Acinic Cell Carcinoma and the Factors Associated With Recurrence
Stefan Rozycki, MD, Joseph W. Spellman, MD, Gabriel Calzada, MD
Introduction: Acinic cell carcinoma (ACC) is a rare salivary gland malignancy treated primarily with surgery, but debate persists regarding adjuvant therapy and management of the cN0 neck. The purpose of this cohort study is to describe and evaluate cohort outcomes including the effect of neck dissection and adjuvant radiotherapy.
Method: Retrospective review of patients with predominantly major salivary gland ACC of the head and neck treated in the Kaiser Permanente Southern California Medical Group from 2006 to 2020. Risk factors for recurrence were evaluated. Disease-specific and recurrence-free survival were stratified by T stage. Subgroup analysis of patients with close/positive margins and N0 neck were performed.
Results: Seventy-eight patients were followed for a mean of 42.6 months. Five- and 10-year recurrence-free survival were outstanding for T1 tumors (100% and 100%) but dropped precipitously in the higher T-stage group (T2/3/4; 73.8% and 49.2%; P=.006). Five-year disease-specific survival was excellent for both groups (100% vs 91.7%) with no significant difference (P=.177). T stage, perineural invasion, and tumor grade significantly affected recurrence. Conversely, gender, age, margin status, lymphovascular invasion, neck dissection, and adjuvant radiotherapy did not affect recurrence rate. In the subgroup with close/positive margins (n=45), adjuvant radiotherapy did not affect recurrence (P=.832). In patients with a cN0 neck, elective neck dissection did not affect overall recurrence (P=.176) nor locoregional recurrence (P=.266).
Conclusion: High-risk pathological features resulted in a high rate of recurrence. However, close or positive margins neck dissection and adjuvant radiotherapy had no effect on recurrence. Five-year disease-specific survival was excellent for both high and low T stages. Therefore, observation may be an acceptable alternative to elective neck dissection and/or adjuvant radiotherapy, particularly in the clinically node negative neck.
Adherence to Prophylactic Intraoperative Antibiotic Dosing in Patients Undergoing Head and Neck Surgery
Rema Shah, Oded Cohen, MD, Jacqueline Dibble, MSN, Danielle Paolillo, MSN, Amanda Cook, DNP, Saral Mehra, MD, MBA
Introduction: This study aims to investigate intraoperative antibiotic regimens in head and neck surgeries with free tissue transfer (FTT), which are expected to require several doses due to their length. To the best of our knowledge, this is the first study to evaluate the adherence to the Surgical Care Improvement Project (SCIP) recommendations for preoperative redosing and its impact on infections in FTT head and neck surgeries.
Method: This retrospective single-institution study reviewed all patients who underwent FTT mucosa-violating oncologic surgeries between March 2017 and June 2019. Any deviation from SCIP recommendations on intraoperative dosage timing and volume was defined as nonadherence. Postoperative infections included surgical site, flap donor site, and systemic infections. Antibiotic data on intraoperative regimens included antibiotic type, dosage, frequency, and duration and were taken from intraoperative anesthesia notes. Antibiotic regimens were categorized as Unasyn, Ancef/Flagyl, clindamycin, and others.
Results: A total of 129 surgeries were included. The mean number of antibiotic doses for surgery was 3.16 (±1.2). The mean number of missed doses was 1.86 (±1.65). Overall, the adherence rate with first dosing recommendations was 100%, compared with 41.7% for dose 2, 23.08% for dose 3, 13.68% for dose 4, 5.26% for dose 5, 2.56% for dose 6, and 0% for dose 7 (P<.00001). While no significant difference was found regarding first dosing of antibiotics, Unasyn (6.4%) had significantly lower rates of average subsequent redosing adherence when compared with Ancef/Flagyl (73.2%), clindamycin (63.3%), and ciproflaxin (100%). The overall, flap-related, donor site and systemic infection rates were 15.5%, 3.2%, and 18.6%, respectively. No association was found between antibiotic regimen and infection rate.
Conclusion: In conclusion, a significant gap exists between adherence to initial dosing compared to redosing guidelines, and that gap increases with time in surgery. Surgeons should stress redosing during the initial surgical pause and consider Ancef/Flagyl regimens over Unasyn.
Adverse Events Associated With Robotic Head and Neck Surgery: A 10-Year Analysis
Priyanka Bisarya, Hemali P. Shah, Ansley M. Roche, MD
Introduction: Robotic surgery using the da Vinci system (Intuitive Surgical) has become an increasingly standard offering by head and neck surgeons. This study aims to catalog adverse events (AEs) related to the use of this system to better characterize the safety of this technique.
Method: The US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports on the use of the da Vinci system for head and neck surgery using a systematic search strategy of the database from 2011 to 2020. After screening of the AE reports, data were extracted from relevant reports.
Results: There were 79 unique AE records obtained by the search, of which 24 were included after screening for relevance and removal of duplicates. Of these, 15 (62.5%) were AEs sustained during transoral robotic surgery (TORS) procedures, and 9 (37.5%) were during robotic thyroidectomy or parathyroid gland procedures. There was reported harm to the patient in 13 incidents (54.2%), and the most common AEs included death (5/13, 38.5%), bleeding events (3/13, 23.1%), and burn injuries (3/13, 23.1%). All AE reports of patient deaths were related to TORS procedures. Device-related AEs, in which there was no harm to patient, were present in 11 reports (45.8%), of which the most frequently reported AE was detachment of the instrument in the patient.
Conclusion: As robotic surgery for head and neck surgery becomes adopted more widely, with over 50,000 such procedures performed in the past decade, it is imperative to understand the potential for AEs related to the use of this technique. However, rare, serious, and life-threatening AEs related to the use of the da Vinci system have been reported and should be discussed with patients preoperatively.
Analysis of Racial Disparities in Head and Neck Cancer Incidence and Mortality in the United States
Tirth R. Patel, MD, Kerstin M. Stenson, MD, Samer Al-Khudari, MD, Mihir K. Bhayani, MD
Introduction: It has been shown that non–Hispanic Black (hereafter, Black) individuals experience worse cancer outcomes across a variety of malignancies, including head and neck cancer, compared with non–Hispanic White (hereafter, White) individuals. In this study, we examined changes in the incidence and mortality of head and neck cancer to assess how this racial disparity has changed over time.
Method: The National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program was used to identify patients diagnosed with head and neck cancers (oral cavity, oropharynx, hypopharynx, and larynx) from 2000 to 2016 for this retrospective study. Average annual percentage change (aAPC) in incidence and mortality (2000 to 2016) were age adjusted to the 2000 US standard population and were calculated overall, by human papillomavirus (HPV) status and by race (White or Black). The Tiwari modification was used to compute confidence intervals and assess trends over time.
Results: From 2000 to 2016, the incidence of overall head and neck cancer diagnoses declined (aAPC, −0.2%; P<.01). Black individuals had a higher overall incidence than White individuals in 2000 (23.5 vs 17.8 per 100,000; P<.01), but this difference had disappeared by 2016. This was driven by a decline in incidence among Black individuals (aAPC, –2.4%; P<.01), while incidence among White individuals remained stable (aAPC, +0.1%; P=.12). Among Black patients, mortality declined in all 4 subsites. Among White patients, mortality declined in all subsites except the oropharynx, for which it increased (+1.3% oropharynx; P<.01). Despite the decline for Black patients, the mortality from head and neck cancer in 2016 remained elevated compared with White patients (11.7 vs 9.3 per 100,000; P=.01).
Conclusion: Despite the elimination of an incidence disparity between Black and White individuals, Black patients continue to experience a higher mortality rate. Further research, specifically on the effects of HPV-related cancers, is needed to elucidate the factors underlying the persistence of this racial disparity in mortality due to head and neck cancer.
Carotid Body Tumor Volume and Postoperative Outcomes: Single-Center Retrospective Review
Steven Goicoechea, MS, Aaron Domack, MD, Eric Thorpe, MD
Introduction: There are discrepancies in the current literature regarding the effect of carotid body tumor (CBT) volume on patient outcomes following surgical resection. The objective of this study is to investigate the impact of CBT volume on postoperative outcomes.
Method: The study was a single-center retrospective chart review of 18 patients with CBT who underwent surgical resection from 2007 to 2021. Patient demographics, symptoms, imaging, and operative reports were reviewed. The primary outcomes were intraoperative and postoperative complications, 30-day readmission, and length of hospital stay. Multivariate regression analysis with fixed effects for age, gender, and comorbidities was completed with Stata (Stata Corporation).
Results: Among the 18 patients identified with CBT, the average age was 48.9 years (range 22–84 years), and 55.6% of patients were female. The most common presenting symptom was painless neck mass (n=14). Six patients had additional paragangliomas or other neuroendocrine tumors (33.3%). Seventy-two percent of patients experienced postoperative complications, including temporary nerve palsy/weakness (n=8) and hoarseness (n=7). The mean time to resolution of postoperative complications was 5.4 months (range, 1 week-40 months), and the mean length of hospital stay was 3.1 days. Multivariate regression analysis found no statistically significant relationships between CBT volume and primary outcomes. However, there were correlations between increased tumor volume and intraoperative complications (odds ratio 1.05; CI, 0.95–1.15; P=.253) and postoperative complications (odds ratio 1.18; CI, 0.95–1.46; P=.141). There were no significant differences in outcomes between patients with and without multiple paragangliomas.
Conclusion: CBTs are rare neoplasms that respond well to surgical treatment. Tumor volume was not statistically significantly related to postoperative outcomes; however, there were correlations between tumor volume and operative and postoperative complications. Management of CBTs should be largely based on associated symptoms, but the rate of tumor volume progression must be considered.
Characterization of Head and Neck Sarcomas in the Berlin-Brandenburg Sarcoma Center
Adam Scheel, MD, Thomas Schrom, MD
Introduction: Sarcomas of the head and neck are rare and heterogeneous malignant tumors. Studies of these tumors are scarce. Consequently, staging and treatment recommendations have been largely based on extrapolated data from other tumor types or other sarcoma sites.
Method: We searched for all patients treated for sarcoma of the head and neck from 2010 to 2020 in the Helios Hospital Bad Saarow, a hospital of the Sarcoma Center Berlin-Brandenburg. Patient characteristics, tumor types, and clinical data were extracted and analyzed.
Results: Seventy-five patients with sarcomas of the head and neck were treated from 2010 to 2020. We analyze the incidence of the sarcoma types, patient characteristics, treatment modalities, and survival. Special attention is given to surgical variables such as surgical technique, surgical margins, and the predictive value of the last TNM staging for head and neck sarcomas.
Conclusion: Head and neck sarcomas are rare and available clinical data are limited. This study characterizes sarcomas of the head and neck in the Berlin-Brandenburg area. Multi-institutional international efforts are necessary to obtain more meaningful results.
Circulating Hybrid Cells and Extranodal Extension in Head and Neck Cancer
Emily N. Ahadizadeh, MD, Daniel R. Clayburgh, MD, PhD, David A. Sauer, MD, Melissa H. Wong, PhD
Introduction: Extranodal extension (ENE) is an indicator of aggressive disease. There are no noninvasive biomarkers to identify ENE in a preoperative setting. Detection of ENE on final pathology is an indication for chemoradiation, resulting in patients undergoing triple therapy and sustaining the cumulative morbidity associated with these intensive treatments. Predicting ENE preoperatively would allow some patients to be treated with chemoradiation and spare them surgery. Circulating hybrid cells (CHC) are a novel neoplastic cell population formed by the fusion of a macrophage and a tumor cell and were found to correlate with aggressive disease in other cancers.
Method: Peripheral blood samples were collected from treatment-naive patients undergoing surgery for oral cavity and oropharyngeal squamous cell carcinoma. Peripheral blood mononuclear cells were stained with antibodies to detect CHCs (cytokeratin and CD45). CHCs were quantified manually using a digital microscope. Patients’ final pathologies were evaluated for ENE status. Statistical analyses determined the relationship between CHC level and ENE on final pathology.
Results: CHC concentration was significantly higher in patients with ENE identified on final pathology in both oral cavity squamous cell carcinoma and in oropharyngeal squamous cell carcinoma (P<.001 for all intergroup differences). CHC numbers are able to predict ENE in both oropharyngeal and oral cavity squamous cell carcinoma (area under the curve=0.83).
Conclusion: CHC concentration can be used as a preoperative indicator of ENE. Further research is needed to determine an exact threshold value, but this preliminary study indicates that CHC levels can be used to determine which patients should forgo surgery and be sent directly to chemoradiation therapy.
Circumferential Peripheral Margins in Head and Neck Cutaneous Melanoma
Hyunseo Jung, MD, MS
Introduction: This study aims to assess the rate of re-excision, recurrence, and survival in patients that undergo excision of head and neck cutaneous melanoma with reduced margins when utilizing circumferential margin assessment, a novel method of pathologic margin analysis, when compared with traditional “bread-loafing” margin analysis.
Method: This is a single center retrospective cohort study of 132 patients who underwent excision of cutaneous melanoma of the head and neck from 2018 to 2021. Every patient in the study underwent excision with enhance margin assessment—reduced and circumferential peripheral margins—as opposed to traditional bread-loafing margin analysis and NCCN guideline of recommended margins based on each T staging. We then calculated the rate of re-excision, rate of locoregional, and metastatic recurrence and survival (disease specific, disease free, and overall) for our patient population and compared these outcomes with those found in the literature that adhered to traditional excision margins and margin analyses. Our analysis shows low re-excision rates and recurrence rates, comparable with patients treated with guideline-recommended margins.
Results: Our analysis shows that enhanced margin analysis via reduced surgical margins and circumferential margins lead to low re-excision and low recurrence rates, comparable to and statistically unchanged from patients treated with guideline-recommended margins.
Conclusion: Enhanced margin assessment by utilizing circumferential margin analysis can allow a surgeon to take reduced surgical margins without compromising oncologic outcome, offering an opportunity for improved cosmetic and functional outcome. We believe this to be a practice-changing finding that will pave the way for more cost-effective surgical management of cutaneous melanoma by avoiding re-excisions that do not improve oncologic outcome and performing same-day reconstruction.
Clinical Outcomes of Patients With Esthesioneuroblastoma: A Single-Center Experience
Haley M. Hullfish, Roy R. Casiano, MD, Zoukaa B. Sargi, MD
Introduction: Esthesioneuroblastoma, or olfactory neuroblastoma, is a rare malignant neoplasm of the sinonasal cavity originating from the olfactory epithelium. This retrospective study was conducted to identify the clinical outcomes of esthesioneuroblastomas.
Method: We retrospectively assessed the clinic features, prognostic factors, treatments, and outcomes of 29 adult patients treated for esthesioneuroblastoma at our center between January 2005 and January 2020. To estimate overall survival (OS) and disease-free survival (DFS), Kaplan-Meier survival analysis was performed.
Results: Of the patients, 21 were male and 8 were female. The median age at the time of surgery was 58 years (range 37–80 years). In terms of Kadish stage, 3 (10.3%), 12 (41.4%), 12 (41.4%), and 2 (6.9%) patients had stage A, B, C, and D. Overall, all 33 (100%) patients were treated with surgery: 27 (93.1%) by endoscopic approach and 2 (6.9%) by combined approach. Eleven (37.9%) patients experienced postoperative complications. After surgery, 24 (82.8%) received radiation alone and 5 (17.2%) received radiation and chemotherapy. The median follow-up time for the cohort was 51 months (range 1–117 months). Four patients (13.8%) died, and 5 patients (17.2%) suffered recurrence during follow-up, 2 of which developed distant metastases to the lung and sacrum. The mean time to recurrence was 4.9 years (range 1–10 years). The mean DFS was 8.5 years (standard error [SE]=.481; 95% CI, 8.253–10.136), with a 5-year DFS of 89.6% and 10-year DFS of 82.8%. The mean OS was 9.2 years (SE=.481; 95% CI, 8.253–10.136), with a 5- and 10-year OS of 92.6%. No significant survival differences were observed between radiation alone and combined treatment with radiation and chemotherapy.
Conclusion: Esthesioneuroblastoma has favorable outcomes, but long-term follow-up is essential as late recurrence is not uncommon. The current standard of care, surgery with radiotherapy, remains an optimal treatment choice.
Clinical Relevance of Perineural Invasion in Patients With Early-Stage Oral Tongue Cancer After Surgery
Young Min Park, MD, Se-Heon Kim, MD
Introduction: We attempted to investigate the prognostic factors and to determine the indications for adjuvant therapy in early-stage (pT1-2N0) oral tongue squamous cell cancer (OTSCC).
Method: We retrospectively analyzed the medical records of 607 OTSCC patients.
Results: A total of 292 patients were enrolled. The 5-year recurrence-free survival was 83.6%, and the disease-specific survival was 95.4%. On multivariate analysis, only gender, perineural invasion (PNI), and depth of invasion (DOI) showed significant correlations with disease recurrence. The 5-year recurrence-free survival was 81.3% in the PNI (+) patient group that received adjuvant radiotherapy, and the 5-year recurrence-free survival was 40.0% in the PNI (+) patient group that did not receive adjuvant radiotherapy.
Conclusion: In pT1-2N0 OTSCC patients, local recurrence is the main recurrence pattern, and PNI and DOI >5 mm are significant prognostic factors related to recurrence. In patients with PNI findings, adjuvant radiotherapy may be considered to prevent disease recurrence.
Clinical Significance of Incidental Head and Neck Findings in a Large Community-Based Lung Cancer Screening Cohort
Lauren Schlegel, Dylan G. Bertoni, MD, Maria Armache, MD, Elizabeth E. Cottrill, MD
Introduction: Lung cancer is the third most common cancer in the United States, with the highest incidence among cigarette smokers. Approximately 70% to 80% of head and neck cancers have also been linked to tobacco use, making it the strongest risk factor. Though not associated with smoking, thyroid nodules are an extremely common pathology, estimated in up to 50% of the adult population on autopsy, with most nodules found incidentally. With current lung cancer screening guidelines among heavy smokers, 15 million people are eligible for screening with low-dose chest computerized tomography (CT). The purpose of this study is to investigate incidental findings of head and neck pathology and determine their clinical relevance in this population of heavy smokers.
Method: A retrospective chart review was conducted utilizing a database of patients who underwent a chest CT through a successful community-based hospital lung cancer screening program in 2020. Demographics, medical history, imaging reports, and any pathology results were analyzed.
Results: A total of 1227 patients received a lung screening CT scan in 2020. The median age of the patient population was 64 (range 50–79) years. Of the patients, 612 (50%) were male, and 1133 (92%) were White. Only 15 (.01%) were found to have thyroid findings noted on their CT report. Two patients were excluded from further analysis due to insufficient availability of chart information. Six patients did receive follow-up for their thyroid findings, and 2 had surgery with benign pathology.
Conclusion: The results of our study demonstrate a lack of significant thyroid findings on lung cancer screening CT for heavy smokers. Of those with significant thyroid findings, we found that few patients underwent further workup. Given the low incidence of findings in this cohort, which may have had lower numbers than other years because of the COVID-19 pandemic, we plan to increase the power of our study by including the prior 5 years of data.
Clinicopathological Predictors of Survival for Parotid Mucoepidermoid Carcinoma: A Systematic Review
Emily YiQin Cheng, Joo Hyun Kim, Elysia M. Grose, MD, Justine Philteos, MD, Marc Levin, MD, David Goldstein, MD, FRCSC, MSc
Introduction: Various prognostic factors are associated with the survival of patients with parotid mucoepidermoid carcinoma (MEC). The aim of this systematic review is to summarize the clinical and pathological prognostic factors on survival outcomes in patients with parotid MEC.
Method: Articles published from database inception to July 2020 on Ovid MEDLINE, Ovid Embase, Cochrane Central, and Scopus were retrieved. Studies reporting clinical or pathological prognostic factors on survival outcomes for adult patients with parotid MEC were included. Data extraction, risk of bias, and quality assessment were conducted by 2 independent reviewers. Data were summarized descriptively and findings were considered to be consistent if the results of at least 75% of the studies analyzing the effect of a specific prognostic factor on multivariate analysis point in the same direction.
