determine the incidence and mortality for various
typically encountered perioperative medical morbidities. Understanding the
incidence of such complications is important in preoperative counseling for
patients, the determination of proper monitoring in the postoperative setting,
and allocation of resources for patients with head and neck cancer.12 In many cases, patients are more concerned with the
implications of anesthesia rather than the immediate postsurgical outcome
from their extirpative procedure. This likely stems from the widespread knowledge
that chronic obstructive pulmonary disease and coronary artery disease increase
anesthetic risk.1
Because head and neck cancer only accounts for approximately 3% of new
cancers diagnosed each year, the absolute number of treated patients is small.13 Furthermore, the increasing interest in organ preservation
strategies has perhaps further decreased surgical volumes in head and neck
oncology. Therefore, it is difficult to assemble a large, prospective series
of patients that can be examined to determine the incidence of perioperative
medical complications. Studies in the otolaryngology literature have therefore
focused primarily on assessing the incidence and outcomes for individual uncommon
medical complications that arise in a series of treated patients. Data can
be extrapolated from other surgical disciplines with some success, but head
and neck procedures alone are associated with increased perioperative risk
compared with other surgical procedures.14
The database constructed for this study represents a very large patient
population who underwent head and neck surgical procedures. Patients have
been extracted from a national database, which includes a wide variety of
medical institutions, from all geographic areas of the United States. The
NHDS data have been previously used to determine the incidence of various
procedures, the prevalence of disease, and year-to-year trends in surgery.7 In general, NHDS data are thought to accurately reflect
disease and surgical mortality but less accurately reflect morbidity.9 The NHDS data collection system consists of a random
sampling of these institutions, carefully chosen to represent an accurate
cross section of medical practice in the United States. Therefore, treatment,
selection, and institutional biases are less likely to play a role. The NHDS
data extracted in this study differ significantly from the patient populations
in most of the head and neck surgical literature in that almost all of the
previously published literature reflects experience from single academic institutions.
This introduces an inherent bias when attempting to determine benchmarks,
since teaching hospitals have a well-documented lower mortality rate and different
patient populations.15 Therefore, we consider
these data suitable benchmarks for the incidence of medical complications
in head and neck surgery.
We examined an aggregate group and a primary procedure group to ensure
that all head and neck procedures would be captured. For example, a patient
with an esophageal cancer may also have cervical metastasis. The primary procedure
for this patient may actually be either the neck dissection or the esophagectomy,
depending on the coding method. Although looking at admissions for which the
primary procedure was a head and neck procedure is probably the most accurate,
it would miss patients who undergo head and neck procedures in conjunction
with other services, such as thoracic surgery or neurosurgery. By examining
both databases, both a conservative and liberal extreme can be analyzed, and
a check for internal consistency is provided.
Our data indicate that the incidence of major medical complications
is not negligible in head and neck surgery. Patients should be counseled that
there is a significant chance of medical complications that may affect the
postoperative course after head and neck surgery. Postoperative pneumonia
is an especially notable risk and carries with it a major impact on overall
mortality. This is likely because these patients often have a history of smoking
with underlying chronic obstructive pulmonary disease, placing them at higher
risk for both pneumonia and its complications.3
Our data suggest that prevention and prompt treatment of postoperative pneumonia
should have a significant impact on mortality after head and neck surgery
and decrease overall LOS.
Interestingly, we found that acute myocardial infarction and acute cerebrovascular
accident are both uncommon complications after head and neck surgery. Furthermore,
the mortality rate occurring with these complications was surprisingly small.
This is likely due to advances in preoperative preparation with optimization
of cardiac status and more intensive monitoring in the postoperative period.16 Therefore, although patients should be counseled
about these 2 risks, they probably do not have a major impact on immediate
perioperative outcomes. Other studies have identified a significant increased
risk for myocardial infarction, specifically in patients with head and neck
cancer.1, 17 The risk of perioperative
stroke is small in head and neck surgery. Causes of stroke may include excessive
handling of the carotid vessels, hypoperfusion, or patient positioning.4 Even given the proximity of these procedures to the
carotid artery, and the likelihood of concurrent carotid vascular disease,
the risk of stroke is small. However, appropriate precautions should be taken
in this group of patients, who may be at increased risk.