Results: A total of 4290 titles were reviewed, 396 retrieved for full-text screening, and 18 included in the review. The average risk of bias was high, and quality assessment for the prognostic factors ranged from very low to moderate. Prognostic factors that were consistently associated with negative survival outcomes on multivariate analysis included histological grade (hazard ratio [HR]=5.66), nodal status (HR=2.86), distant metastasis (HR=3.10 to 5.80), intraparotid metastasis (HR=13.52), and age (HR=1.02 to 6.86). Prognostic factors that inconsistently reported associations with survival outcomes were TNM stage, T classification, and N classification.
Conclusion: Histological grade, nodal status, distant metastasis, intraparotid metastasis, and age were associated with worse survival outcomes. These prognostic factors should be considered when determining the most appropriate treatment and follow-up plan for patients with parotid MEC.
Combined CD103 TILs and PD-L1 Score Predicts Survival in Recurrent Larynx Squamous Cell Carcinoma
Joshua Smith, MD, Susan Ellsperman, MD, Emily Bellile, MS, Jonathan McHugh, MD, Chad Brenner, PhD, Matthew Spector, MD
Introduction: In an evolving era of immunotherapeutic options for persistent or recurrent laryngeal squamous cell carcinoma (LSCC), there is a need for improved biomarkers of treatment response and survival to impact optimal treatment selection and prognostication. Herein, we sought to explore correlations between tumor infiltrating lymphocytes (TILs) and tumor PD-L1 Combined Positive Score (CPS) and their combined association with survival outcomes in a large institutional cohort of patients with persistent or recurrent LSCC.
Method: This was a retrospective cohort study at a single academic medical center. Immunohistochemistry staining for TILs and tumoral PD-L1 was performed on a tissue microarray of persistent or recurrent LSCC specimens. Correlations between TIL subsets and PD-L1 CPS were examined using Pearson correlation coefficient and survival outcomes were analyzed with the Kaplan-Meier method and log-rank tests.
Results: Only CD103+ TILs showed a statistically significant, weakly positive correlation with PD-L1 CPS (r2=0.264, P<.015). No other TIL subsets correlated with PD-L1 CPS in our cohort. Patients with tumors showing high CD103+ TILS and/or high PD-L1 CPS staining had the best overall survival (OS; hazard ratio [HR]: 0.48 [0.25–9.90], P=.02), DSS (HR: 0.30 [0.13–0.70], P=.005) and disease-free survival (DFS; HR: 0.48 [0.22–1.02], P=.06). In a multivariable analysis, the most favorable survival outcomes were seen in patients with pN0 tumors showing high CD103+ TILs and/or high PD-L1 CPS: OS (HR: 0.45 [0.24–0.86], P=.02), DSS (HR: 0.28 [0.12–0.64], P=.003), DFS (HR: 0.40 [0.19–0.86], P=.02).
Conclusion: In our cohort of persistent or recurrent LSCC, only CD103+ TILs correlated with PD-L1 CPS. A combined biomarker score incorporating CD103+ TILs and PD-L1 CPS greatly enhanced survival discrimination. This model may have additional utility in predicting response and survival benefit of immunotherapies in persistent or recurrent LSCC.
COVID-19 Pandemic Impact on Quality of Life in Newly Diagnosed Head and Neck Cancer Patients
Sophia Matos, MD, Arun Sharma, MD, MS, Dana L. Crosby, MD, MPH
Introduction: The head and neck cancer (HNC) disease and treatment process creates highly visible disfigurement and a fundamental impact on vital functions in this anatomical region, which can lead to an emotionally traumatic illness experience. These factors make HNC patients vulnerable to significant change in quality of life (QOL). There has been little research regarding the psychosocial effects of the coronavirus disease 2019 (COVID-19) pandemic on this group, and we want to explore how their QOL has changed in this unique situation.
Method: This is a retrospective study identifying 400 patients with newly diagnosed HNC in the time period of March 2015 to March 2021 who completed the University of Washington Quality of Life Questionnaire (UW-QOL), collected as part of routine clinical care at our institution. Patients diagnosed between March 2015 and December 2019 were classified in the pre–COVID-19 group, while those diagnosed between March 2020 and March 2021 were classified in the COVID-19 group. Only patients with newly diagnosed HNC who completed the UW-QOL were included. Patients with a diagnosis of skin, thyroid, and sinonasal cancer; those who were unwilling or unable to take part in the study; and those with recurrent HNC were excluded.
Results: A total of 353 participants who met criteria were included. Patients diagnosed with HNC during the COVID-19 pandemic had significantly decreased scores in the chewing and speech sections of the UW-QOL (P<.01 and P<.05, respectively). More patients ranked a decreased mood as a point of concern in the COVID-19 group (29.82% vs 26.45%). There were no significant differences in global QOL scores between groups.
Conclusion: HNC patients experienced a similar overall QOL prior to and during the COVID-19 pandemic. However, some domains of HNC-specific QOL were negatively affected during the COVID-19 pandemic. Patients had more concerns about their mood during the pandemic compared with before the pandemic. The results of this study may be used to inform patient treatment and patient education as well as to alleviate pandemic-related concerns for this vulnerable population.
Delayed Osteonecrosis of the Jaw in a Patient With Multiple Myeloma: A Diagnostic Conundrum
Nicholas A. Rossi, MD, Kareem B. Haroun, MD, Grant R. Conner, MD, Vicente A. Resto, MD, PhD, Rohan R. Joshi, MD, Orly M. Coblens, MD
Introduction: An unintended consequence of longitudinal improvement in the efficacy of cancer treatment is the potential introduction of long-term complications for patients. This can include osteonecrosis of the jaw, a potentially devastating side effect of either bisphosphonates or denosumab therapy.
Method: This study included case presentation and literature review.
Results: A male inmate in his 40s with a history of multiple myeloma presented for evaluation of a 6-month history of a tender palatal lesion. He endorsed recent bloody rhinorrhea and spontaneous exfoliation of almost all dentition from the left maxilla. Three years prior to presentation, he was diagnosed with multiple myeloma and treated with denosumab immunotherapy and palliative radiation to the left hip. His treatment regimen additionally included 2 years of zoledronic acid; however, it was discontinued 1 year prior to evaluation. A computed tomography scan was obtained and showed a nonspecific, destructive bony lesion of the hard palate. In-clinic biopsy showed benign squamous mucosa with dystrophic calcification and associated inflammatory cells. Given the lack of definitive diagnosis, he was taken to the operating room, where the open cavity of maxillary bone was explored and biopsies were taken. After removal of loose bony fragments, the remaining underlying maxillary bone and surrounding soft tissue appeared healthy and vascular. The cavity was packed and closed with chromic gut suture. The final pathologic diagnosis was maxillary osteonecrosis of the jaw. The patient was treated according to the pentoxifylline, tocopherol, clodronate (PENTOCLO) protocol. After 3 months of treatment, extensive mucosalization had occurred, nearly covering the previously exposed bone, and his pain had significantly improved. He will continue PENTOCLO protocol therapy for 1 year.
Conclusion: The case herein was a delayed development of maxillary osteonecrosis of the jaw 1 year after discontinuation of both zoledronic acid and denosumab, a rarely reported presentation worth noting for all otolaryngologists involved in head and neck oncologic care.
Delivery of High-Quality Head and Neck Microvascular Reconstruction in Underserved Patients With a Language Barrier
Ethan Faries, David J. Hernandez, MD, Andrew T. Huang, MD, Angela D. Haskins, MD, Jonathan Shum, MD, DDS
Introduction: Head and neck microvascular free tissue transfer (MVFTT) is well established in reconstruction after oncologic resection, resection of benign masses, or facial nerve paralysis and requires complex postoperative care. A language barrier may be an obstacle in effective communication of expectations and postoperative instructions, which may affect complication rates and 30-day emergency department (ED) visits and readmissions. Thus, we aimed to compare the characteristics and outcomes for MVFTT patients who required translation services with those who did not require translation services at a tertiary care public hospital.
Method: This retrospective cohort study utilized demographic and surgical data of consecutive patients undergoing head and neck MVFTT gathered from 2016 to 2020 at a tertiary care public hospital. Patients included in the study represent an underserved, diverse population that includes many immigrants and non-English speakers. The exposure was MVFTT of the head and neck, and the main outcome measured was the number of total complications (surgical and medical) and 30-day ED visits and readmissions.
Results: Among 122 patients, 25 (20%) utilized translation services and 97 (80%) did not. The languages spoken by patients who required translation were Spanish (n=24) and Burmese (n=1). Most patients (language barrier and English speakers) were discharged home (96% and 93%, respectively). The rate of flap success (no total flap loss and no total or partial loss) was high in the language barrier group (100% and 96%) and among English speakers (98% and 94%). When considering all surgical and medical complications and 30-day ED visits or readmissions, the rate for the language barrier group (n=12, 48%) was like the English-speaking group (n=49, 51%), P=.826.
Conclusion: Our institution demonstrates that if a hospital system is well equipped to manage language barriers, we can avoid increases in complication rates and 30-day ED visits and readmissions after head and neck MVFTT for patients who require a translator compared with native English speakers.
Development and Validation of the Modified Fragility Index in Head and Neck Cancer Surgery
Koorosh Semsar-Kazerooni, Keith Richardson, MD, Véronique-Isabelle Forest, MD, FRCSC, Michael P. Hier, MD, FRCSC, MD, Marco A. Mascarella, MD
Introduction: This study aims to develop and validate a clinically useful modified index of fragility (mIFG) to identify patients at risk of fragility and to predict postoperative adverse events.
Method: An observational study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2018. All patients undergoing nonemergency head and neck cancer surgery were included. A 7-item index (mIFG) was developed using variables associated with frailty, cachexia, and sarcopenia, drawn from the literature (weight loss, low body mass index, dyspnea, diabetes, serum albumin, hematocrit, and creatinine). Multivariable logistic regression was used to model the association between mIFG, postoperative adverse events and death. A validation cohort was then used to ascertain the diagnostic accuracy of the mIFG.
Results: A total of 23,438 cases were included (16,407 in the derivation group and 7031 in the validation group). Totals included 4273 postoperative major adverse events (AE) and deaths, 1023 postoperative pulmonary complications, and 1721 wound complications. Using the derivation cohort, the 7-item mIFG was independently associated with death, major AEs, and pulmonary and wound complications, when controlling for significant covariates. The mIFG predicted death and major adverse events using the validation cohort with an accuracy of 0.70 (95% CI, 0.63-0.76) and 0.64 (95% CI, 0.63-0.66), respectively. The mIFG outperformed the modified frailty index.
Conclusion: The modified index of fragility is a reliable and easily accessible tool to predict the risk of postoperative adverse events and death in patients undergoing head and neck cancer surgery.
Does Tumor Volume Predict Salvage Total Laryngectomy in T3 Laryngeal Cancer Treated Primarily With Radiation?
Sophia Dang, MD, Rahilla A. Tarfa, PhD, Zainab Balogun, MS, Timothy Gao, Mohammad R. Issa, MD, Seungwon Kim, MD
Introduction: TNM classification is prognostic in laryngeal cancer. Tumor volume has been shown to be prognostic in T1/T2 laryngeal cancers treated primarily with radiation therapy, although these studies are limited. It is unclear if this relationship exists in T3 laryngeal cancers. Studies are scarce on whether a tumor volume-prognosis relationship exists for more advanced tumors. Our group wanted to study if a tumor size threshold exists in T3 larynx cancers that would predict more aggressive disease and should prompt consideration for immediate surgery.
Method: We conducted a retrospective cohort study consisting of patients who were diagnosed with T3 laryngeal squamous cell carcinoma between 2006 and 2020. Data collected included age, sex, race, alcohol use, primary tumor volume, metastatic cervical lymph node volume, total combined tumor load (tumor + cervical lymph node volumes), and radiation treatment complications. Outcomes examined also included 2-year disease-free survival (DFS) and overall survival (OS) and 5-year DFS and OS. Univariate Cox regression, Kaplan-Meier analysis, and multivariate Cox regression were performed controlling for age, sex, and alcohol use.
Results: A total of 64 patients were analyzed. We observed that age, sex, and alcohol use had no marginal influence on recurrence. We also found that patients older than 60 years were significantly more likely to have disease recurrence when controlling for sex and alcohol use, compared with those younger than 60 years (with predicted hazard ratio 2.18, P=.05 in multivariate Cox regression) with a total median time-to-recurrence of 0.88 years. The tumor volume threshold for 2-year recurrence was 10.05 mm3 (P=.1) and for 5-year recurrence was 12.1 mm3 (P=.07).
Conclusion: Our preliminary analysis showed that age >60 years was associated with higher rates of recurrence. Our data demonstrated that tumor volume is associated with worse outcomes for 2-year and 5-year recurrence but did not reach statistical significance, likely due to low power. Additional data are required to better assess if tumor volume is predictive of recurrence in T3 laryngeal cancer.
Donor Site–Specific Pain Following Fibula or Scapula Free Flap Reconstruction
Catharine B. Kappauf, MD, Brandon S. Gold, Rocco M. Ferrandino, MD, MSCR, Scott A. Roof, MD
Introduction: Fibula and scapula free flaps are common choices for osteocutaneous reconstruction in the head and neck, each with broad utility but also postoperative morbidity. Pain is an important aspect of morbidity, but no study has compared donor site–specific pain between fibula and scapular tip free flaps.
Method: We prospectively compared donor site pain among 18 patients undergoing fibula or scapular tip free flap for head and neck reconstruction at a single tertiary care center. All patients were consented for a randomized controlled trial that showed futility of ropivacaine infusion for pain reduction at the donor site. This study is a secondary analysis of that cohort. Postoperative donor site and global pain were assessed using a visual analog scale (VAS) at 8-hour intervals for 48 hours following surgery. In addition, data were collected on differences in total opiate consumption, achievement of physical therapy milestones, length of stay, and patient satisfaction.
Results: Of 18 patients, 8 (44%) underwent fibula free flap and 10 (56%) underwent scapular tip free flap reconstruction. Most (56%) patients underwent surgical resection for cancer, while many (44%) had osteoradionecrosis or benign ameloblastoma. Average donor site pain scores were significantly higher for patients who had a scapular free flap (47.4 vs 23.7, P=.001). Global pain was also significantly higher following scapular free flap (P=.002). Patients used similar amounts of opioids postoperatively, but those with fibula free flaps reported more pain relief and were less likely to report that their pain interfered with physical activity.
Conclusion: Fibula free flap reconstruction is significantly less painful than scapular tip free flap reconstruction, locally and globally. Improved pain control plays a role in patient satisfaction and participation in physical activities following surgery, thus impacting postoperative rehabilitation and overall recovery. Donor site–specific pain should be taken into consideration when selecting the appropriate osteocutaneous free flap for head and neck reconstruction.
Effect of Body Mass Index Status on Postoperative Outcomes in Patients Undergoing Major Head and Neck Surgery
Ryan M. Kong, Naomi Newen, Jennifer J. Liang, MD, Natalya Chernichenko, MD
Introduction: Low body mass index (BMI) is associated with risk of developing head and neck cancer and poorer outcomes, but there is a paucity of literature using a national surgical database. This study seeks to investigate the effect of BMI status on 30-day postoperative outcomes of patients with head and neck squamous cell carcinoma (HNSCC).
Method: A retrospective cohort study was done querying the American College of Surgeons National Surgical Quality Improvement database between 2007 and 2017. Patients undergoing major surgery for HNSCC were included, and patients without a calculated BMI were excluded. BMI groups were stratified based on the World Health Organization criteria: underweight (<18.5), normal (18.5–24.9), preobesity (25.0–29.9), obesity I (30.0–34.9), obesity II (35.0–39.9), and obesity III (≥40). Multivariate logistic regression analysis controlling for pre-/perioperative variables with P<.05 in univariate phase were used to evaluate BMI status as a risk factor for adverse postoperative outcomes.
Results: A total of 8663 patients were isolated. Underweight patients were significantly most likely to be identified as African American, have a modified Charlson Comorbidity Index or American Society of Anesthesiology score >3, and have HNSCC in larynx/hypopharynx (all, P<.05). Underweight patients also significantly had the longest operative time (426.6 vs ≤383.5 minutes; all, P<.05) and length of stay (11.4 vs ≤9.0 days; all, P<.05) compared with all other BMI groups. Multivariate logistic regression showed underweight patients had increased odds of wound (odds ratio [OR] 1.5) or cardiac complications (OR 2.4) as well as mortality (OR 2.0) (all, P<.05). Preobesity to obesity III were protective for wound complications while preobesity to obesity I were protective for sepsis-related complications (all, P<.05).
Conclusion: HNSCC patients with underweight BMI had significantly increased odds of wound/cardiac complications and mortality, had longer length of stay or operative time, and were more likely to be identified as African American. There may exist possible disparities in the African American population contributing to a higher rate of underweight status.
Establishment of a Simple Prediction System for Oropharyngeal Cancer
Ching-Chih Lee, MD, PhD, Huai-Pao Lee
Introduction: Besides p16 status, several clinical prognostic factors, like extranodal extension(ENE), or biomarkers, such as epidermal growth factor receptor (EGFR), and programmed cell death ligand 1 (PD-L1) have been explored in oropharyngeal cancer (OPC). The aim of this study was to establish a simple prediction model for OPC in an Asian country.
Method: A clinical research database of Kaoshiung Veterans General Hospital was used between 2013 and 2018. Patients characteristics such as age, gender, tumor stage, differentiation, and treatment modality were extracted from the database. Patients diagnosed after 2018 were staged with seventh AJCC staging system with p16 status. Immunohistochemisty analysis of p16 status, p53, EGFR, Ki-67, and PD-L1 of tumor specimen was performed. The status of ENE was evaluated according to the pathological analysis or radiological features. The main outcome was the disease-specific mortality. Univariate and multivariate Cox regression was used to establish a prediction model for OPC.
Results: Of the 116 OPC patients included, 88.8% were male and the mean age was 57±9.9; p16(+) presented in 39 (34%) patients. Independent prognostic factors for 5-year disease-specific survival (DSS) were p16(-) (hazard ratio [HR]. 1.7; 95% CI, 0.92-3.15), EGFR (HR, 2.19; 95% CI, 1.22-3.93), and T4 classification (HR, 2.51; 95% CI, 1.43-4.4). ENE, PD-L1, and Ki-67 were not statistically significant predictors for the main outcome. Summation of the above-mentioned 3 factors were used to stratify the OPC patients. The prediction accuracy of summation score had better discriminability and prediction accuracy for survival, compared with clinical TN classification and AJCC seventh stage. Five-year DSS was 67%, 53%, 39%, 0% for patients with 0-3 risk factors, respectively. In brief, patients with ≥2 risk factors incurred the worst outcomes.
Conclusion: Independent prognostic factors for OPC were p16(-), EGFR over-expression, and T4 classification. Patients with ≥2 factors incurred the worst outcomes. More aggressive treatment modality might be considered for high-risk OPC patients.
Evaluating Clinical Profile and Safety in Outpatient Versus Inpatient Neck Dissections
Kyle P. Davis, MD, James R. Gardner, MD, Deanne King, MD, Emre A. Vural, MD, Mauricio A. Moreno-Vera, MD, Jumin Sunde, MD
Introduction: Economic health care constraints and pandemic-related limitations in operating room (OR) and hospital bed availability has increased interest in patient selection and safety of performing outpatient procedures. Comparisons in outcomes between outpatient vs inpatient neck dissection (ND) are currently lacking.
Method: The 2019 NSQIP data set was queried to identify patients who underwent unilateral or bilateral neck dissections (CPT codes 38720 and 38724) without any other concurrent/additional procedures. Bilateral patients were identified as having a ND CPT code as both the primary and additional procedure. Differences in preoperative clinical profiles and patient outcomes were evaluated between both cohorts.
Results: A total of 642 patients met inclusion criteria for statistical analysis and 234 (36.4%) were classified as an outpatient procedure. Females were more likely to undergo outpatient ND than males (40.6% vs 32.5%; P=.040). There was no difference in functional health status prior to surgery between inpatient and outpatient ND (independent: 96.3% vs 97.9%; P=.436). Inpatient ND patients had higher ASA classifications compared with the outpatient group (ASA 3+: 62.5% vs 50.4%; P=.004). General surgeons were more likely to perform outpatient ND compared with otolaryngologists (48.2% vs 31.9%; P<.001). Comparing inpatient vs outpatient ND, there was no difference in rates of superficial incisional surgical site infection (2.7% vs 1.3%; P=.277), wound disruption (0.7% vs 0.4%; P=.520), return to operating room (2.2% vs 0.9%; P=.344) or readmission (3.2% vs 1.7%; P=.316).
Conclusion: Male patients and those with higher ASA classifications were more likely to undergo inpatient ND. There were no differences in return to OR or readmission between inpatient and outpatient NDs.
Evaluation of Patient Sleep Disturbances After Head and Neck Surgery
Vivek Pandrangi, MD, Maisie L. Shindo, MD, Ryan J. Li, MD
Introduction: Sleep deprivation in hospitalized patients has been shown to be associated with worse health outcomes. This study was undertaken to evaluate overnight events that may impact sleep among patients hospitalized after head and neck surgery.
Method: A retrospective study from September to November 2021 of patients hospitalized at a tertiary university hospital after head and neck surgery was conducted. Data on events occurring between 8:00 pm and 6:00 am were evaluated for the first 7 days on standard adult wards. Events were categorized each hour as vital sign check, pain score, nursing or physician intervention, voiding, bowel movement, capillary blood glucose (CBG) check, routine laboratory testing, and imaging. Medication use was categorized as pain, gastrointestinal, home or routine postoperative, sleep, or prophylactic. Vital sign checks associated with clinical events requiring intervention were separately recorded.
Results: There were 108 patients included and 319 sleep nights identified. The mean number of hourly events per night was 14.4±4.5, and the mean percentage of hours with events was 56%±18%. Of 4600 hourly overnight events recorded, the most common were vital sign checks (17.8%), pain scores (17.2%), and pain medication use (16%). Of the 817 vital sign checks, 68% occurred between 10:00 pm and 5:00 am. In addition, only 5% of vital sign checks were associated with clinical action and follow-up. Sleep medications were used in 29% of sleep nights. Significant univariate variables for increased hourly overnight events based on the mean were evaluated using a linear regression model. Factors associated with increased hourly overnight events were diabetes mellitus (2.77±0.62; 95% CI, 1.54–4.0), inpatient status (1.89±0.76; 95% CI, 0.40–3.38), free tissue reconstruction (1.47±0.66; 95% CI, 0.18–2.76), and chronic pain (1.28±0.55; 95% CI, 0.19–2.36).
Conclusion: Overnight postoperative disturbances are frequent. Implementing measures such as reducing vital sign checks for low-risk patients and adjusting medication administration schedules may improve patient sleep and hospital quality of life.
Evaluation of the Safety and Effectiveness of Robotic-Assisted Neck Dissections
Vusala Snyder, Brandon Smith, Umamaheswar Duvvuri, MD, PhD
Introduction: While the robotic neck dissection procedure has been well described, long-term control and survival rates have yet to be determined. This study seeks to characterize meaningful outcomes of robotic neck dissections and compare them to the traditional, open approach.
Method: A retrospective, matched cohort study of neck dissections completed at UPMC from 2017 to 2021 was conducted. Twenty-three robotic-assisted neck dissections (RAND) were identified and matched to 40 open neck dissections (OPEN) in a preferred 1:2 ratio. Matching characteristics included primary cancer site, preoperative clinical N-stage, age at time of surgery, human papillomavirus status, and previous chemoradiation treatment. Additional information was collected on patient demographics, surgery characteristics, and outcomes. Comparisons were made using t test, χ2 test, Fisher exact test, Kaplan-Meier Wilcoxon (KMW) test, and hazard ratio (HR) with P<.05 indicating significance.
Results: Overall, the RAND and OPEN groups had similar demographic and disease characteristics. Surgically, RAND procedures required fewer drains and had lower rates of complications. There was no difference in estimated blood loss, number of lymph nodes obtained, or need for adjuvant therapy. Long term, there were no differences in the rates of local, locoregional, and distant recurrence of primary disease between RAND and OPEN procedures. There were also no differences in postprocedure disease-free survival time. However, RAND patients did demonstrate increased overall survival compared with OPEN patients.
Conclusion: This study is the first to provide a meaningful comparison of the long-term effectiveness of robotic surgery compared with the traditional, open approach. Long term, robotic neck dissections were shown to be as effective as open neck dissections in their safety and ability to control disease recurrence. Overall, this study demonstrates that the robotic neck dissection is an effective intervention for controlling head and neck squamous cell carcinoma.
Extracervical Approaches During Resection of Substernal Thyroid Goiters: A Systematic Review and Meta-Analysis
Najm Khan, MBS, Craig A. Bollig, MD, Yingting Zhang, MLS, AHIP, Kassie Bollig, MD, MSCE
Introduction: While most thyroidectomies to remove a substernal goiter (SSG) can be accomplished through a transcervical approach, an extracervical approach (ECA) via sternotomy or thoracotomy is necessary in a minority of cases. The prevalence of ECA during resection of SSG has not been investigated through a systematic review. We sought to systematically review the literature to determine the prevalence of ECAs for SSG excision.
Method: Search strategies were implemented using PubMed, Cochrane, Scopus, Web of Science, and Google Scholar from inception to July 2021 to capture prospective and retrospective cohort studies and case series. The population of interest was adults age >18 years undergoing SSG surgical excision. Intervention was thyroidectomy and main outcome was rate of ECA via sternotomy or thoracotomy. Studies were categorized into the 3 most common distinct definitions: goiter descending below the plane of the thoracic inlet (definition 1), 50% of thyroid mass extending below the sternal notch (definition 2), and goiter extending ≥3 cm below the suprasternal notch when the neck is hyperextended (definition 3). Two reviewers independently extracted data for analysis and performed a quality assessment using the MINORS criteria. PROSPERO registration was completed and PRISMA guidelines were followed. Meta-analysis was completed using a random-effects model to estimate the pooled prevalence of each distinct definition.
Results: Of the 551 studies identified, 69 studies were included in meta-analysis of the prevalence of ECAs during resection of SSG. Definition 1 included 3441 patients from 31 studies, and the estimated prevalence was 6.12% (95% CI, 3.48–9.34; I2=90.72%). Definition 2 included 2957 patients from 26 articles, and the estimated prevalence was 10.30% (95% CI, 7.07–14.00; I2=85.63%). Definition 3 included 2921 patients from 12 articles, and the estimated prevalence was 4.46% (95% CI, 2.17–7.40; I2=84.38%).
Conclusion: Thoracic approaches are necessary to resect SSG in a small but significant proportion of cases. Rates of ECAs vary according to the definition of SSG used.
Factors Impacting Rural Access to Head and Neck Cancer Care During COVID-19
Nicholas C. Purdy, DO, Kenneth Altman, MD, PhD, Vincent Desiato, DO, Ryan Hellums, DO, Priscilla Pichardo, DO, Kevin Stavrides, MD
Introduction: Access to specialty care is challenging in rural health environments, and this has been compounded by the COVID-19 pandemic. Routes to establishing care for head and neck cancer patients are especially important. We sought to quantify our referral patterns and processes to identify opportunities for optimization.
Method: Retrospective review was performed of patients with initial head and neck tumor board presentation between January 1, 2020, through December 31, 2021. Assessed time points were date of referral, biopsy, pathological diagnosis, imaging order, imaging obtained, and initial presentation at head and neck tumor board.
Results: A total of 429 patients were included. Squamous cell carcinoma (n=350, 81.6%) made up the majority, and most common primary sites were oropharynx (27.4%), oral cavity (20.3%), larynx (16.9%), and cutaneous (16.5%). At time of referral, 37.6% of patients had biopsy proven diagnosis. Average time to tumor board was 22 days, and significantly greater in those undiagnosed at referral (29 vs 14 days). Distance to provider did not correlate with time to tumor board. The period since the onset of the COVID crisis did not appear to affect access to care once in our system. However, there was evidence that patients presented with advanced locoregional disease during COVID-19.
Conclusion: This study creates an approach to map access to care, evaluating critical time points and opportunities to expedite multiple steps that initiate therapy for head and neck cancer. There are both external (rural geography and the COVID-19 pandemic) and internal aspects that may pose barriers to access. Identification of these barriers allows for improved timely access to care in this susceptible population.
Fasciocutaneous Parascapular Free Flap: A Reliable Reconstructive Option for Head and Neck Surgical Defects
Meade C. Edmunds, MD
Introduction: This study aimed to define perioperative factors and surgical outcomes for patients who underwent fasciocutaneous parascapular free flap reconstruction of complex head and neck defects after tumor extirpation.
Method: This study included patients who underwent reconstruction of complex head and neck surgical defects using fasciocutaneous parascapular free flap at a single tertiary care center between October 2005 and December 2018, with a focus on patient demographic characteristics, postoperative flap and donor site complications, frequency of need for flap revision, and 30-day all-cause mortality.
Results: Included in the study were 129 patients. A total of 67 patients (51.9%) had received radiation, chemotherapy, or a combination prior to surgery. Primary defect locations included cutaneous (28.7%), oral cavity (29.5%), oropharynx (3.9%), nasopharynx (3.1%), sinus/orbit (19.4%), infratemporal fossa (3.1%), hypopharynx (3.1%), and larynx (9.3%). Flap complications occurred in 43 patients (33.3%), including venous congestion (6), hematoma (7), dehiscence (18), anastomotic leak (5), fistula (7), infection/abscess (1), partial necrosis (8), and complete necrosis (7). Donor site complications included wound dehiscence (6), hematoma (5), and a combination of the two (1). Operative flap revision was required in 28 patients. The overall success of the reconstruction was 94.6%.
Conclusion: Fasciocutaneous parascapular free flaps is an attractive choice for reconstruction of head and neck surgical defects due to the availability of a large skin paddle, consistency of the vascular supply, ease of flap harvest, and versatility and resiliency of the donor tissue.
Frailty and Outcomes After Mandibulectomy With Osseous Free Flap Reconstruction
Elisabeth Hansen, MSc, Rosh Sethi, MD, MPH, Eleni Rettig, MD, Ravindra Uppaluri, MD, PhD, Donald Annino, MD, DMD, Laura Goguen, MD
Introduction: Frailty has been associated with worse postoperative outcomes. We sought to examine the degree of frailty among patients undergoing osseous free flap (OFF) mandibular reconstruction and to assess frailty as a predictor of outcomes.
Method: Retrospective chart review of OFF mandibular reconstructions between January 2015 and August 2021. A modified frailty index was calculated using preoperative comorbidities and functional status. Primary outcomes were inpatient Clavien-Dindo (CD) IV critical care complications, surgical site or medical complications, disposition, discharge with tracheostomy tube, length of stay (LOS), and unplanned 30-day readmission. Frailty was defined as ≥1 frailty-defining diagnosis.
Results: Ninety-four cases were identified. The mean patient age was 64.4 years (SD 8.9). The surgical indication was cancer (n=65, 69%) or osteoradionecrosis. Fifty-three cases (56.4%) had ≥1 frailty-defining diagnosis, specifically 1 (n=30, 56.6%), 2 (n=17, 32.1%), or 3 (n=6, 11.3%). The mean LOS was 12.7 days (SD 6.2). A minority of patients had any CD IV (N=6, 6.4%) or surgical site complication (n=40, 42.6%). Frailty at the time of surgery was not associated with discharge to a rehabilitation facility (P=.326), discharge with tracheostomy tube (P=.061), LOS (P=.104), or unplanned readmission (P=.807), nor with postoperative complications including CD IV complication (P=.227) or the composite of all postoperative complications (P=.674).
Conclusion: To our knowledge this, is the largest series assessing frailty as a predictor of outcomes for mandibulectomy with OFF reconstruction. We find an overall low degree of frailty and no association between frailty and outcomes, suggesting this operation can be performed for mildly frail patients without worse outcomes.
Functional Larynx in Late Open Partial Horizontal Laryngectomies for T3–T4 Laryngeal Cancer
Andressa Freitas, SLP, Pedro Henrique Gonçalves, MD, Fernando Dias, MD, Izabella Santos, MD, PhD, Emilson Freitas, MD, Fernando Luiz Dias, MD, PhD
Introduction: Open partial horizontal laryngectomy (OPHL) is usually described for the treatment of initial laryngeal cancer. Recently, it is being discussed as an option for the treatment of selected tumors at moderately advanced stages as an alternative to maintain a functional larynx.
Method: A retrospective cohort study of patients with laryngeal cancer, pathologically staged as T3 or T4 treated with OPHL-II/III, enrolled in Brazilian National Cancer Institute (INCA) Section of Head and Neck Surgery in 1995–2019. Patients received functional assessment during the postoperative period of the larynx physiological functions, both swallowing and breathing.
Results: There was a high prevalence of patients (93.5%) who were able to breathe without the aid of a tracheostomy, and 86.5% patients had exclusive oral feeding with multiple consistencies. The type of surgery, the age at surgery, tobacco abuse, and previous radiotherapy affected the functional outcomes.
Conclusion: Some factors may have been responsible for the relationship between a worse functionality of the larynx and an increased age of the patient at surgery, including the accumulation of comorbidities that can add to the dysfunctions caused by cancer treatment. OPHL types II and III are feasible surgical procedures for moderately advanced and advanced laryngeal cancer, presenting high prevalence of functional larynx after the rehabilitation.
Geniculate Ganglion Decompression by Endoscopic Ear Surgery
Fernando Garcia Dumandzic, MD, Daniel Perez Gramajo, MD, Gloria V. Requena, MD, Eduardo M. Soto, MD
Introduction: Facial nerve (FN) palsy occurs in 7% to 10% of patients with longitudinal fractures of the petrous bone. Management in these cases requires rapid surgical exploration to assess the type of neural injury (inflammation, edema, section), with endoscopic ear surgery being a conservative and quick access option for the assessment and treatment of nerve injuries.
Method: This was a clinical case presentation reporting decompression of the geniculate ganglion by transcanal endoscopic ear surgery in a patient with traumatic facial palsy secondary to longitudinal fracture of the petrous bone by carabeoencephalic trauma (ECT). Clinical history and complementary studies (analytical, audiological, tomography with 3-dimensional reconstruction, electrophysiological study of the facial nerve) were reviewed, in addition to cases reported in the bibliography. The method included a transcanal approach with a 30° endoscopic view, creation of a posterior tympanomeatal flap, atticotomy incus and head of malleus extraction, identification of cochleariform process, decompression with bone capsule curette, and partial ossicular replacement with incus.
Results: A 22-year-old male patient was consulted for hearing loss in the right ear and right peripheral facial palsy after ECT House-Brackmann VI. Petrous bone computed tomography showed longitudinal fracture, with compression at the level of the geniculate ganglion. Transcanal endoscopic surgical exploration was performed, locating the geniculate ganglion with monitoring of the facial nerve and decompression of the same.
Conclusion: Transcanal FN endoscopic decompression is a safe and effective method. However, careful preoperative imaging should be performed to adequately indicate this minimally invasive treatment rather than more extensive surgeries.
Going Off Guidelines: Missed Adjuvant Therapy Among Surgically Treated Oral Cavity Cancer: An NCDB Study
Patrick T. Tassone, MD, Michael C. Topf, MD, Laura M.Dooley, MD, Tabitha Galloway, Gregory Biedermann, Michael Trendle
Introduction: Postoperative adjuvant therapy is often recommended for oral cavity squamous cell carcinoma because of advanced stage or other pathologic markers. Patient factors associated with failure to receive adjuvant therapy remain understudied.
Method: Patients with surgically treated oral cavity squamous cell carcinoma and known adjuvant therapy status were extracted from National Cancer Database (NCDB). Indications for radiation were T3-4, N2-3, lymphovascular invasion, extranodal extension, or positive margins and for chemotherapy, ENE or positive margins. Patients with indications but not treated were considered to have missed adjuvant therapy. Factors were examined for associations with missed therapy by logistic regression model. Cox proportional hazard analysis was performed to examine overall survival.
Results: Included were 45,649 patients. Among 21,111 patients with an indication for adjuvant radiation therapy, 6605 (28.7%) did not receive it. Among 8879 patients with an indication for adjuvant chemotherapy, 4038 (45.5%) did not receive it. Patient factors significantly associated with missed radiation were age over 69 (odds ratio [OR] 2.05; 95% CI, 1.83-2.31), comorbidity score above 1 (OR 1.30; 95% CI, 1.27-1.44), academic treatment facility (OR 1.30; 95% CI, 1.18-1.44), White race (OR 1.18; 95% CI, 1.02-1.37), and increased travel distance (OR 1.39; 95% CI, 1.26-1.54). Advanced age was associated with missed chemotherapy (OR 3.03; 95 % CI, 2.69-3.42). Adjuvant radiation when indicated was associated with improved overall survival on multivariable analysis (hazard ratio [HR] 0.61; 95% CI, 0.57-0.65). Adjuvant chemotherapy when indicated was associated with modestly improved overall survival (HR 0.89; 95% CI, 0.84-0.94).
Conclusion: According to data from NCDB, over a quarter of patients miss adjuvant radiation after oral cavity resection. Advanced age was the most impactful factor associated with missed adjuvant therapy; older patients may be at risk of off-guidelines treatment in oral cavity squamous cell carcinoma. Missed adjuvant treatment was associated with worse overall survival in this retrospective database study.
Growth Factor and Hormonal Receptors Expression in Oral Squamous Cell Carcinoma: Correlation With 10-Year Survival
Yumna Adnan, PhD, Syed Muhammad Adnan Ali, PhD
Introduction: Oral squamous cell carcinoma (OSCC) comprises most of head and neck neoplasms and is one of the highest ranking and lethal cancers in Pakistan due to prevailing mouth habits. Hormonal receptors act as prognostic markers and targets for therapy in some cancers, but their application in OSCC is largely unexplored. This study aimed to evaluate the expression of hormonal receptors in OSCC patients and correlate it with 10-year overall and disease-free survival.
Method: Immunohistochemistry for Her-2, AR, ER, and PR was performed on 100 formalin-fixed paraffin-embedded primary OSCC specimens from the years 2005 to 2010. Receptor expression was correlated with mouth habits and clinicopathological features and patient survival was analyzed using Kaplan-Meier method and Cox regression univariate analysis.
Results: In 100 patients, there were 57 males and 43 females. Immunopositive Her-2 expression was observed in 21% of patients, AR in 13%, ER in 3% and 0% for PR. Patients with betel quid/areca nut mouth habits had significantly absent Her-2 expression (P=.035). Also, Her-2–negative patients were also negative for AR expression (P=.002). Her-2–positive patients had poor 10-year survival (P=.041). A trend of low-survival and high-recurrence rate was observed in AR-positive patients, but this was not significant (P=.072). No statistically relevant correlations were seen in the case of ER and PR.
Conclusion: Her-2 is a valuable marker for predicting long-term prognosis, and Her-2–positive OSCC patients may benefit from anti–Her-2-targeted therapy.
Head and Neck Cancer Mortality: Regional Differences in Hospice Use
Julia Canick, Justin Barnes, MD, MS, Rebecca Rohde, MD, MPH, Dina Abouelella, MPH, Eric Adjei Boakye, PhD, Nosayaba Osazuwa-Peters, PhD, MPH, CHES
Introduction: With more than 15,000 annual deaths from head and neck cancer (HNC), an important aspect of end-of-life care for these patients is place of death. Recent evidence suggests an increasing preference for home/hospice at end of life; however, it is unclear whether there is variation in home/hospice use based on region or urban status. We described differences in place of death of HNC patients based on their region and urban status.
Method: Using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database for HNC mortality (1999 to 2019), place of death was dichotomized as home/hospice vs other, by the US Department of Health and Human Services (HHS) regions (regions 1–10), and by urbanization status, using the 2013 Urban-Rural Scheme for Counties (large central metro to nonmetro). Multivariable logistic regression analyses estimated odds of place of death being home/hospice and being urban/metro, adjusting for both clinical and nonclinical variables, including anatomic subsite, age, race, sex, educational level, and marital status.