Acute renal failure is associated with a very high likelihood of mortality
in both patient groups. Although its overall incidence is small, acute renal
failure probably reflects one component of multiple organ system failure in
a patient with a poor postoperative outcome and, therefore, is highly correlated
with death. The extremely low incidence of pulmonary embolism is likely due
to increased awareness and standard perioperative prophylaxis against deep
venous thrombosis. Also, most patients undergoing head and neck surgery are
ambulatory soon after surgery, decreasing their risk for deep venous thrombosis.
Moreano et al18 found a similar incidence of
0.4% of pulmonary embolism among patients undergoing head and neck surgery
in a single institution study.
Aside from the mortality implications of perioperative medical complications,
such complications have a definite impact on LOS, as our data demonstrate.
Such impact needs to be considered in preoperative counseling for patients
regarding expected LOS. In addition, minimizing such complications will likely
decrease LOS, conserving valuable resources.
Mortality from otolaryngologic procedures is rare. However, it would
seem that patients undergoing head and neck surgical procedures do manifest
a nonnegligible mortality rate, approximating 2% to 3%. This mortality rate
holds true for most of the operative sites, with operations on the esophagus
having a significantly higher mortality rate. Other authors19
have reported higher mortality and morbidity rates for esophageal procedures
as well. Mortality rates approximating 15% to 20% for esophageal procedures
are not uncommon, especially when esophageal resection is involved. Looking
at the esophageal procedures subset, esophageal resection and endoscopic resection
and destruction of esophageal lesions carried higher mortality rates. These
procedures may be performed by thoracic surgeons and gastroenterologists,
as well as by otolaryngologists. Nonetheless, these procedures were part of
the operative log for the American Board of Otolaryngology and are therefore
included in the data. Such procedures should be approached with caution, regardless
of the specialist performing the procedure.
Notably, procedures that involved the salivary glands, face and sinonasal
region, and the thyroid and parathyroid glands had exceedingly low mortality
rates. Interestingly, these sites are often affected by tumors other than
squamous cell carcinoma, which may help explain the low mortality rates encountered
with these sites. Furthermore, procedures that involve these sites are often
shorter and do not involve entering the cervical portion of the upper aerodigestive
tract. Procedures that involve the pharynx have been associated with increased
complication rates.20
Length of stay has become the focus of an increasing number of health
care utilization studies. To conserve resources and provide more efficient
care, substantial efforts have been directed at reducing LOS. Part of that
effort includes the shift from the inpatient to the outpatient arena for many
surgical procedures. For example, our database does not include noninterventional
endoscopic procedures, such as direct laryngoscopy, esophagoscopy, or bronchoscopy,
as part of a staging endoscopy. First, these patients are not likely to be
admitted. Second, these procedures are not listed as part of the American
Board of Otolaryngology head and neck procedure list
used to extract the data.
Our data clearly indicate that patients undergoing head and neck surgical
procedures have an LOS that approximates 1 week. Procedures involving any
part of the upper aerodigestive tract that is involved with deglutition (pharynx,
larynx, or esophagus) are associated with a substantial increase in LOS. In
addition, increasing patient age was also found to be associated with an increased
LOS. This may be due to additional comorbidities that elderly patients have.
However, several studies2, 21 have
documented that head and neck surgery in elderly patients is not significantly
associated with additional risk. Our data demonstrate that increasing age
is associated with additional morbidity in head and neck surgery. Finally,
the occurrence of a medical complication significantly increased the LOS by
almost 3-fold. This suggests that diligence in preventing medical complications
should assist in decreasing LOS for patients undergoing head and neck surgery.
Additional effort should be directed at decreasing LOS for patients undergoing
head and neck surgical procedures, when appropriate. Several studies22, 23 have emerged showing that the use
of critical pathways in head and neck surgery may decrease LOS and provide
more cost-efficient care.