Results: Over the study period, there were 260,630 deaths, 47.4% of which were at home or hospice. There were regional differences in odds of home/hospice use. Compared with patients in New England/region 1 (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont), HNC patients were more likely to die at home/hospice in the Pacific Northwest/region 10 (Arkansas, Idaho, Oregon, Washington; adjusted odds ratio [aOR] 1.73; 95% CI, 1.64, 1.83) and less likely in the Eastern section/region 2 (New Jersey, New York, Puerto Rico, US Virgin Islands; aOR 0.93; 95% CI, 0.89, 0.97). Furthermore, large central metro areas had significantly lower rates of dying at home/hospice than did all other settings.
Conclusion: Almost half of HNC patients use hospice/home for end of life, and there are significant differences in place of death based on region and urban status.
Head and Neck Cancer Treatment Adherence and Health Literacy
Jeewanjot Grewal, MD, Amy Williams, PhD, Maria Olex, PsyD, Mary Kate Miller, PsyD, Farzan Siddiqui, MD, PhD, Samantha Tam, MD
Introduction: Poor health literacy and cognitive function is associated with poor adherence, quality of life, higher mortality, and health care utilization. Both cognitive function and health literacy has been found to be lower in patients with head and neck cancer (HNC) compared with the general population. This study aims to investigate the relationship between cognitive function, health literacy, treatment adherence, and overall survival (OS).
Method: All adult patients with a new diagnosis of HNC and completed Montreal Cognitive Assessment (MoCA) and the Rapid Evaluation of Adult Literacy in Medicine (REALM-SF) were eligible for inclusion. Major outcome measures were (1) treatment adherence (compliance with tumor board recommendations) and (2) treatment delays (treatment breaks or changes). Patient demographic and disease characteristics were collected. Risk factors for poor treatment adherence and treatment delays were compared using logistic regression. OS was compared using Cox proportional hazards model.
Results: Among 181 patients included from August 2017 to September 2020, 96 patients (61.9%) scored in the impaired range on the MoCA, with 10 (6.4%) scoring in a range associated with moderate cognitive impairment. Twenty-eight patients (71.9%) were reading at levels of inadequate health literacy. Patients receiving adjuvant radiation therapy had lower odds of treatment adherence compared those receiving primary radiation (odds ratio=0.113, 95% CI, 0.026 to 0.48). Patients with greater years of education (hazard ratio [HR]=0.73/y, 95% CI, 0.57 to 0.933) and higher MoCA score (HR=0.76/point, 95% CI, 0.66 to 0.89) had better OS. After controlling for treatment adherence and treatment delays, the effect of education and MoCA score on OS was no longer significant.
Conclusion: Patients with HNC with lower education or poorer cognitive function had worse overall survival. However, after adjusting for treatment adherence and treatment delays, this difference was attenuated. Therefore, increased resources to ensure treatment adherence in patients with reduced cognitive functioning or education may reduce disparities in HNC outcomes.
Human Papillomavirus–Associated Laryngeal Dysplasia in an HIV-Positive, Nonsmoking Patient
Sarah K. Rapoport, MD, Nada Farhat, MD, Mark S. Courey, MD
Introduction: Human papillomavirus (HPV)–driven anal dysplasia with progression to cancer is a well-recognized disease entity. It occurs in more than 50% of patients with HIV, even those on antiretroviral therapy with well-controlled viral loads whose CD4 (cluster of differentiation antigen 4) levels have been restored to normal. HPV-driven laryngeal dysplasia with progression to cancer has not been reported in HIV-positive patients.
Method: To bring awareness to this potential new disease entity, we present a case report of an HIV-positive patient who presented with multifocal laryngeal dysplasia/carcinoma in situ (CIS) associated with the presence of high-risk strands of HPV.
Results: A 49-year-old man, with no history of smoking, presented with a several-month history of dysphonia. He was concurrently under surveillance for HPV-driven anal dysplasia. Office laryngeal exam revealed keratotic plaques with surrounding erythema. The patient’s laryngeal lesions did not respond to medical therapy. Laryngeal biopsy identified multifocal CIS associated with high-risk strands of HPV by RNA analysis. The patient’s viral load had been well controlled with antiretroviral medication and his CD4 count had been maintained within in a normal range. His disease has been recurrent and has responded to serial biopsy and ablation. He continues with nearly normal voice.
Conclusion: Patients with dysphonia and HIV infection, including those with well-controlled disease, may benefit from surveillance to identify HPV-driven dysplasia. HPV-driven laryngeal dysplasia may follow a similar course to HPV-driven anal dysplasia in this patient population and the incidence may be increasing. Clinicians treating patients with laryngeal disorders should be aware of this new entity.
Human Papillomavirus in Head and Neck Cancer: Knowledge Gaps in Primary Care Physicians
Jyoti Sharma, MD, Mattie R. Rosi-Schumacher, MD, Michele M. Carr, DDS, MD, PhD
Introduction: Human papillomavirus (HPV) is widely known for causing cervical cancer. However, HPV also plays a large role in head and neck cancer (HNC). Our objective was to determine baseline knowledge of HPV among primary care physicians and provide an educational lecture to increase knowledge of the head and neck subsites affected by HPV, specifically the oropharynx.
Method: Residents and attendings in internal medicine, pediatrics, or the combined Med-Peds were included. A 26-question preintervention survey was distributed, followed by a 1-hour grand rounds-style presentation. A 23-question postlecture survey was then distributed. Information regarding each participant was collected including field of medicine, training level, and previous education about HPV. Pretest and posttest knowledge responses were compared nonparametrically.
Results: A total of 72/75 (96%) of the prelecture survey participants were residents; 3 (4%) were attendings. Of the participants, 52 (69.3%) had previous education on cervical and anogenital HPV cancers and only 36 (48%) had previous education on oropharyngeal HPV. Of the participants, 45/75 (60%) returned the postlecture survey, with 42/45 (93%) responding that they would change their practice based on what they had learned. Prelecture, 4/75 (5.3%) knew that HNC was the most common HPV-related cancer, while postlecture, 28/45 (62.2%) knew that HNC was most common (P<.001). Prelecture, 36/75 (48%) said HPV-positive HNC is more common in males while postlecture 38/45 (84.4%) indicated it was more common in males (P<.001).
Conclusion: While many primary care physicians have learned about HPV and its link to cervical cancer, there is a gap in education on HPV-related head and neck cancer.
Human Papillomavirus–Related Multiphenotypic Sinonasal Carcinoma Narrative Review
Mohammed A. Alessa, MBBS, SBORL
Introduction: Human papillomavirus (HPV)–related multiphenotypic sinonasal carcinoma (HMSC), formerly known as HPV-related carcinoma with adenoid cystic carcinoma-like features, is a recently described neoplasm as a provisional entity in the most recent World Health Organization classification of head and neck tumors, as a candidate to be a separate tumor entity, different from adenoid cystic carcinoma and squamous cell carcinoma.
Method: A comprehensive literature review was conducted using the MEDLINE and Embase databases with a primary objective of identifying all documented cases of HMSC in the English-language literature from January 2010 to December 2020, leading to the inclusion of 18 articles for review.
Results: Upon reviewing the 18 articles with our case report, a total of 73 cases of HMSC were documented. The age mean (SD) was 54.04 (±12.64) with nearly similar gender distribution, affecting males (n=34, 46.6%) and females (n=38, 52.1%), and a case of unspecified gender (n=1, 1.4%). Tumor site was documented in all cases, with nasal cavity being the most common site of origin (n=45, 61.6%), the sinuses (n=7, 9.6%), and sinonasal (n=17, 23.3%); 1 patient had the tumor in the sinonasal area including the hard palate (n=1, 1.4%), 2 patients were presented with the tumor originating primarily from the oral cavity (n=2, 2.8%), and 1 patient had sinonasal tumor with metastasis to orbital and intracranial region at presentation (n=1, 1.4%). The treatment plan was documented in 61 (83.6%) patients. Fifty-nine patients (80.8%) were treated surgically. The other 2 patients had not undergone any surgical intervention: 1 patient (1.4%) was treated by radiotherapy, and the other patient (1.4%) was treated by chemoradiation therapy.
Conclusion: HPV-related HMSC has an indolent course, thus, maximizing treatment by multimodalities may increase the survival rate but does not prevent metastasis.
Identifying a High-Risk Preoperative Hemoglobin in Head and Neck Reconstruction
Munib Ali, Steven Nakoneshny, Khara Sauro, PhD, Joseph Dort, MD, MSc, FRCSC, Robert Hart, MD, FRCSC
Introduction: Anemia is a common comorbidity in head and neck surgical oncology and can predispose patients to perioperative blood transfusion (PBT) following free flap reconstruction. Given the infrastructural and health-related sequelae of PBT, this study aimed to characterize the high-risk preoperative hemoglobin (Hgb) level at which there is increased PBT risk and utilization.
Method: Consecutive patients undergoing free flap surgery for malignant neoplasms of the head and neck at our tertiary care center between 2012 to 2018 were included. Osteoradionecrosis and benign pathology were excluded. The primary exposure variable was low preoperative Hgb. The outcome variables included proportion receiving PBT and the mean units of blood transfused. The PBT window was intraoperative until discharge. Variables included in the multivariate logistic regression model were preoperative Hgb (g/L), sex (male vs female), body mass index (underweight vs not underweight), T stage (1/2 vs 3/4), and Clavien-Dindo Classification (I–IIIa vs IIIb–V). Preoperative Hgb was analyzed in increments of 10 g/L to determine both PBT risk and blood product usage.
Results: A total of 363 free flaps were included in the final analysis. Preoperative anemia (<120 g/L; P<.0001, OR=0.94) was the strongest predictor of PBT in multivariate analysis. We also found that Clavien-Dindo class IIIb–V (P=.007, odds ratio [OR]=3.23), underweight patients (P=.018, OR=4.39), and high T stage (P=.042, OR=2.14) also increased PBT risk. The odds of PBT doubled each 10-g/L decrement below 120 g/L Hgb. When investigating blood volume, a 7-fold increase in mean units of PBT was found for anemic patients (<120 g/L Hgb).
Conclusion: This study determined that a preoperative Hgb of 120 g/L is a critical threshold below which patients are at increased transfusion risk and receive more blood. Anemia, however, is a modifiable risk factor for PBT and may allow clinicians to strategize ways to mitigate unnecessary PBT. A review of transfusion practices and emerging preoperative modalities such as intravenous iron therapy should be explored.
Impact of Flap Size on Outcomes With the Supraclavicular Artery Island Flap
William Ruffin, DO, Gal Thomas, MD
Introduction: The use of the supraclavicular artery island flap (SCAIF) in head and neck reconstruction has increased in recent years. The objective of this study is to examine the role of flap size on successful SCAIF transfer.
Method: A review of patients undergoing SCAIF reconstruction between January 2014 and March 2022 was performed. Flap failure was defined as >50% loss of the skin paddle. Total flap surface area was examined. Multivariate analysis was also performed to evaluate the association of other demographic factors associated with flap failure.
Results: Eighty-nine flaps were performed over the study period. Overall success rate was 82% (73/89). Mean flap surface area was 42.3 cm2. Successful flaps were observed to have a mean surface area of 44.7 cm2, compared with 32.3 cm2 for failed flaps (P=.059). Flaps were 3.9 times more likely to fail if less than 25 cm2 (P=.02) and 81% more likely to succeed if greater than 50 cm2 (P=.05). On multivariate analysis, a history of chronic obstructive pulmonary disease, not active smoking, was the strongest predictor of outcome, with a 7-fold risk of flap failure (P=.008).
Conclusion: While it is necessary to account for experience and learning curves when incorporating the SCAIF into practice, it would appear that larger flaps have a greater likelihood of success. Theoretically, it could be supposed that larger flaps have a greater likelihood of capturing the appropriate angiosomes. Application of these principles to the harvesting of smaller flaps requires further study.
Impact of Malnutrition on Postoperative Outcomes in Patients Undergoing Major Head and Neck Surgery
Ryan M. Kong, Naomi Newen, Jennifer J. Liang, MD, Natalya Chernichenko, MD
Introduction: Nutritional status has an important role on outcomes of head and neck cancer patients and have been investigated in recent years. This study seeks to investigate the impact of malnutrition on 30-day postoperative outcomes of patients with head and neck squamous cell carcinoma (HNSCC).
Method: A retrospective cohort study was conducted by querying the American College of Surgeons National Surgical Quality Improvement database between 2007 and 2017. Preoperative albumin was used as a biological marker for malnutrition and to stratify patients into hypoalbuminemia (HA; <3.5 g/dL) and normal albumin groups. Patients undergoing major surgery for HNSCC were included, and patients without a preoperative albumin level were excluded. Multivariate logistic regression models controlling for pre-/perioperative variables with P<.05 in univariate phase were used to evaluate malnutrition as a risk factor for adverse postoperative outcomes.
Results: Of the total patients (n=6205), 15.3% had HA and were significantly more likely to be African American or Hispanic as well as have modified Charlson Comorbidity Index or American Society of Anesthesiology scores >3 (all, P≤.001). These patients had significantly longer length of stay (LOS; 14.3 vs 7.0 days; P≤.001). Multivariate logistic regression showed patients with HA had increased odds of overall wound (odds ratio [OR] 1.5), pulmonary (OR 1.5), or cardiac complications (OR 1.8) as well as mortality (OR 3.6; all, P<.05). In addition, they had increased odds of bleeding requiring transfusion (OR 1.9), pneumonia (OR 1.4), failure to wean (OR 1.7), acute renal failure (OR 9.2), and cardiac arrest (OR 3.3; all, P<.05).
Conclusion: HNSCC patients with malnutrition had significantly increased odds of adverse postoperative outcomes, longer LOS, and were more likely to be African American or Hispanic. This study highlights the importance of prevention and treatment of malnutrition within this patient population.
Impact of Palliative Treatment on Survival in Oral Cavity Malignancies
Kirolos M. Georges, BA, David A. Cohen, BA, Ryan Jin, BS, Christopher J. Didzbalis, BA, Salma Ahsanuddin, BS, Richard Chan Woo Park, MD
Introduction: Palliative treatments (PT) remain a therapeutic option in patients with advanced oral cavity cancers (OCC) to improve quality of life and possibly prolong life while undergoing treatment. This study assesses the influence of PT on survival in patients with OCC.
Method: The 2010-2016 National Cancer Database was queried for all cases of OCC. Clinicopathologic features among patients only receiving PT (surgery, radiotherapy, chemotherapy, pain management, or combination PT) were compared. Patients with distant metastatic disease were excluded. Kaplan-Meier and Cox regression analyses were used to determine survival differences between groups.
Results: In total, 566 cases of PT in OCC were analyzed, of which 102 (18.0%) received surgery, 215 (37.9%) received radiotherapy, 70 (12.4%) received chemotherapy, 120 (21.2%) received pain management, and 59 (10.4%) received other PT combinations. PT was mostly utilized in patients with advanced AJCC stages in the form of pain management or radiation therapy (P=.05). Five-year overall survival (5YOS) was poor among all PT groups, with the lowest rates seen in patients receiving palliative radiation at 4.90% (P<.001); 5YOS was 28.2%, 11.6%, 18.9%, and 15.3% (P<.001) for surgery, chemotherapy, pain management, and other palliative care combinations, respectively. On Cox regression, radiation therapy (hazard ratio [HR] 1.722; 95% CI, 1.29-2.299, P<.001), chemotherapy (HR 1.451; 95% CI, 1.013-2.079; P=.042), pain management (HR 1.393; 95% CI, 1.01-1.921, P=.044), and other palliative care combinations (HR 1.883; 95% CI, 1.314-2.7, P=.001) were significantly associated with worse survival compared with palliative surgery alone. Patients 70 years or older (HR 1.823; 95% CI, 1.457-2.28, P<.001) had significantly worse survival than patients younger than 70.
Conclusion: OCC patients receiving palliative therapies most frequently have advanced AJCC stages and low overall survival rates; thus, patients’ goals of care should be considered during treatment. Palliative surgery appears to prolong survival compared with other palliative therapies.
Impact of Preoperative Metabolic Equivalent Status on Surgical Outcomes in Head and Neck Cancer Patients
Gabriela M. DeVries, MD, Christopher A. Sullivan, MD
Introduction: The association between functional status and postoperative complications in cancer surgery is well described in the literature; however, utilization of preoperative screening tools to predict postoperative outcomes in head and neck cancer patients are lacking.
Method: This was a retrospective medical chart review of 221 patients with squamous cell carcinoma (SCC) of the aerodigestive tract, from 2014 through 2020, who underwent surgical resection and completed a standardized metabolic equivalent task (MET) questionnaire during their preoperative visit. MET is the objective measure of the ratio of the rate at which a person expends energy, relative to the mass, while performing various physical activities. METs are measured on a scale from 1 to 10, where 1 MET is equivalent to the energy expended when sitting quietly. The MET measurements were divided into 3 groups: METs >10-7 is group 1; METs 6-4 is group 2; METs 4-1 is group 3. Length of stay (LOS) and postoperative adverse events (systemic and wound-related complications) were identified in the cohort in attempt to determine a correlation with MET status.
Results: Of the total patients, 48% experienced postoperative adverse events. Of these patients, 20% were located in MET group 3, 75% were located in MET group 2, and 8% were located in MET group 1. Of the patients, 20.8% had a performance equivalent to 4 or less METs, 64.7% had 4-6 METs, and 14% had more than 7 METs. MET group 1 (n=32) mean LOS was 5.56 days, while MET group 2 (n=143) mean LOS was 8.69 days (P=0.005). MET group 2 (n=143) mean LOS was 8.69 days, while MET group 3 (n=46) mean LOS was 12.67 days (P=.06). MET group 1 (n=32) mean LOS was 5.56 days, while MET group 3 (n=46) mean LOS was 12.67 days (P=.002). The logistic regression adjusted r2 was 65.29% for predicting adverse events and LOS duration from MET status.
Conclusion: Low MET status was found to be associated with an increased LOS, and 96% of adverse events were in patients who were in MET groups 2 and 3. Given these findings, MET status could be utilized to counsel patients regarding their chances of postoperative adverse events and increased LOS.
The Impossible Secondary Tracheoesophageal Puncture: Mission Accomplished
Courtney B. Shires, MD, Lauren Ottenstein, Merry E. Sebelik, MD
Introduction: It is common to have a postlaryngectomy patient in which traditional transoral secondary tracheoesophageal puncture (TEP) cannot be accomplished. Many patients have kyphosis or scarring of the neck that prevents placement of a rigid esophagoscope, therefore preventing TEP placement. Other surgeons have described techniques using flexible esophagoscopes with insufflation under local anesthesia or sedation. We describe a technique to allow TEP placement in these challenging patients under general anesthesia.
Method: Over several years, we have used our technique in patients for whom traditional methods of TEP with rigid esophagoscope were unsuccessful or not attempted due to the anticipated high probability of failure. The patient is placed under general anesthesia in the operating room. The tapered end of a size 36 French chest tube is cut off. The chest tube is placed in the pharynx backwards with the cut end sticking out the mouth. The chest tube is advanced into the esophagus. One of the fenestrations of the chest tube is placed behind the planned TEP puncture site. The flexible bronchoscope or small flexible esophagoscope is placed into the chest tube. As the trocar from a Provox puncture kit is placed into the posterior tracheal wall and into the anterior esophageal wall, the surgeon watches the trocar being pushed through the esophagus and into the lumen of the chest tube. The blue guidewire is placed into the trocar and advanced to the oral cavity. The trocar is removed. The flexible scope and chest tube are withdrawn. The surgeon attaches the prosthesis to the guidewire and pulls this through the pharynx and esophagus.
Results: We have successfully placed TEPs in many challenging patients. We place each of these patients under general anesthesia to help with precision, as these cases innately are very challenging without a moving or anxious patient. We use a chest tube to provide protection to the posterior esophageal wall during puncture, in contrast to previous methods using a flexible esophagoscope and insufflation.
Conclusion: We describe a method of placing secondary TEPs in very challenging postlaryngectomy patients.
Inhibition of Integrin β1 Reduces Radioresistance in Oral Squamous Cell Carcinoma
Sungjun Park, Sei Young Lee
Introduction: Radioresistance is a big hurdle in the treatment of oral cavity squamous cell carcinoma. We tried to evaluate whether integrin β1 is important in radiosensitivity, perineural invasion, and aggressiveness using radioresistant oral squamous cell carcinoma (OSCC) cell lines.
Method: Radioresistant OSCC cells that mimic real radiotherapy protocol were used. The expression of integrin β1 was inhibited by shRNA. Upon inhibition of integrin β1 expression, adhesion to neuronal cells, sensitivity to radiation, invasiveness, and migration of OSCC15 and 25 cells were analyzed.
Results: We found that adhesion to neuronal cells and expression of integrin β1 are increased in radioresistant OSCC15 and 25 cells compared with control radiosensitive cells. When the expression of integrin β1 is inhibited, adhesion to neuronal cells, resistance to radiation exposure, invasiveness, and migration of OSCC15 and 25 cells were reduced.
Conclusion: Our data suggest that integrin β1 critically contributes to the maintenance of radioresistance in OSCC cells. Furthermore, integrin β1 was associated with the aggressiveness of radioresistant OSCC cells. Future in vivo experiments are warranted to evaluate the targeting integrin β1 emerges as new therapeutic target in radioresistant OSCC.
Institutional Management of Incidental, Synchronous Thyroid Malignancy in Primary Head and Neck Cancer Patients
Tian Y. Song, MD, Sarah Jeoung, Jennifer Brooks-Fontanarosa, MD, MPH, Matthew C. Miller, MD
Introduction: Up to 5% of patients with primary head and neck cancer have synchronous thyroid cancer. Currently, there is no clinical guideline for thyroid cancer in this patient group; therefore, an analysis of our institutional management and outcomes over 10 years was performed to support management decision making.
Method: A retrospective chart review at a large, multicenter academic hospital from October 2011 to October 2021 was conducted. Patients aged 18 years or older with diagnosis of head and neck and thyroid cancers within 6 months who were treated at our institution were included. Primary outcomes were demographics, method of diagnosis, histologic thyroid cancer diagnosis, thyroid cancer management, complications, and recurrences.
Results: A total of 4160 patients met search criteria of head and neck cancer diagnosis; 34 patients met search criteria for synchronous cancers; 18 patients were excluded after chart review; 15 patients were included in analyses. Institutional incidence of synchronous head and neck and thyroid cancers was 0.36%, of which, 86.67% were papillary thyroid carcinoma. Of synchronous thyroid cancers, 46.67% were incidentally found during neck dissection; 40% were found during imaging workup for head and cancer; 13.33% were found on clinical exam. Of the patients, 80% underwent indicated treatment for thyroid cancer and 20% were observed due to very advanced head and neck cancer (stages IV disease). There were no adverse events associated with treatment vs observation of thyroid cancer. There were no thyroid cancer recurrences.
Conclusion: Papillary thyroid carcinoma was the most common incidental thyroid cancer found in patient with head and neck cancer at our institution. Most patients underwent indicated thyroid cancer treatment without adverse events. Observation of thyroid cancer was recommended for patients with very advanced staged head and neck cancer, and there was no progression of thyroid cancer on follow-up. However, 2 of the 3 patients in the observation group died from head and neck cancer and thus long-term evaluation of thyroid cancer progression was unable to be performed.
Intraoperative Facial Nerve Monitoring and Postparotidectomy Facial Outcomes: A Pilot Study
Heather Johns, MD, Hawa Ali, MD, Brandon W. Peck, MD, Christine Lohse, MS, Linda X. Yin, MD, Eric J. Moore, MD
Introduction: Electromyographic facial nerve monitoring (FNM) is used during parotid surgery to assist with nerve identification and preservation. This study aimed to assess whether the frequency and amplitude of alarms on FNM has predictive value on the rate of facial paresis after parotidectomy. In addition, the utility of daily facial rehabilitation exercises (DFREs) in patients with postoperative facial nerve paresis following parotid surgery was assessed.
Method: A randomized prospective study of adults undergoing parotidectomy at 2 tertiary referral centers between August 2015 and July 2016 was performed. Demographics, tumor type, and FNM data were analyzed for impact on postoperative facial paresis (graded using Facial Nerve Grading Scale 2.0). Postoperatively, patients with facial paresis were randomized to a trial of DFREs vs no intervention. Facial function was scored monthly for 3 months via video visits and time-to-normal facial function was compared.
Results: A total of 72 procedures performed on 68 patients was included. The rate of facial paresis on postoperative day 1 was 57%. Patient age, comorbidities, tumor size, tumor position, histology, surgeon experience, and operative time did not predict postoperative paresis; however, the amount of parotid tissue removed did (P=.026). Fifty-nine procedures had FNM data available. The frequency and cumulative amplitude of provoked facial nerve stimulations did not predict postoperative paresis. However, the percentage change in amplitude of a supramaximal stimulation before and after dissection (ΔSMax) did predict postoperative paresis (P=.02). In patients with postoperative paresis, DFREs did not shorten the time-to-normal facial function compared with the control group (average 51 vs 44 days, P=.65).
Conclusion: Our findings suggest that the number and cumulative amplitude of provoked stimulations during parotid surgery does not affect the rate of facial paresis. The only predictive variable for facial paresis was the ΔSMax. Self-directed facial rehabilitation exercises do not significantly hasten the recovery of postparotidectomy paresis.
Intraoral Approach to a Parapharyngeal Space Tumor in a Patient Presenting With Obstructive Sleep Apnea
Navroop Gill, Nadia G. Mohyuddin, MD, Susan Haley, Masayoshi Takashima, MD
Introduction: Parapharyngeal space (PPS) tumors are rare and account for 0.5% of head and neck tumors, with most being benign and of salivary gland origin. Here we describe a transoral resection of a PPS tumor found intraoperatively only after tonsillectomy.
Method: A 42-year-old man presented to the otolaryngology clinic with a several-month history of loud snoring, witnessed apneas, daytime fatigue, and mental clouding. Physical examination revealed an elongated uvula with enlarged asymmetric tonsils. The patient was diagnosed with obstructive sleep apnea (OSA) and recommended for an adenotonsillectomy and partial uvulectomy. Following an uncomplicated tonsillectomy, a large mass was palpated in the right tonsillar fossa deep to the constrictor muscles. A transoral approach was used to bluntly dissect into the PPS, and a 5.5-cm mass was entirely removed from the surrounding tissue.
Results: Final pathology was consistent with a benign pleomorphic adenoma with focal extension to inked surface of the margins. The patient was presented at the head and neck tumor board and will undergo close clinical and radiographic surveillance.
Conclusion: The presentation of our patient with primarily OSA symptoms, intraoperative findings of a PPS lesion, and subsequent transoral approach for removal is a unique course of discovery and treatment of a prestyloid pleomorphic adenoma. Despite its rarity, this case highlights the need to have a high index of clinical suspicion for possible PPS tumors when presented with asymmetric oropharyngeal exam findings in the setting of an obstructive breathing pattern.
Intraoral Microscopic Sialolithotomy for Management of Submandibular Sialolithiasis
Emad Magdy, MD, PhD (ORL), Mahmoud Alaaeldin, MD, MRCS (ENT), Omneya Gamaleldin, MD, PhD, Mohamed Taha, MD, Mohamed Fathalla, MD, PhD (ORL)
Introduction: Sialendoscopy is the standard treatment for sialolithiasis; however, larger submandibular stones may require an intraoral combined approach. This study describes and assesses the use of the operating microscope for intraoral stone extraction for such cases.
Method: A retrospective chart review of 62 patients with submandibular stones (total of 64 procedures), operated on over a 6-year period in a tertiary university hospital from September 2014 to January 2021. Patient demographics, operative findings, postoperative follow-up and complications were reported. Preoperative radiologic assessment of stone number, size, and location was achieved by noncontrast computed tomography (CT) scan ± magnetic resonance (MR) sialography. Success was defined as successful intraoral stone extraction with no symptom recurrence at least 12 months postoperatively.
Results: The study included 43 male and 19 female patients, with a mean age of 38±12 years. All patients were operated using a microscopic intraoral sialolithotomy technique. Sixty-three of the 64 glands operated had their stones successfully extracted (98.4%); however, true success was estimated as 93.8% (60/64) because 3 more patients got recurrent stones within a year postoperatively. The proximal location of the biggest stone was identified in 74.6% of patients, whereas the intraglandular location was found in 6.4%. The mean operative time of the technique was 55 minutes. The use of adjunctive sialendoscopy to our microscopic technique was significantly correlated with having more than 3 stones (mean 3.4 stones vs 1.2 stones; P<.001; 95%, CI, −3.19 to −1.25). Only minor complications included temporary lingual paraesthesia (7.8%) and postoperative ranula (1.6%).
Conclusion: Microscopic intraoral sialolithotomy is a highly effective, time-saving, and safe technique for medium-sized to large submandibular sialolithiasis. The high microscopic magnification allows the surgeon to address all stone locations including intraglandular calculi and to clearly identify and safeguard the lingual nerve decreasing morbidity.
Laryngeal Cancer Survival Trends in a Large Managed-Care Organization From 1988 to 2015
Justin D. McLarty, MD, Paul D. Kim, MD
Introduction: Trends in management of laryngeal cancer have changed over the past few decades. Here we contribute the laryngeal cancer data from the Kaiser Permanente Southern California (KPSC) cancer database. Our objective is to present laryngeal cancer data from a large managed-care organization in the United States.
Method: A retrospective review of patients diagnosed with laryngeal cancer (n=2259) from 1988 to 2015 was performed. Five-year survival and treatment modality trends are the main outcomes. The analysis is limited to patients who had diagnosis in the year 2015 or earlier to have 5-year survival information. Stage and subsite information were reported from 2004 onward (n=892). Treatment modalities, surgery type, and race/ethnicity were reported for all years.
Results: No significant change in laryngeal cancer incidence (mean=3.6 per 100,000; P=.30) or overall 5-year survival (mean=65.6%; P=.38) was seen. No trends in cancer stage were noted. Our data reflect changing treatment of laryngeal cancer. There was a strong trend in increasing use of chemotherapy during the 1990s and even more in the 2000s (>10-fold increase; P<.0001). There was a clear diminution in use of surgery during the 1990s and 2000s. More recently, we found increasing use of surgery in early cancers and decreasing use in advanced cancers. There was reciprocally decreased radiation use in early cancers and increased in late cancers. Glottic cancers had better survival compared with supraglottic cancers overall (P<.001). Our data suggest a trend that did not achieve statistical significance toward improving 5-year survival for supraglottic cancers both early and late (n=195; P=.27), which was not seen with glottic cancers (n=697, P=.51).Conclusion: Changing trends in the management of laryngeal cancer and a trend toward improved survival in supraglottic cancer but not glottic cancer are seen in our data. Supraglottic cancers showed worse survival than glottic cancers did. Increasing use of chemotherapy in advanced cancers and increased use of surgery in early cancers were notable trends. Nonoperative management overall appeared to peak in the 2000s.
Laryngectomy Patients: Incidence and Associated Factors in Patients 55 Years and Younger
Alexandra H. Rose, MBBS, Kacie R. Oglesby, MD, Anne C. Kane, MD, Gina D. Jefferson, MD, Lana L. Jackson, MD, Oishika Paul, MPH
Introduction: Laryngeal carcinoma contributes worldwide to more than 180,000 new cases and 100,000 deaths annually. Historically this cancer was seen in higher rates in older White men; however, there is now a rising incidence in younger patients.
Method: Retrospective chart review of patients at a single tertiary center who underwent laryngectomy for laryngeal cancer from 2013 to 2020. Patients 55 years of age and younger at diagnosis were compared with patients 56 years of age and older.
Results: A total of 192 patients were included in the study, 52 of whom were ≤55 years at diagnosis and 140 were ≥56 years at diagnosis. Among both cohorts, there was male predominance (84.6% vs 82.1%). Of the younger patients, 57.7% were African American and 42.3% White compared with 60% African American and 37.9% White patients in the older cohort. Of the younger patients, 56.6% were smokers at the time of surgery vs 37.9% in the older group (P=.019). The younger group was more likely to require adjuvant therapy than the older patients; 38 (76%) of the younger patients underwent chemoradiation, whereas 85 (68.5%) in the older gorup received chemoradiation. Twenty-six (50%) patients were salvage surgery in the younger group compared with 76 (54.3%) in the older cohort. Overall staging in the young and older cohorts, respectively, was I (1.9% and 2.9%), II (5.8% and 9.3%), III (20% and 13.6%), IVA (61.5% and 68.6%), IVB (7.7% and 3.6%), and IVC (1.9% and 2.1%). Tracheoesophageal puncture (TEP) use was successful in 38 (88.4%) of patients in the younger cohort compared with 89 (78.1%) in the older cohort. There was no statistically significant difference in 2- and 5-year disease-free survival or 2-year overall survival between cohorts. There was statistical significance favoring the young in 5-year overall survival (P=.04).
Conclusion: The younger cohort presented with an overall higher stage and were more likely to require triple modality therapy, suggesting more aggressive disease pathology. TEP use was more successful in our younger patients suggesting younger patients were more willing to participate in speech rehabilitation after total laryngectomy.
Laryngotracheal Transplant: Patient and Caregiver Beliefs and Perceptions
Stephanie Zacharias, PhD, CCC-SLP, Danielle Grandjean, Susan Curtis, Richard Sharp, David G. Lott, MD
Introduction: Human laryngeal allotransplantation has been contemplated as an option following a laryngectomy; however, there is a paucity of data regarding the ethical and psychosocial beliefs of laryngotracheal transplant (LT) candidates. The objective of this project was to explore laryngotracheal transplant candidates’ and their caregivers’ perceptions of the transplant process. With this information, the care team will be best informed and trained to provide top tier care for laryngeal transplant patients.
Method: In-depth qualitative interviews were completed with patients and their caregivers, who were potential candidates for a laryngotracheal transplant. Qualitative interviews were administered by an experienced qualitative interviewer. Interviews were semistructured and designed to understand the patient’s and caretaker’s motivation for pursuing a laryngotracheal transplant. Specifically, to ascertain whether their decision to have a laryngeal transplant is informed, conflicted, or coerced. Interviews were completed via Zoom and recorded. Next, interviews were transcribed verbatim. NVivo was used to identify themes and trends, and analyze relationships, to draw deeper conclusions and insights.
Results: Eight LT candidates and their caregivers were recruited over 18 months. Semistructured interviews were completed, designed to explore how the patient and caregiver weigh the risks and benefits of transplantation and whether they have misconceptions about anticipated surgical outcomes. Data collected to date show high expectations for improvement of quality of life. Themes and individual insights will be presented and discussed.
Conclusion: Exploring the perspectives of participants and caregivers will add significantly to the existing body of knowledge by providing a robust understanding of the total experience of patients who pursue laryngotracheal transplant. This evidence may demonstrate the importance of providing laryngeal transplant as a treatment option and the importance of patient decision making.
Late Free Flap Failure in Head and Neck Reconstruction: Unusual Etiology in Two Case Studies and Literature Review
Mohamed Zahran, MD, PhD, Ahmed Youssef, MD, PhD (ORL)
Introduction: The development of modern microvascular surgical techniques has enabled the reliable transfer of free vascularized tissue. This allowed for predictable reconstruction outcomes with excellent surgical success rates. However, devastating consequences of partial or total flap failure and subsequent loss may occur. This usually occurs in the first 48 to 72 hours postoperatively. Flaps rarely fail in the late postoperative period, and it remains poorly understood why flaps fail after day 7.
Method: We presented 2 patients in whom flap failure occurred after the seventh postoperative day (POD). Complete flap failure occurred after PODs 9 and 27 in our cases. During the postoperative period, there was no evidence of early occlusion or insult to the vascular integrity such as venous/arterial compression.
Results: The cause of late flap failure was due to thrombophlebitis secondary to infection from the tracheostomy neck fistula. This assumption was supported by recurrent failure of anastomoses revision.
Conclusion: In patients who develop late free flap complications, deep neck infections related to the tracheostomy site should be considered as a possible cause—even in the absence of obvious signs of infection. With patients requiring tracheostomy and free flap reconstruction, we would advise that no lateral or superior dissection is performed during tracheostomy.
Local Application of Fibroblast Growth Factor Receptor Inhibitor AZD4547 Inhibits UVB-Induced Cutaneous Squamous Cell Carcinoma Without Local Skin and Systemic Toxicity
Rema Anisha Kandula, MBBS, MD, Ahmad J. Kasabali,Brian Latimer, Kenneth McMartin, Alok R. Khandelwal, PhD, Cherie-Ann O. Nathan, MD
Introduction: Cutaneous squamous cell carcinoma (cSCC) is the second most common form of skin cancer, affecting more than 2 million Americans annually. Cumulative sun exposure plays a leading role in the pathogenesis of cSCC. In our previous studies, topical application of fibroblast growth factor receptor (FGFR) inhibitor AZD4547 was associated with a significant reduction in ultraviolet B (UVB)–induced acute skin changes such as epidermal hyperplasia and hyperproliferation. Furthermore, chronic, topical application of AZD4547 was associated with significant inhibition in UVB-induced tumor incidence and multiplicity. Unfortunately, oral administration of FGFR inhibitors in clinical trials for solid tumors is associated with notable side effects. Therefore, our objective was to investigate whether topical administration of AZD4547 could potentially circumvent systemic absorption, leading to a low toxicity profile.
Method: Mice were topically administered AZD4547 (400 µg/200 µL acetone) followed by exposure to UVB 3 times a week for a period of 50 weeks. Blood was collected at the end of the study. AZD4547 was extracted using methanol extraction and concentrated using a Savant SpeedVac system. Samples were reconstituted in 25% acetone/75% water solution and analyzed using Reverse-phase high-performance liquid chromatography (HPLC; Shimadzu) with a Zorbax Eclipse C18 3.5-µm 4.6- × 150-mm analytical column operated at ambient temperature and gradient elution using 0.1% trifluoroacetic acid (TFA; Mobile A) and 0.1% TFA in acetonitrile.
Results: Data from HPLC analysis demonstrated nonappreciable absorption of AZD4547 (78–90 nm) in the long-term topical dosing paradigm, suggesting that the topical application of AZD4547 was not systemically absorbed and the effect of treatment was restricted to the local skin tissue. In addition, using histological analysis, no local skin toxicity was observed in the AZD4547-treated group control to acetone-treated cohort.
Conclusion: Based on the efficacy and low-systemic absorption profile, AZD4547 could potentially be utilized as a topical agent to both prevent and treat UVB-induced cSCC.
Lymph Node Count as a Predictor Of Outcome For N+ Oral Cavity SCC
Mahmoud Alaaeldin, MD, MRCS (ENT), Tazheh Kavoosi, MD, Connor Cannizzaro, Mark Marzouk, MD
Introduction: The treatment of head and neck squamous cell carcinoma (SCC) presents a challenge given the paucity of specific guidelines rooted in evidence-based prognostic factors. The purpose of this study is to assess whether the number of lymph nodes retrieved during neck dissection is a reliable predictor of overall survival or disease-free survival in patients with node-positive (N+) oral cavity SCC patients.
Method: A retrospective chart review of 83 patients who underwent neck dissection for oral cavity squamous cell carcinoma in a tertiary university hospital by a single surgeon from March 2015 through December 2020. Data collected included demographics, history of previous irradiation, presence of distant metastasis, total lymph node count, number of positive nodes, presence of extracapsular extension (ECE), and presence of neck recurrence at follow-up. Multivariate Cox regression analysis was performed to assess for a relationship between node count, overall survival, and disease-free survival.
Results: Eighty-three patients were analyzed at a median follow-up period of 38 months. Sixty male and 23 female patients had a mean age of 62±10 years. The mean count of lymph nodes retrieved from a single side neck dissection was 26±11. Forty-three patients (51.8%) were pathologically N+. Among those, only previous irradiation and presence of ECE (not node count) yielded a significant correlation with neck recurrence (P=.001 and .047, respectively). A lymph node count greater than 18 was significantly associated with better overall survival but not disease-free survival (χ2=4.17, P=.04 and χ2=0.48, P=.48, respectively).