One limitation of the present study is that it fails to capture patients
who undergo surgery, are discharged from the hospital, and then experience
a significant complication after discharge. These patients may return to the
hospital of origin or be treated at a second hospital for their complication.
To fully measure extended perioperative complications, one should include
this group of patients, which may approximate an estimated 5% to 8% of patients,
up through 30 days after discharge. Because our methods overlook this group
of patients, it is likely that some of the morbidity and mortality estimates
may in fact be higher when one considers 30-day postoperative morbidity and
mortality rates.
CONCLUSIONS
Medical morbidity and mortality rates for head and neck surgery are
relatively low (5.65% and 2.98%, respectively). Pulmonary complications are
the most frequently encountered postoperative morbidity.
When a major medical complication occurs, both the odds for death and
the LOS increase significantly (increase in odds, 5.65, and a 3-fold increase
in LOS).
Contrary to other reports, increasing age is associated with increased
rates of medical complications and mortality in head and neck surgery.
AUTHOR INFORMATION
Accepted for publication July 13, 2000.
From the Division of Otolaryngology, Brigham and Women's Hospital,
Harvard Medical School, Boston, Mass (Dr Bhattacharyya); and Department of
Otolaryngology, Montefiore Medical Center, Albert Einstein College of Medicine,
Bronx, NY (Dr Fried).
Corresponding author and reprints: Neil Bhattacharyya, MD, Division
of Otolaryngology, Brigham and Women's Hospital, Harvard Medical School, 333
Longwood Ave, Boston, MA 02115.
REFERENCES
| |
1. Pelczar BT, Weed HG, Schuller DE, Young DC, Reilley TE. Identifying high-risk patients before head and neck oncologic surgery. Arch Otolaryngol Head Neck Surg. 1993;119:861-864.
ABSTRACT
2. Clayman GL, Eicher SA, Sicard MW, Razmpa E, Goepfert H. Surgical outcomes in head and neck cancer patients 80 years of age
and older. Head Neck. 1998;20:216-223.
FULL TEXT
|
ISI
| PUBMED
3. McCulloch TM, Jensen NF, Girod DA, Tsue TT, Weymuller EA Jr. Risk factors for pulmonary complications in the postoperative head
and neck surgery patient. Head Neck. 1997;19:372-377.
FULL TEXT
|
ISI
| PUBMED
4. Nosan DK, Gomez CR, Maves MD. Perioperative stroke in patients undergoing head and neck surgery. Ann Otol Rhinol Laryngol. 1993;102:717-723.
ISI
| PUBMED
5. Rao MK, Reilley TE, Schuller DE, Young DC. Analysis of risk factors for postoperative pulmonary complications
in head and neck surgery. Laryngoscope. 1992;102:45-47.
ISI
| PUBMED
6. International Classification of Diseases, Ninth Revision, Clinical
Modification. Washington, DC: Public Health Service, US Dept of Health and Human
Services; 1988.
7. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 13. 1998;(139):1-119.
8. Deaths and hospitalizations from chronic liver disease and cirrhosis—United
States, 1980-1989. MMWR Morb Mortal Wkly Rep. 1993;41:969-973.
PUBMED
9. Derkay CS. Pediatric otolaryngology procedures in the United States: 1977-1987. Int J Pediatr Otorhinolaryngol. 1993;25:1-12.
FULL TEXT
|
ISI
| PUBMED
10. Singh B, Cordeiro PG, Santamaria E, Shaha AR, Pfister DG, Shah JP. Factors associated with complications in microvascular reconstruction
of head and neck defects. Plast Reconstr Surg. 1999;103:403-411.
ISI
| PUBMED
11. Brown MR, McCulloch TM, Funk GF, Graham SM, Hoffman HT. Resource utilization and patient morbidity in head and neck reconstruction. Laryngoscope. 1997;107:1028-1031.
FULL TEXT
|
ISI
| PUBMED
12. Downey RJ, Friedlander P, Groeger J, et al. Critical care for the severely ill head and neck patient. Crit Care Med. 1999;27:95-97.