Conclusion: Within a single institution, the count of lymph nodes retrieved during a neck dissection of N+ oral cavity SCC does not significantly affect the incidence of neck recurrence. However, retrieving greater than 18 nodes is associated with improved overall survival rates. Additionally, history of previous radiation treatment and presence of extracapsular extension negatively affect the disease progression.
Lymph Node Ratio as a Prognosticator in Oropharyngeal Squamous Cell Carcinoma: A Meta-analysis
Tiffany Chen, Michael Shih, Shaun Nguyen, MD, Cherie-Ann O. Nathan, MD
Introduction: The purpose of this systematic review and meta-analysis is to determine the prognostic value of lymph node ratio (LNR) in oropharyngeal squamous cell carcinoma (OPSCC) patient outcomes.
Method: A systematic search of PubMed, CINAHL, Scopus, and Cochrane library was conducted following PRISMA guidelines. Due to the inclusion of database studies, meta-analysis was conducted with various subgroups to avoid patient overlap.
Results: A total of 9 studies met inclusion criteria, with 6 studies eligible for meta-analysis. The number of patients in each subgroup were 1303, 5218, and 5987. Age (58.3 [SD 9.1], 60.8 [9.7], 60.8 [9.7]) and gender (15.6%, 17.6%, 18.0% female) were similar across all subgroups. The risk ratio of 5-year overall survival (OS) was 0.62 (95% CI, 0.51, 0.76), 0.67 (0.53, 0.86), and 0.67 (0.55, 0.82), depending on subgroup analyzed. The risk ratio for 5-year recurrence-free survival (RFS) was 0.39 (0.27, 0.57) and for 5-year disease-specific survival (DSS) was 0.79 (0.66, 0.96). In the human papillomavirus (HPV)–positive cohort (n=4451), the risk ratio for 5-year OS was 0.81 (0.67, 0.98) and for 5-year RFS was 0.45 (0.31, 0.64).
Conclusion: Pooled risk ratios indicate that 5-year OS, RFS, and DSS are lower in patients with LNR above the cutoff. Findings suggest that LNR can serve as a valuable prognostic tool in OPSCC and may help improve risk stratification. Future studies should focus on controlling for confounding variables and comparison by HPV status.
Machine Learning for Prediction of Free Flap Failure in Head and Neck Microvascular Reconstruction
Ameen Amanian, MD, Shreyash Sonthalia, Edward Wang, Jamie Kwon, Jenny Gui, Eitan Prisman, MD, MA
Introduction: Free flap microvascular reconstruction is commonly used in a head and neck surgeon’s armamentarium for cancer management. Currently, a predictive model of free flap failure does not exist. Therefore, we aimed to develop a machine-learning (ML) clinical model to identify factors that predict free flap failure.
Method: A single-institutional surgical database of patients since 2014 until present was retrospectively reviewed. Inclusion criteria included patients aged 18 years and older with a diagnosis of a head and neck neoplasm who underwent free flap reconstruction. Free flap failure was defined by complete loss of flap not amenable to salvage surgery. A 3-fold cross-validation was performed during training of the algorithm. The classification models were trained on 75% of the data set and tested on the remaining 25%. The performance of the models were evaluated by the area under the receiver operating characteristic curve (AUC).
Results: A total of 474 patients were included in this study. The mean age of the patients were 62.16 years. The overall prevalence of free flap failure in the data set was 3.16%. The most common free flap performed included radial forearm (n=213). In total, 120 patients had a history of prior radiotherapy. Utilizing a feature selection algorithm, 10 variables were identified as most predictive for free flap failure: Charlson Comorbidity Index, prior radiation, tracheostomy, cigarette pack-years, alcohol use, body mass index, specific use of a fibula or radial forearm flap, American Society of Anesthesiologists class, and 2-vein reconstruction. The random forest classifier showed the highest predictive capability for free flap failure (AUC of 0.723), higher than that of logistic regression (AUC of 0.605).
Conclusion: In this study, we developed a novel machine-learning model to predict free flap failure. The random forest classifier demonstrated superior predictive performance. Next steps will entail development of a clinical decision support tool to aid microvascular surgeons with predicting patients at risk of free flap failure to allow health care teams to intervene early and prevent this rare yet catastrophic occurrence.
Management of Carotid Stent Extrusion in Irradiated Patients
Emily Montgomery, MS, Aurora G. Vincent, MD, Charles M. Llewellyn, MD, Yadranko Ducic, MD
Introduction: Carotid stent extrusion is a rare but highly morbid event, and patients who have undergone irradiation to the head and neck tissues may be at increased risk of stent extrusion. Herein, we review our experience with carotid stent extrusion among head and neck cancer patients with the goal of determining the optimal management strategy.
Method: We conducted a retrospective review of carotid stent extrusion in irradiated head and neck cancer patients treated by the senior author between 2000 and 2021 at a tertiary care hospital. Independent variables included reason for stent placement, stent location (cervical internal carotid artery [ICA] or common carotid artery [CCA]), history of irradiation, and patient demographics. Outcome measures included time from stent placement to extrusion, elected management (observation vs re-stent vs patch/bypass graft), and any complications.
Results: Six patients met inclusion criteria; all presented with bleeding, and the time between stent placement and subsequent extrusion ranged from 7 days to 9 months. Two patients with ICA stents were treated with observation or revision stent placement; both suffered a stroke. Four patients with CCA stents were managed with definitive repair (bypass venous graft or venous patch graft). Patients were followed for 1 year after extrusion; all who had undergone definitive surgical management were alive 12 months later.
Conclusion: Carotid stent extrusion is a rare but serious complication in irradiated head and neck patients. In this series, patients treated with definitive surgical management (venous bypass or patch repair) had fewer complications than those treated with stent revision or observation. Revision stent placement can be a useful immediate management tool in this population, but we feel stent repair should be converted to a bypass or patch repair within a few weeks to avoid extrusion. Further study is necessary to elucidate the best management techniques in this population.
Medullary Thyroid Carcinoma Without Mortality
Muhammed F. Shand, MD, William Montagne, MD, Robert C. Wang, MD
Introduction: Medullary thyroid carcinoma (MTC) is an aggressive cancer with high morbidity and mortality. Risk factors include older age, tumor size greater than 2 cm, and regional and metastatic disease. Here we present a group of 9 patients with MTC without mortality.
Method: This study was a retrospective case series of adult patients with MTC who were referred to a single attending for surgical management. Patients underwent thyroidectomy with or without central neck dissection or lateral neck dissections between November 2014 and October 2021. Surgeries were carried out at 1 of 2 hospitals. Patients with distant metastasis were excluded. The primary outcome measure was mortality. Secondary outcomes measures included demographics, preoperative calcitonin level, preoperative carcinoembryonic antigen, tumor size, regional metastasis, distant metastasis, postoperative calcitonin levels, most recent calcitonin levels, years since procedure, and postoperative complications/readmissions.
Results: For the 9 patients, the mortality rate was 0%, with most literature reports ranging from 10% to 15% for a 5-year mortality. Of note, there was 1 mortality in a patient who had distant metastasis before surgery during this time frame. Our average age was 57 (range 24–79) years. The average number of years since surgery was 4.2 (range 0–7) or average months of 56.6 (range 3–86). Average surveillance calcitonin level was 23.6 (range 1–42). Preoperative calcitonin reached more than 8000 pg/mL.
Conclusion: In our set of patients, without distant metastasis, we were able to achieve a mortality rate of 0% over an average of 4.2 years.
Metastatic Renal Cell Carcinoma to the Thyroid With Internal Jugular Tumor Thrombosis
Ryan N. Hellums, DO, Kevin J. Kovatch, MD, Michael Friscia, Tyler Schwartz, MD, Shreya Jammula, Phillip K. Pellitteri, DO
Introduction: Metastatic renal cell carcinoma (RCC) represents 25% to 30% of metastatic thyroid malignancies. Propensity for RCC to demonstrate intravascular extension to the inferior vena cava is well documented; however, an analogous phenomenon of intravascular extension to the internal jugular vein (IJV) from thyroid gland metastasis, with resultant tumor thrombosis, has not been reported.
Method: A 71-year-old man with a history of RCC, requiring bilateral nephrectomy and hemodialysis, presented with a large vascular mass involving the right thyroid lobe. Biopsy demonstrated metastatic RCC. Imaging demonstrated tumor thrombosis of the ipsilateral IJV, extending inferiorly to the junction of the brachiocephalic, subclavian, and IJVs in the mediastinum.
Results: Prophylactic preoperative embolization of the ipsilateral inferior thyroid artery was performed. Surgical excision required control of both the IJV in the neck and the mediastinal venous great vessels via sternotomy, prior to right subtotal thyroidectomy and venotomy for en bloc resection. Primary repair of venotomy was performed. Extent of tumor thrombus was limited to the brachiocephalic vein, with no evidence of direct extension into the wall of the IJV.
Conclusion: This report highlights the potential for RCC to involve the great venous vessels of the neck and mediastinum by intravascular extension in patients with metastatic disease to the thyroid. Surgical management should involve careful preoperative planning with comprehensive imaging, consideration of preoperative embolization in vascular tumors, and a multidisciplinary surgical approach. Venotomy with direct extraction of tumor thrombus allows en bloc resection and preservation of venous drainage in appropriately selected patients without direct vascular invasion.
Minimally Invasive Open Approach With Enucleation of Low-Grade Chondrosarcoma: Outcomes From a Novel Technique
Jeffanie Wu, Madelyn N. Stevens, MD, Miriam R. Smetak, MD; James L. Netterville, MD
Introduction: Laryngeal chondrosarcomas are rare malignant tumors that are typically low grade and carry a favorable prognosis. Treatment involves surgical excision via endoscopic approach, open partial laryngectomy, or total laryngectomy. Here, we present long-term outcomes in a series of patients who underwent minimally invasive open resection via a lateral laryngotomy approach.
Method: A cohort of patients from a single academic institution was selected. A small neck incision was used in an open approach to the larynx. A lateral laryngotomy incision was made into the laryngeal cartilage directly over the tumor, and the tumor was enucleated without violating the airway. Care was taken to maintain cricoarytenoid support.
Results: Nine patients with low- to intermediate-grade chondrosarcoma were identified. Median length of follow-up was 3.5 years (range 1 months to 17 years). The most common presenting symptoms were dysphonia, dysphagia, and dyspnea. All patients underwent open lateral laryngotomy approach. Four patients had total resection of tumor; the remaining 5 patients had subtotal resection removing 90% to 95% of tumor. Of the 9 patients, 4 required additional interventions, of which 3 had subtotal resection at their initial surgical intervention. One patient ultimately underwent total laryngectomy due to transformation of tumor from low- to high-grade chondrosarcoma. One underwent partial hemilaryngectomy due to the significant size of the subglottic mass and symptoms of dysfunctional larynx at follow-up. Two additional patients underwent re-enucleation via lateral laryngotomy approach. Only 1 patient had a long-term tracheostomy in place at follow-up due to patient preference, and the upper airway was noted to be patent. The most common postoperative symptom was dysphonia. All 9 patients were alive at most recent follow-up.
Conclusion: Here, we describe a novel minimally invasive approach to resect low-grade chondrosarcoma. This technique allows for excellent tumor resection without laryngeal compromise and was laryngeal sparing in all but 1 patient, providing prolonged symptom relief and maintenance of quality of life for patients.
Multidisciplinary Care Improves Patient Outcomes for Carotid Body Paragangliomas
Kirsten Wong, Kenric Tam, MD, Eric K. Tran, Maie A. St. John, MD, PhD
Introduction: Carotid body tumors (CBTs) are highly vascular, glomus tumors arising from paraganglion cells of the carotid body. Surgical treatment can be performed by otolaryngology–head and neck surgeons (OHNS), vascular surgeons, or a combination of both. For large tumors, combination of care between head and neck and vascular surgeons leads to better outcomes.
Method: A retrospective chart review of 79 patients who had CBT resections between 1998 and 2020 at Ronald Reagan UCLA Medical Center was conducted. Factors reviewed included the operating surgical subspecialty, tumor size measured by magnetic resonance or computed tomographic imaging, tumor pathology, estimated blood loss (EBL), and adverse events including cranial nerve deficits.
Results: Ages ranged from 16 to 82 years, with an average age of 50. The group was 44% male and 56% female, with 11.4% of patients having undergone a previous resection for a contralateral CBT. The operating surgical subspecialty was composed of 24.1% OHNS, 41.8% vascular surgery, and 31.6% combined OHNS and vascular. Of CBT resections, 54% had preoperative embolization. No statistically significant difference in EBL was noted for surgeries with and without embolization when controlled for tumor size (P=.34). For every 10-mm increase in CBT, there was a corresponding 98.8-mL increase in EBL (R2=0.94). CBT size was similar for OHNS (29.9 mm) and vascular surgery (30.8 mm) but was significantly larger for combined OHNS and vascular cases (37.9 mm, P=.008). EBL was significantly higher in combined cases (300.6 mL) compared with OHNS only (123 mL) or vascular only (203 mL). When a patient’s care was provided by one surgical subspecialty, the incidence of cranial nerve injury or Horner syndrome was 9.8%. In combined OHNS and vascular cases, the incidence dropped to 4%.
Conclusion: CBTs can be managed safely and effectively by both vascular and OHNS with minimal differences in EBL or adverse events. However, combined OHNS and vascular cases had significantly better outcomes and decreased incidence of cranial nerve injury despite involving larger tumors. Complex CBT resections benefit from the combined efforts of both specialties.
Neutrophil-to-Lymphocyte Ratio as a Predictor of Surgical Outcomes in Head and Neck Cancer
Derek D. Kao, Rocco M. Ferrandino, MD, MSCR, Scott A. Roof, MD, Keith M. Sigel, MD, PhD
Introduction: Neutrophil-to-lymphocyte ratio (NLR) is correlated with systemic inflammation and identifies patients at risk of complications after surgery. We investigated NLR as an independent prognostic indicator of surgical complications in patients with head and neck cancer (HNC).
Method: We conducted a retrospective study of 13,438 patients in the Veterans Affairs Surgical Quality Improvement Program who underwent surgery for HNC between 2000 and 2020 with prospectively collected information on postoperative mortality and complications. We calculated NLR values from lab values collected in the 90 days prior to surgery and dichotomized NLR using the Youden J statistic (NLR=3.64). We then fit logistic regression models adjusting for age, sex, race/ethnicity, surgery year, smoking, alcohol use, Charlson Comorbidity Index score, American Society of Anesthesiology (ASA) class, procedure, body mass index, and preoperative hematocrit and creatinine, comparing outcomes for high-NLR to low-NLR patients. Lastly, we used the models to construct clinical prediction nomograms for adverse outcomes.
Results: The median age was 63 years, 98% were men, and 77% were White. In adjusted models, high NLR was associated with an increased odds of 30-day mortality after surgery (odds ratio 1.93; 95% CI, 1.29–2.88), having 1+ complications (1.27; 1.13–1.43), failure to wean (1.41; 1.11–1.80), and pneumonia (1.62; 1.30–2.02) compared with low NLR. A high NLR did not increase the odds of reoperation, cardiac arrest, myocardial infarction, coma, stroke, major bleeding, deep vein thrombosis, sepsis, pulmonary embolism, reintubation, acute renal failure, progressive renal insufficiency, urinary tract infection, or superficial or deep wound infections. Using these findings, a clinical prediction nomogram including age, ASA score, and NLR category stratifies postoperative mortality risk from 0.1% to 10%.
Conclusion: In a cohort of veterans undergoing HNC surgery, NLR was an independent prognostic indicator of postoperative 30-day mortality, having 1 or more surgical complications, failure to wean, and pneumonia. NLR, ASA score, and age can predict postoperative mortality and major adverse events.
Outcomes of Mesh Cranioplasty in Scalp Free Tissue Reconstruction: A Systematic Review and Meta-analysis
Katherine Chang, MD, Lydia Zhong, David Lee, MD, Lauren Yaeger, MA, MLIS, Patrik Pipkorn, MD, MSCI
Introduction: The aim of this study is to systematically review the literature to determine the prevalence and risk of free flap and postoperative complications in scalp free tissue reconstruction with mesh cranioplasty.
Method: We performed a systematic review and meta-analysis using a search strategy created with a medical librarian using multiple databases and identified 186 studies in May 2021. Two reviewers independently performed the review, data extraction, and quality assessment. Cohort studies of patients with free tissue reconstruction of a scalp defect with or without mesh cranioplasty were included. Studies that did not report whether mesh was used or did not separate outcomes by mesh use were excluded. The primary outcomes were free flap failure (total and partial failure) and postoperative complications (hematoma, wound dehiscence or infection, microanastomosis compromise). A random-effects model was used for the meta-analysis to estimate prevalence and prevalence ratios (PRs).
Results: A total of 29 studies and 452 cases of scalp free tissue reconstruction were identified. Pooled prevalence of free flap failures and postoperative complications in patients with mesh cranioplasty were estimated at 7% (95% CI, 3%–17%; P=.85; I2=0%) and 27% (95% CI, 18%–39%; P=.27; I2=18%), respectively. Subgroup analysis to estimate PRs of complications was performed in 8 studies and 228 cases. Mesh cranioplasty was not associated with a significantly increased risk of free flap failure or postoperative complications when compared to cases without mesh cranioplasty; pooled PR 1.21 (95% CI, 0.50–2.88; P=.90; I2=0%) for free flap failure and PR 1.40 (95% CI, 0.67–2.91; P=.13; I2=38%) for postoperative complications.
Conclusion: Overall, mesh cranioplasty does not significantly increase the risk of free flap compromise or postoperative recipient site complications. Future higher-quality studies are needed to further evaluate the impact of synthetic mesh on complications in free flap reconstruction.
Outcomes of Osteonecrosis and Benign Segmental Mandibular Free Flap Reconstruction
Natalie T. Austin, BS, Kyle P. Davis, MD, James R. Gardner, MD, Deanne King, MD, Jumin Sunde, MD, Mauricio A. Moreno-Vera, MD
Introduction: Despite the common belief patients requiring free tissue transfer for mandibular osteonecrosis (osteoradionecrosis or bisphosphonate-related osteonecrosis of the jaw) have worse outcomes, no studies, to our knowledge, directly compare results of osteonecrosis free tissue reconstructions with benign mandibular lesions requiring segmental mandibulectomy. The aim of this study was to assess perioperative and functional outcomes of patients with osteonecrosis compared with benign lesions.
Method: This was a retrospective review of all patients who underwent segmental mandibulectomy and bone-containing free tissue reconstruction of the mandible for osteonecrosis or benign pathology between September 2011 and March 2021 at a single tertiary referral center. Demographic, preoperative, surgical, and postoperative variables were collected from the medical records.
Results: Forty-two patients underwent segmental mandibulectomy and free flap reconstruction for osteonecrosis (n=28) or benign (n=14) pathology. Patients with benign pathology were younger (43.0 vs 62.7 years; P<.001) and had larger bony defects (12.0 vs 8.9 cm; P=.003). There was no statistical difference in 30-day medical complications (7.1% vs 0.0%; P=.592), 30-day surgical complications (17.9% vs 7.1%; P=.645), flap failure (7.1% vs 0.0%; P=.592), reoperation within primary stay (10.7% vs 14.3%; P=1.000), or 30-day reoperation rate (14.3% vs 14.3%; P=1.000). Average postoperative days with a feeding tube was higher for osteonecrosis but not statistically significant (103.0 vs 41.0 days; P=.091). No statistical differences were found among any 1-year outcomes (osteonecrosis vs benign): revision surgery within 1 year (17.9% vs 0.0%; P=.566), 1-year hardware extrusion (3.8% vs 14.3%; P=.384), or 1-year NPO status (9.1% vs 0.0%; P=1.000).
Conclusion: Within our cohort, those with osteonecrosis requiring free flap reconstruction did not reveal statistically significant worse surgical or functional outcomes compared with benign pathologies despite several categories trending toward worse outcomes for osteonecrosis.