FULL TEXT
|
ISI
| PUBMED
13. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics 1999. CA Cancer J Clin. 1999;49:8-31.
FREE FULL TEXT
14. Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ. Cardiac risk of noncardiac surgery: influence of coronary disease and
type of surgery in 3368 operations. Circulation. 1997;96:1882-1887.
FREE FULL TEXT
15. Hartz AJ, Krakauer H, Kuhn EM, et al. Hospital characteristics and mortality rates. N Engl J Med. 1989;321:1720-1725.
ABSTRACT
16. Strauss M, Bellian K. Otolaryngology care unit: a safe and cost-reducing way to deliver quality
care. Laryngoscope. 1999;109:1428-1432.
FULL TEXT
|
ISI
| PUBMED
17. Ogawa A, Kanda T, Sugihara S, Masumo H, Kobayashi I. Risk factors for myocardial infarction in cancer patients. J Med. 1995;26:221-233.
FULL TEXT
|
ISI
| PUBMED
18. Moreano EH, Hutchison JL, McCulloch TM, Graham SM, Funk GF, Hoffman HT. Incidence of deep venous thrombosis and pulmonary embolism in otolaryngology–head
and neck surgery. Otolaryngol Head Neck Surg. 1998;118:777-784.
FULL TEXT
|
ISI
| PUBMED
19. Dudhat SB, Mistry RC, Fakih AR. Complications following gastric transposition after total laryngo-pharyngectomy. Eur J Surg Oncol. 1999;25:82-85.
FULL TEXT
|
ISI
| PUBMED
20. Newman JP, Terris DJ, Pinto HA, Fee WE Jr, Goode RL, Goffinet DR. Surgical morbidity of neck dissection after chemoradiotherapy in advanced
head and neck cancer. Ann Otol Rhinol Laryngol. 1997;106:117-122.
ISI
| PUBMED
21. Shaari CM, Urken ML. Complications of head and neck surgery in the elderly. Ear Nose Throat J. 1999;78:510-512.
PUBMED
22. Cohen J, Stock M, Andersen P, Everts E. Critical pathways for head and neck surgery: development and implementation. Arch Otolaryngol Head Neck Surg. 1997;123:11-14.
ABSTRACT
23. Hanna E, Schultz S, Doctor D, Vural E, Stern S, Suen J. Development and implementation of a clinical pathway for patients undergoing
total laryngectomy: impact on cost and quality of care. Arch Otolaryngol Head Neck Surg. 1999;125:1247-1251.
FREE FULL TEXT
RELATED ARTICLE
Archives of Otolaryngology–Head & Neck Surgery Reader's Choice: Continuing Medical Education
Arch Otolaryngol Head Neck Surg. 2001;127(2):229-230.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Comorbidity as a Major Risk Factor for Mortality and Complications in Head and Neck Surgery
Ferrier et al.
Arch Otolaryngol Head Neck Surg 2005;131:27-32.
ABSTRACT
| FULL TEXT
Complications and Determinants of Length of Stay for Inpatient Pediatric Otolaryngologic Procedures
Shapiro and Bhattacharyya
Arch Otolaryngol Head Neck Surg 2003;129:169-172.
ABSTRACT
| FULL TEXT
The Influence of Reconstructive Modality on Cost of Care in Head and Neck Oncologic Surgery
Petruzzelli et al.
Arch Otolaryngol Head Neck Surg 2002;128:1377-1380.
ABSTRACT
| FULL TEXT
Assessment of the Morbidity and Complications of Total Thyroidectomy
Bhattacharyya and Fried
Arch Otolaryngol Head Neck Surg 2002;128:389-392.
ABSTRACT
| FULL TEXT
Clinical Care Pathway for Head and Neck Cancer: A Valuable Tool for Decreasing Resource Utilization
Gendron et al.
Arch Otolaryngol Head Neck Surg 2002;128:258-262.
ABSTRACT
| FULL TEXT
|