Outcomes of Patients With Scalp Malignancies Undergoing Outer Calvarial Drilling
Tony Peter, MD, Colten Wolf, Shawn Choe, Amy Pittman, MD
Introduction: Cutaneous scalp malignancies with persistently positive deep margins beyond the periosteum require further resection with drilling the outer calvarial bone. There are limited data on the oncologic outcomes associated with this technique so the objective of this study was to characterize the outcomes of patients with cutaneous malignancies of the scalp who underwent outer table calvarial drilling.
Method: A single-institution retrospective chart review was conducted of medical records from 2011 to 2021 of all patients undergoing outer calvarial drilling. The primary outcome was overall survival and disease-free survival. Demographic data, tumor pathologies, history of immunosuppresion, reconstructive techniques, recurrence rates, follow-up periods, and forms of adjuvant therapies were collected and analyzed. Statistical analysis was performed with Fisher exact tests to identify patient variables that influenced the primary outcomes.
Results: Thirty-nine patients underwent outer calvarial drilling for scalp malignancies with an average follow-up period of 17 months. There has been an increased frequency of this technique over the past 10 years. Most patients were male (29/39, 75%), and most patients (34/39, 87%) were immunocompetent. The recurrence rate was 26%, with an average time to recurrence of 23 months. Disease-free survival was seen in 33 of 39 (85%) patients, and overall survival was seen in 92% (36/39) of cases. The addition of adjuvant therapy in this population did not show any significant difference in disease-free survival (P=.607) or in overall survival (P=.556). Immunosuppressed patients had worse disease-free (P=.019) and overall survival (P=.038).
Conclusion: Cutaneous scalp malignancies undergoing outer table calvarial drilling yield good oncologic outcomes despite being unable to assess a true deep margin status. This technique is used with increasing frequency at our institution. Immunosuppressed patients had worse outcomes. There was no benefit with adjuvant therapy in terms of disease-free or overall survival in this study population.
Parathyroid Carcinoma: An NCDB Analysis to Understand Diagnostic Challenges and Outcomes of a Rare Endocrine Tumor
Symone Jordan, MPH, Tyler Pluchino, MD, Elizabeth D. Cash, PhD, Jeffrey B. Jorgensen, MD, Jeffrey M. Bumpous, MD
Introduction: Parathyroid carcinoma (PC) is a rare, often fatal, malignancy, for which staging and preoperative diagnosis is difficult. Advancements in treatment have been limited due to small samples and conflicting data on prognostic factors. We hypothesize that utilization of a national database will allow us to generate a sample size large enough to assess whether patients with large tumor size, high levels of hypercalcemia, concomitant bone and renal disease, or palpable neck masses will have a higher likelihood of harboring PC.
Method: A retrospective analysis of a cohort of patients with PC in the National Cancer Database (NCDB) with available data from 2004 to 2018 was conducted. Patients with a primary site code of C75.0 and histology codes 8000, 8010, 8140, and 8290 were included. Demographic factors and disease and treatment characteristics were evaluated. Hypothesis tests were conducted using χ2, independent samples t tests along with univariate and multivariable logistic regression and Cox proportional hazards models to examine associations of PC diagnosis with outcomes.
Results: The final cohort included 598 patients. Mean age was 57.6±13.5 years (range 22-90); 290 (48.5%) were female. Mean tumor size was 33.14±49.9 mm (median 26.0, range 2-860). Three patients had bony metastases at the time of diagnosis. Regarding treatment, 36 patients (6%) underwent surgery, 98 (16.4%) received radiation, and 5 (0.8%) received chemotherapy. The median follow-up was 6.6 years (max 15.9 years), and overall survival for the full follow-up period was 76.1%. Older age at diagnosis and larger tumor size were significantly associated with poorer overall survival (odds ratio [OR]=1.052; 95% CI=1.037-1.066; P<.001 and OR=1.347; 95% CI=1.030-1.763; P=.030, respectively).
Conclusion: Age and tumor size but not gender, nodal status, or the addition of regional lymph node surgery to primary tumor extirpation were significantly related to overall survival. Further hypothesis tests of NCDB data are underway in efforts to better inform treatment of rare cancers such as PC.
Patient Decision Making in Management of Small Papillary Thyroid Cancer
Sarah C. Shearer, MD, Eric L. Wu, MD, Keon M. Parsa, MD, Dave Boyd, MS, Braeden Lovett, MD, Bruce J. Davidson, MD
Introduction: Guidelines support active surveillance (AS) as an acceptable option for small (<1 cm) papillary thyroid cancers (PTC), but data are lacking regarding patient preferences for AS vs surgical treatment. The objective of this study is to determine healthy subjects’ preferences for managing small PTC and ascertain what evidence could change their initial preference.Method: Ninety-five adults were surveyed from April to October 2021. The survey included demographic information and familiarity with AS. Subjects chose surgery or AS given a scenario in which they were diagnosed with small PTC. Subjects were provided 6 true statements regarding AS and PTC, and those who initially chose surgery were again asked their preferences. The primary outcome was to determine if those who initially chose surgery would change their preference. A second objective was to ascertain which statements were rated most convincing in favor of AS.
Results: Demographics included a mean age of 51 years, 65% female, 88% White, and 72% college graduates. AS, unfamiliar to 65% of respondents, was initially chosen by 37%, but prior familiarity with AS was not associated with this choice. After reviewing the 6 statements, nearly half (47.4%) of those who initially selected surgery changed their response to AS. Of those who initially chose surgery, the most convincing statement in favor of AS was “Your doctor recommends watching and waiting” (36%). Of those who initially chose AS, the 2 statements that were most convincing in affirming their choice were “Your doctor recommends watching and waiting” (57%) and “Many other patients have been monitored successfully without surgery” (57%). There were no significant differences in demographics of those who changed their minds, although 58% of female vs 32% of male respondents changed their minds (P=.061).
Conclusion: Our survey indicates that some patients may change their initial preference after learning about AS. Many respondents found their physician’s recommendation to be convincing. These data suggest that shared decision making about management of PTC can be influenced by physician recommendations.
Patterns of Substance Use Among Individuals With Parental Head and Neck Cancer
Tara E. Mokhtari, MD, Suresh Mohan, MD, Neil Bhattacharyya, MD
Introduction: Tobacco and alcohol use are known modifiable risk factors for the development of head and neck cancers (HNCa). The objective of this study was to investigate patterns of tobacco and alcohol use among adults in the United States with a parental history of HNCa.
Method: The Cancer Control Module of the National Health Interview Survey (NHIS) 2015 was queried to identify individuals with a family history of HNCa. Patterns of tobacco and alcohol use were investigated in this population. Outcomes measured in the course of this investigation include (1) data regarding active (including intensity of use) vs previous tobacco use among individuals with family history of HNCa and (2) data regarding alcohol use trends for subjects with parental history of HNCa (including intensity of use).
Results: There were 3.2 million adults identified with a parental history of HNCa (2.5 million paternal and 0.7 million maternal). There were significant differences in tobacco use among individuals with a family history of HNCa (P=.02). Individuals with parental HNCa history were more likely to be former smokers (28.5% vs 21.7%) and less likely to be never-smokers (57.3% vs 63.9%) than individuals with no parental HNCa history. Despite a parental HNCa history, 457,000 adults remained current smokers (14.2%). A total 200,000 adults remained heavy drinkers (9.4%) despite a parental HNCa history, although this was not statistically significant vs the general population (7.4%, P=.31).
Conclusion: Individuals with parental history of HNCa are more likely to have used tobacco and have rates of alcohol use consistent with population averages. Current smokers with a history of parental HNCa present an immediate opportunity for targeted smoking cessation. These findings provide impetus to extending alcohol and tobacco screening to families of HNCa patients.
Perioperative Outcomes in Head and Neck Surgery Following Implementation of ERAS Protocol
Maria C. Masciello, MD, Joshua D. Waltonen, MD, Nelson H. May, MD, Rebecca C. Walsh, PA-C
Introduction: Enhanced Recovery After Surgery (ERAS) protocols are multimodal care pathways designed to improve recovery rates after surgery. The current study compares outcomes in patients undergoing head and neck free flap reconstruction prior to and after implementation of a free flap–specific ERAS protocol.
Method: Chart review of head and neck cancer patients who underwent free flap reconstruction at a tertiary referral academic institution (2013–2021). Outcomes include complication rates, emergency department (ED) visits/hospital readmissions, all-cause mortality, and length of stay. Fisher exact test was used for all tests other than the ED visits/readmits (2-sample Wilcoxon test) and length of stay (2-sample t test).
Results: Thirty patient charts were reviewed (15 preprotocol, 15 postprotocol). Of preprotocol patients, 67% incurred nonwound-related complications compared with 33% postprotocol (P=.14). Sixty percent of preprotocol patients experienced wound complications compared with 20% of postprotocol (P=.06). Total complications were less for the postprotocol compared with the preprotocol group (40% and 80%, respectively; P=.06). All-cause mortality within 6 months was 17% for preprotocol group and 0% for postprotocol (P >.99). There were 14 ED visits/readmissions in the preprotocol group compared with 2 in the postprotocol group (P=.16). Average length of stay was unchanged (P=.45).
Conclusion: Preliminary results show that ERAS protocol implementation does not significantly alter perioperative outcomes; however, there is a trend toward fewer total complications (P=.06) and wound-related complications (P=.06) postprotocol. Study power is currently limited by sample size; however, additional data collection is planned and should improve power to detect any such trends.
Phenotypes of Head and Neck Flap Patients and Prevalence of Complications Within Subgroups
Beau Idler, BA, Hanna Luong, BS, Daniela Brake, MD, Brent Chang, MD
Introduction: Preoperative factors relating to complication rate after head and neck flap surgery remain an area of uncertainty, and accurate identification of those patients more likely to experience complications would allow for targeted care. With cluster analysis, a previously unused tool among head and neck flap patients, we sought to elucidate phenotypes of subgroups at higher risk for adverse events.
Method: The ACS-NSQIP database was queried for patients who underwent flap surgery with an otolaryngologist between 2012 and 2020. Patients were clustered on pre-operative characteristics and labs. Cluster analysis was performed using the Kamila algorithm. After clustering, groups were compared with χ2 testing and ANOVA.
Results: Included were 2344 patients (mean age 62.1 years; 67% male); 11.7% of patients had an unplanned readmission and 42.9% experienced an intra- or postoperative complication. Three clusters were found, with cluster 1 containing 266 patients, cluster 2 containing 1002, and cluster 3 containing 1076. Cluster 1 had the highest rate of complications (60.9% vs 40.4% and 40.8%, respectively, P<.001). Significant distinguishing features of cluster 1 included elevated platelet count (440/nL vs 287 and 188, P<.001) and higher rates of smoking within a year of surgery (51.1% vs 32% and 26.4%, P<.001). Surprisingly, this group had lower rates of type 2 diabetes (3.8% vs 10.6% and 9.6%, P=.008) and lower BMI (23.3 vs 26.6 and 26.6, P<.001). The most common and significant complication among cluster 1 was intraoperative or postoperative transfusion (43.2% vs 23.3% and 23.6%, P<.001).
Conclusion: Cluster analysis distinguished a specific subgroup of head and neck flap patients who experience complications at 42% higher rates than the average (odds ratio 2.07). Identification of this subgroup in clinical practice could allow for more tailored treatment to reduce peri- and postoperative complications.
Polypharmacy on Quality of Life in Head and Neck Cancer Patients
Brandon Yeshoua, Ido Badash, MD, Francis Reyes, Ashley Yi, James Kim, MD, Kevin Hur, MD
Introduction: Polypharmacy has been recognized as a risk factor for adverse medical outcomes including reduced patient safety and medication noncompliance. Limited research has examined the association between the number of medications a patient takes to their health-related quality of life among head and neck cancer patients.
Method: A cross-sectional study of head and neck cancer patients from May 2021 to January 2022 was performed at 2 tertiary medical centers. Patients were consented to complete a survey collecting information on sociodemographic factors, medical history, and psychometric variables. The outcome of interest was health-related quality of life, measured using the EQ-5D-3L. Linear regression models were used to examine the association between health-related quality of life and the number of medications, categorized by quartiles. The models were adjusted for age, gender, race and ethnicity, income, education, and comorbidities.
Results: In the analytical sample (n=120), 61.8% of the patients were female, and the mean age was 50.8 years. There were observed differences in age, race/ethnicity, and education among the 4 quartiles of medication usage (P<.05). Older individuals and those with higher educational degrees were more likely to be taking a higher number of medications. In addition, individuals identifying as Hispanic/Latino had the highest average number of medications overall and were the most prevalent population within the uppermost quartile. Individuals identifying as either White or Asian were significantly more prominent in the first and second quartiles of number of medications. After adjusting for all covariates, patients in the highest quartile of number of home medications reported the lowest EQ-5D-3L scores compared with those in the first quartile (P=.006; SE=.057).
Conclusion: Polypharmacy among head and neck cancer patients was associated with lower health-related quality of life scores. Further studies investigating interventions that reduce unnecessary medication use among head and neck cancer patients may be helpful for improving these patients’ quality of life.
Postoperative Opioid Guidelines Reduce Prescription Size and Use Without Impact on Patient Satisfaction
Sophia Dang, MD, Tanvi Rana, Kelly E. Daniels, MD, Jonathan Li, MD, Alexander Duffy, MD, David M. Cognetti, MD
Introduction: Previously, we assessed postoperative opioid-prescribing habits and opioid use after common head and neck surgeries. More than 50% of prescribed opioids went unused. Based on these findings, we instituted multimodal, evidence-based guidelines for postoperative pain management. We evaluated their effects on (1) opioids prescribed, (2) opioids consumed, (3) patient satisfaction, and (4) departmental perceptions toward the opioid epidemic and prescribing guidelines.
Method: Procedure-specific opioid prescription guidelines were created based on data from phase I of our study. Procedures included sialendoscopy (sialo), parotidectomy (parotid), parathyroidectomy/thyroidectomy (thyro), and transoral robotic surgery (TORS). Patients ≥18 years without opioid use disorder or hospitalization >7 days who underwent one of these procedures from May 2019 to May 2020 were included. Data were collected at their first postoperative appointment. Attending physicians were surveyed before and after phase I to assess their perceptions regarding postoperative pain management.
Results: Implemented guidelines reduced average prescribed morphine milligram equivalents (MME) by 48% (sialo), 63% (parotid), 60% (thyro), and 42% (TORS). Mean consumed MME was reduced from 31.0 to 7.8 (sialo), 42.9 to 15.5 (parotid), 30.3 to 17.4 (thyro), and 212.4 to 148.5 (TORS). Percentage of unused MME remained unchanged despite reduced prescription sizes. Patient satisfaction scores were similar. We did not observe any significant changes among attitudes of attending physicians regarding postoperative pain management after implementation of prescription guidelines.
Conclusion: Postoperative opioid-prescribing guidelines reduce opioid prescription size and patient use across studied procedures without affecting patient satisfaction in pain control or overall care. Perception of opioid availability may affect opioid use since the percentage of unused MME did not change with reduced prescription size. Institutions should consider adopting evidence-based guidelines to minimize the amount of postoperative opioids prescribed.
Postoperative Radiation Therapy Refusal in Major Salivary Gland Malignancies
Keshav Shah, BS, Ryan M. Carey, MD, Aman Prasad, Karthik Rajasekaran, MD, Robert M. Brody, MD, Jason A. Brant, MD
Introduction: Major salivary gland cancers (MSGC) are often treated with primary surgery followed by adjuvant therapy for high-risk pathology. Patients with these cancers may opt out of recommended postoperative radiation therapy (PORT) for many reasons and may suffer worse outcomes due to inadequate treatment.
Method: We conducted a retrospective cohort study of patients in the National Cancer Database diagnosed with MSGC from 2004 to 2016, assessing overall survival and risk factors for refusal of recommended PORT based on demographic, socioeconomic, and clinical factors. Multivariable logistic regression and a multivariable Cox proportion hazards model were used to conduct the analysis.
Results: Of the 4704 patients included in the final analysis, 211 (4.5%) opted out of recommended PORT. Multivariable analysis controlling for various socioeconomic factors demonstrated increased PORT refusal for age >74 years (odds ratio [OR] 4.34, CI [2.43-7.85]), Asian race (OR 2.25, CI [1.10-4.23]), and certain facility types (comprehensive cancer center, OR 2.39, CI [1.08-6.34]; academic research program, OR 3.29, CI [1.49-8.74]; integrated network cancer program, OR 2.75, CI [1.14-7.7]). Contrastingly, N2 stage was associated with decreased PORT refusal (OR 0.67, CI [0.45-0.98]). The 5-year overall survival for patients who received and refused PORT were significantly different at 65.8% and 53.8%, respectively (P<.001). When controlling for a number of patient and disease factors, PORT refusal was independently associated with significantly lower overall survival (hazard ratio 1.54, CI [1.21-1.98]).
Conclusion: Patient refusal of recommended PORT in MSGC is rare and associated with a variety of disease and socioeconomic factors, including advanced age, Asian race, and treatment at specific facility types. PORT refusal may decrease overall survival. Our findings may assist clinicians in counseling patients and identifying those who may be more likely to opt out of recommended PORT.
Practice Patterns of Advanced Head and Neck Adenoid Cystic Carcinoma
Michael Papazian, Jamie R. Oliver, Alex J. Gordon, Moses M. Tam, MD, Babak Givi, MD
Introduction: The role of primary surgery is poorly defined in locally advanced adenoid cystic carcinoma (ACC), a slow-growing malignancy that often presents with invasive disease. Our objective was to compare treatment outcomes for ACC of the head and neck with the greatest extent of local invasion (stage T4b).
Method: All patients with T4b ACC of the head and neck diagnosed 2004-2018 in the National Cancer Database were identified. Demographics, clinical characteristics, treatment details, and survival were analyzed. Treatment-related outcomes were analyzed using univariable and multivariable Cox regression.
Results: A total of 557 cases of T4b ACC were identified. The nasal cavity and paranasal sinuses were the most common site of origin (242, 43.4%). The majority were N0 (454, 81.5%) and M0 (464, 83.3%). Among patients without metastases, the majority (287, 61.9%) underwent definitive treatment including radiation therapy (RT; 80, 27.9%), chemoradiation therapy (CRT; 62, 21.6%), surgery with RT (115, 40.1%), and surgery with CRT (30, 10.4%). The median follow-up was 44.5 months (IQR: 26.7-82). Overall survival was 76.7% and 66.0% at 3 and 5 years, respectively. The positive margin rate for surgical resection was 78.5% and did not vary significantly across subsites. In spite of this, 3-year survival was significantly higher for patients treated with surgery (82.1%) compared with those treated without surgery (71.3%, P=.03) and surgical treatment was associated with significantly higher survival on univariable (hazard ratio [HR]: 0.57, P=.03) and multivariable Cox regression (HR: 0.47, P<.001) controlling for age, sex, comorbidities, site, and nodal staging. Stratified by site, this effect was most pronounced for oral cavity tumors (HR: 0.36, P=.006).
Conclusion: Long-term survival is common in very advanced ACC of the head and neck. Primary surgery was associated with longer survival, particularly in oral cavity tumors. A carefully selected subset of patients with very advanced adenoid cystic tumors might benefit from consideration of surgical treatments.
Prediction of Lymph Node Metastasis of Early Oral Cancer by RNA Expression and Epigenetic Profiles
Doh Young Lee, Woo-Jin Jeong, MD, Myung-Whun Sung, MD, PhD, Kwang Hyun Kim, MD, PhD
Introduction: There are several technical challenges in using transcriptome data to model patient conditions. We aimed to evaluate the feasibility of epigenetic profiles combined with RNA expression profile for predicting the metastasis of early oral cancers.
Method: The genomic data of the following 2 groups from the head and neck cancer cohort of Seoul National University and Cancer Genome Atlas (TCGA) data were compared: (1) N0 group, T1/2 and N0, and (2) N+ group, T1/2 and N+ of oral cancers. mRNA sequencing and whole-genome bisulfide sequencing were performed to analyze the gene expression and methylation profile. By epigenomic deconvolution using the public reference methylation profile, cell type–specific gene expression profiles were analyzed. Proportion of cell types and the gene expression profile of cancer cells of the N0 and N+ groups were compared, and the correlation between methylation profile and gene expression of each group was analyzed.
Results: In overall samples, unsupervised estimation by epigenomic convolution revealed 5 constituent cell types: cancerous epithelial cell 1, cancerous epithelial cell 2, normal-like epithelial cell, stromal cell, and immune cells. There was no significant difference of cell type proportion between N0 and N+ groups. In cancerous epithelial cell types, extracellular matrix disassembly, epithelial-mesenchymal transition, and cell migration were up-regulated, and those associated with keratinization were down-regulated. When analyzing the pure cancerous epithelial cells, there were 68 up-regulated marker genes associated with hypomethylation and 76 down-regulated genes associated with hypermethylation. Among those, the following genes related to Hippo and Notch signaling pathways showed significantly strong association: Nrf2, Muc5b, Hey1, Fzd7, TGF-beta, Notch, Muc4, Hes6. Immunohistochemical stain revealed the similar pattern with gene expression profile.
Conclusion: Hippo signaling pathway and Notch signaling pathway are associated with lymph node metastasis by epigenetic modification without genetic mutation.
Profound Oral Cancer Disparities in the US-Affiliated Pacific Islands
Kurtis Young, Hannah Bulosan, Janos Baksa, MIM, Yongju Jeong, MS, Lee Buenconsejo-Lum, MD, Andrew Birkeland, MD
Introduction: Oral cavity cancers (OC) in the Pacific Islands (PI) are poorly described despite the disproportionately higher incidence in certain populations. This study attempts to better characterize the incidence, staging, and management of OC in the PI.
Method: A retrospective review was conducted across the US-affiliated Pacific Islands (USAPI) between the years 2007 and 2019. Patient data for individuals with primary head and neck cancers from the Pacific Regional Central Cancer Registry (PRCCR) database were compared with that from the National Cancer Institute’s Surveillance Epidemiology and End Results (SEER). All cohorts were age adjusted to the 2000 US Standard Population. Statistical analyses for categorical variables were performed via χ2 test.
Results: A total of 585 patients with primary head and neck cancers were included from the PRCCR database. The average age was 54.5±12.9 years, and most patients were male (76.8%). Most of these patients had cancers coded to “oral cavity,” in general (62.9%). Of the 368, subsite analysis revealed the proportional incidence of cheek and other mouth cancers was higher in 6 of 9 of the jurisdictions when compared with the United States (P<.001). Anterior tongue cancers were more common in the Northern Mariana Islands compared with the United States (P<.001). Patients in the PI group were less likely to be detected earlier (SEER stage 1) for cancers of the cheek and other mouth (P=.07), anterior tongue (P<.001), and lips (P<.001) when compared with the United States. However, tonsillar and tongue base malignancies occurred at higher incidence proportions in the United States compared with several USAPI states/territories.
Conclusion: Many USAPI populations are burdened with higher incidences of OC with later staging and worse prognosis. Further investigation is recommended to evaluate OC-related outcomes and mortality across the USAPI region. In addition, the association between OC and sociocultural customs such as betel nut chewing should be explored.
Prognosis of Distant Metastatic Sites in Oropharyngeal Squamous Cell Carcinoma
Danielle Victoriano, BA, Daniel O. Kraft, BA, Ryan M. Carey, MD, Robert M. Brody, MD, Karthik Rajasekaran, MD, Jason A. Brant, MD
Introduction: Oropharyngeal squamous cell carcinoma (OPSCC) is an increasingly common disease, with survival closely associated with human papillomavirus (HPV) status. While development of distant metastasis is rare, it bears a devastating prognosis for patients. The objective of this study was to determine survival outcomes based on different sites of distant metastasis.
Method: The National Cancer Database was queried for patients with squamous cell carcinoma of the tonsil, base of tongue, and oropharynx from 2004 to 2015. Only patients presenting initially with distant metastasis were included. Patients with more than 1 primary malignancy, missing mortality data, and incomplete or inconsistent staging were excluded.
Results: The query found 746 patients who presented with distant metastatic tumors with 411 having HPV-positive disease. The most common sites of distant metastasis were lung (49%), bone (18%), and liver (6%). In Cox multivariable analysis, distant metastasis to lung showed improved survival among all patients (hazard ratio [HR] 0.75; 95% CI, 0.59-0.94; P=.01); this difference disappeared when stratified by HPV status. Among HPV-negative patients, brain metastases were associated with poorer survival (HR 15.6; 95% CI, 3.22-75.7; P<.01).
Conclusion: Among patients with OPSCC presenting with distant metastases, the most common sites were lung, bone, and liver. For all patients, metastases to lung were associated with improved survival. For HPV-negative patients, metastases to brain were associated with poor survival. No other significant differences in survival based on site of metastasis stratified by HPV status could be identified. Further work is needed to characterize prognostic factors in patients presenting with distant metastatic disease.
Recurrence Patterns of Early-Stage Oral Tongue Squamous Cell Carcinoma
Nicole Crimi, Joo Hyun Kim, Justine Philteos, MD, Elysia M. Grose, MD, Marc Levin, MD, David P. Goldstein, MD, FRCSC, MSc
Introduction: Survival rates of oral squamous cell carcinoma (OSCC) are significantly reduced by local or locoregional recurrence. However, current guidelines aiming to detect and treat recurrences early on are not specific to oral tongue squamous cell carcinoma (OTSCC), the most common type of OSCC. The purpose of this systematic review was to identify the patterns of local and locoregional recurrence in patients who received surgical treatment of curative intent for early-stage OTSCC.
Method: In May 2021, online databases including MEDLINE, Embase, Scopus, and Cochrane were searched for studies that discuss the recurrence of early-stage OTSCC treated surgically with curative intent. All titles, abstracts, and full texts were reviewed independently by 2 authors for eligibility and inclusion in this systematic review. Data pertaining to study demographics and time to local or locoregional recurrence for patients undergoing tumor resection alone vs patients with elective neck dissection (END) were extracted from the included studies.
Results: The database search identified 49 studies assessing the local and locoregional recurrence of OTSCC based on the experiences of 5968 patients. During follow-up, 13.8% of patients had local recurrence and 23.1% of patients had locoregional recurrence. Local recurrence occurred in 16.4% of END patients and 9.2% of patients undergoing surgical resection alone (P=.0042). The mean time-to-detection of local recurrence was 25.26 and 23.85 months in the END and surgical resection groups, respectively. Locoregional recurrence occurred in 17.5% of END patients and 29.6% of patients undergoing surgical resection alone (P=.0006), after a mean of 18.15 and 8.3 months, respectively.
Conclusion: Based on the findings of this study, patients undergoing END have fewer events of locoregional recurrence when compared with patients who only undergo primary tumor resection for early-stage OTSCC. The findings also suggest a greater time to locoregional recurrence in END patients. The information within this study will be valuable in guiding follow-up recommendations for OTSCC.
The Re-excision Rate of Head and Neck Cutaneous Melanoma: Is a 2-Staged Procedure Necessary?
Bailey Minehart, MD, Tyler J. McElwee, MD, Carley Boyce, Ashley C. Mays, MD
Introduction: The purpose of our study is to assess the re-excision rates of head and neck cutaneous melanoma within the Louisiana State University institution and determine if staged cutaneous melanoma excision outweighs the anesthesia risks, hospital cost, and scheduling burden of a second procedure.
Method: The study is a retrospective review of subjects who underwent excision of head and neck cutaneous melanoma from January 2014 to July 2020. The subjects were collected from Our Lady of the Lake in Baton Rouge, Louisiana, and University Medical Center in New Orleans, Louisiana. Demographics including age, race, and gender were collected as well as biopsy type, original T stage, Breslow depth, Clark level, mitotic rate, microsatellites, peripheral and margin involvement, deep margin involvement, final TNM stage, margin size, need for sentinel lymph node biopsy, need for parotidectomy, need for neck dissection, need immunotherapy, reconstruction type, need for re-excision of positive margins, follow-up dates, and recurrence.
Results: Between 2014 and 2020, a total of 219 cases were found to meet the inclusion criteria. Of the 219 cases, approximately 41 cases required re-excision (18.7%). Of the 41 cases that required re-excision of margins, only 1 case was not reconstructed at the time of first excision. Most cases were closed by adjacent tissue transfer (n=16). Most re-excisions were performed for T1 melanomas (n=10), followed by Tis (carcinoma in situ; n=8). None of the subjects who required a second excision had a recurrence of melanoma at the end date of the study.
Conclusion: Given that only 18.7% of head and neck cutaneous melanoma required additional excision for positive margins and that the overwhelming majority of these cases were reconstructed at the time of first excision, we recommend single-stage head and neck cutaneous melanoma excision. This aids in decreasing the cost of operation room time and anesthesia and burden of duplicate preoperative testing. Implementing single-stage excision also frees surgeons from a scheduled second procedure that greatly benefits high-volume institutions.
Retrospective Review of Interventional Sialendoscopy- and Sialendoscopy-Assisted Procedures: 5-Year Experience
Juan Yanez-Siller, MD, MPH, Somasumdaram Subramaniam, MD, Guillermo Maza Malave, MD, Ricardo L. Carrau, MD, MBA
Introduction: Sialendoscopy is increasingly used as a preferred surgical tool to manage salivary gland disease, primarily related to sialolithiasis and sialadenitis. Various authors have published their data regarding this evolving tool. We add our experience to the published data, providing important information regarding outcomes related to this procedure.
Method: A retrospective chart review was performed of 194 adult patients with salivary gland disorders who underwent interventional sialendoscopy between January 1, 2011, and December 31, 2016, at our institution. Demographic and clinical data, location of disease, preoperative imaging findings, sialendoscopy findings, outcomes, and complications were evaluated.
Results: Sialendoscopy was performed in a total of 194 patients for 241 cases in 70 males and 124 females (median age=49.5 years, range 12–85 years) with 323 ducts (201 parotid 62.1% and 122 submandibular 37.9%). The most frequent indications for sialendoscopy were significant gland swelling and pain (in 93.0% and 69.9%, respectively, of cases at presentation). Salivary stones (≥1) were encountered intraoperatively in 102/323 (31.6%) ducts. Of these, 31/102 (30.4%) were fully addressed via a purely sialendoscopy, 11/102 (10.8%) via a combined approach (sialodochotomy to enter duct followed by endoscopy), whereas a hybrid intervention (endoscopy plus either transfacial or transoral dissection) was performed in 44 (42.2%). Stone removal was unsuccessful in 6/102 (5.9%). Gland preservation was possible in all cases. Stenosis was present in 209/323 (64.7%) ducts. Preoperative imaging results were confirmed by sialendoscopy in 181 (92.8%) patients. Complete, partial, and no relief of symptoms were seen in 213/323 (65.6%), 68/323 (21.1%), and 43/323 (13.3%) of addressed glands, respectively. Most common intraoperative complication was duct rupture (2.1%).
Conclusion: Sialendoscopy is an effective method to diagnose and treat salivary gland disorders in adults. Apart from relieving patients’ symptoms in most cases, it circumvents the need for gland removal, which may otherwise be indicated.
Retrospective Review of Interventional Sialendoscopy in Patients With Radioiodine-Induced Delayed Sialadenitis
Juan Yanez-Siller, MD, MPH, Somasumdaram Subramaniam, MD, Guillermo Maza Malave, MD, Ricardo L. Carrau, MD, MBA
Introduction: Radioiodine therapy (RAI) is an established treatment for thyroid carcinoma in selected cases. Delayed sialadenitis is a known complication of RAI. Sialendoscopy is an effective technique for the diagnosis and treatment of obstructive and nonneoplastic salivary gland disorders.
Method: A retrospective chart review was performed on 21 adult patients with salivary gland disorders and a history of RAI exposure and delayed sialadenitis who underwent interventional sialendoscopy between January 1, 2011, and December 31, 2016, at our institution. Demographic and clinical data were evaluated.
Results: Sialoendoscopy was performed by a single surgeon in 21 patients (1 man and 20 women; median age=45 years, range 20–73 years) with a history of RAI exposure (28 operative cases, 43 glands/ducts [27 parotid and 16 submandibular]). All patients developed sialadenitis following RAI. None had a history of sialadenitis prior to RAI. The average time from RAI to sialendoscopy was 19.8 months (SD±15.3). Significant pain (92.9% of cases) was the most common indication for sialendoscopy, followed by significant swelling (78.6% of operative cases). A single stone was encountered in a single patient (2.3% of ducts). Forty-one of the addressed ducts (95.3%) were affected by stenosis. Dilation was successful in 34/41 (83%) of stenosed ducts while unsuccessful in 7/41 (17%) ducts. A total of 14 stents were placed (32.6% of ducts), and no gland excisions were performed. Complete or partial resolution of symptoms was achieved in 25/43 (55.8%) and 8/43 (18.6%) of the addressed glands, respectively, while no symptom resolution occurred in 10/43 (23.7%) of the ducts that were addressed. Duct rupture was the most common intraoperative complication (2/43; 4.7%). Gland preservation was possible in all cases.
Conclusion: Sialendoscopy is an effective method for diagnosis and treatment of symptoms in most cases of RAI-induced delayed sialadenitis.
Retrospective Review of Interventional Sialendoscopy Patients With Radiation Therapy–Associated Sialadenitis
Juan Yanez-Siller, MD, MPH, Somasumdaram Subramaniam, MD, Guillermo Maza Malave, MD, Ricardo L. Carrau, MD, MBA
Introduction: Disorders of the salivary glands are a known sequelae of radiation therapy (RT) used for the treatment of head and neck cancer. Sialendoscopy is an established method to diagnose and treat obstructive and nonneoplastic salivary gland disorders.
Method: A retrospective chart review was performed on 194 adult patients with salivary gland disorders who underwent interventional sialendoscopy between January 1, 2011, and December 31, 2016, at our institution. Demographic and clinical data, including age, sex, duration of symptoms, outcomes, and complications, were evaluated.
Results: Sialendoscopy was performed by a single surgeon on 5 adult patients (1 man and 4 women; median age 40.5 years, range 26–63 years) with prior history of RT and major salivary gland dysfunction for a total of 5 operative procedures and on total of 7 major salivary gland ducts (2 parotid, 5 submandibular). Four patients had received RT specifically for head and neck cancer, and 1 patient had undergone RT for breast cancer in the early 1990s. All patients developed salivary gland dysfunction post-RT. Significant swelling was present in 5/7 (71.5%) glands, and pain was present in 4/7 (57.1%) of the glands addressed. The average duration of symptoms prior to sialendoscopy was 2.3 months. Sialolithiasis was encountered in 2/7 (28.6%) ducts and stenosis in 6/7 (85.7%) ducts. Dilation was performed in all 6 stenosed ducts. Gland preservation was possible in 100% of cases. Complete resolution of symptoms after sialendoscopy was achieved for all 7 (100%) addressed glands at last follow-up (mean=5.2 months, range 1–31 months). The most frequent complication was persistence of swelling for at least 1 week following surgery.
Conclusion: Sialendoscopy may be an effective option for diagnosis and treatment of symptoms of RT-induced salivary gland disease.
Retrospective Review of Sialendoscopy in Sjögren Syndrome With Major Salivary Gland Dysfunction
Juan Yanez-Siller, MD, MPH, Somasumdaram Subramaniam, MD, Guillermo Maza Malave, MD, Ricardo L. Carrau, MD, MBA
Introduction: Sialendoscopy is an established method to diagnose and treat obstructive and nonneoplastic salivary gland disorders and may be an option for treatment of patients with Sjögren syndrome (SS).
Method: Retrospective chart review was performed on 12 adult patients with major salivary gland dysfunction and history of SS who underwent interventional sialendoscopy between January 1, 2011, and December 31, 2016, at our institution. Demographic and clinical data, including age, sex, sialendoscopy findings, outcomes, and complications of sialendoscopy, were evaluated.
Results: Sialendoscopy was performed on 12 adult patients (2 men and 10 women; median age 39.5, range 24–71 years) on a total of 33 major salivary gland ducts (22 parotid, 11 submandibular) in 18 operative procedures. Six patients (50%) had biopsy-confirmed SS and 6 patients (50%) had suspected SS. Significant pain was present in 24/33 (72.7%) and significant swelling in 9/33 (27.3%) of glands at presentation. The average duration of symptoms prior to sialendoscopy was 31.8 months (median: 13 months). Sialolithiasis was encountered in 3/33 while ductal stenosis occurred in 27/33 of affected glands. Two-thirds (66.7%) of sialolith affected ducts were addressed with pure sialendoscopy; one-third (33.3%) required intraoral duct dissection for stone delivery. Ductal dilation was performed in 30/33 of the addressed glands, with 22/33 and 4/33 of these being fully or partially successful, respectively. Complete resolution of sialadenitis signs and symptoms occurred in 25/33 glands (78.1%), while 3/33 (9.1%) saw partial relief and 5/33 (15.2%) no relief of sialadenitis signs and symptoms at a mean follow-up of 9.1 months.
Conclusion: Sialendoscopy is effective in the treatment of major salivary gland sialadenitis in patients with SS.
Risk of Occult Contralateral Neck Metastasis in Early-Stage HPV-Related Cancer of the Base of the Tongue
Austin C. Cao, BA, Erin R. Cohen, MD, Robert M. Brody, MD, Karthik Rajasekaran, MD
Introduction: HPV-related oropharyngeal squamous cell carcinoma of the base of the tongue (BOT OPSCC) has a high rate of contralateral nodal metastasis and is frequently treated with bilateral neck dissection or adjuvant radiation. BOT OPSCC patients with low-risk cancer staging have been discussed as candidates for contralateral neck treatment de-intensification. The objectives of this study are to (1) determine the rate of occult contralateral nodal positivity in ipsilateral pN0-1 disease and (2) describe recurrence outcomes in pN0-1 patients who do not undergo contralateral neck treatment.
Method: A retrospective review was performed on patients with HPV-related pT1-2 BOT OPSCC with (1) no clinical evidence of contralateral neck metastasis, (2) pN0 or pN1 (AJCC seventh ed.) following ipsilateral neck dissection, and (3) treatment with primary transoral robotic surgery (TORS) from March 2007 to March 2021. Data collected included patient demographics, histopathology, and surveillance. Kaplan-Meier analysis and Fisher exact test were used to compare cohorts.
Results: Seventy-six patients met selection criteria, including 37 pN0 and 39 pN1. Of these patients, 29% (22/76) underwent elective contralateral neck dissection. The rate of occult contralateral neck metastasis was 0% (0/22) in patients who underwent contralateral neck dissection. Of the patients who did not undergo contralateral neck dissection (29 pN0, 25 pN1), 35% (19/54) received adjuvant radiation and 65% (35/54) were observed after primary surgical treatment. Progression-free survival at 1 year after treatment was 95% (18/19) in adjuvant therapy patients and 94% (33/35) in those under observation only.
Conclusion: HPV-related pT1-2 BOT OPSCC patients with pN0-1 disease have low rates of pathologic contralateral nodal positivity. Unilateral neck management may be considered in these patients to reduce toxicity related to contralateral neck treatment.
Sarcopenia Versus Overall Survival Among Oropharyngeal Cancer Patients Undergoing Radiation Therapy
Andres Frias, Anne Rajkumar, JonCarlos Anderson, Jan Niec, Kaleb Darrow, Christien Kluwe
Introduction: There is evidence that suggests oropharyngeal (ie, base of tongue, tonsillar) cancer patients have among the most significantly compromised swallowing function relative to other head and neck cancers. To our knowledge, our study will be the first regarding the relationship between sarcopenia, radiation therapy, and survival outcomes in oropharyngeal head and neck cancer patients.
Method: We retrospectively enrolled 172 patients with oropharyngeal cancer who underwent definitive radiotherapy (RT)±chemotherapy at an academic center from 2013 to 2019. We measured bilateral temporalis muscle thickness (TMT) on computed tomography imaging used for radiation plan design. Sarcopenic patients were defined by a TMT ≤25th percentile. We measured pre-RT neutrophil-to-lymphocyte ratio (NLR), with high NLR defined as ≥75th percentile. Patients were subdivided into 4 body mass index (BMI) categories: underweight (BMI: <18), normal weight (BMI: 18.5-25), overweight (BMI: 25-30), and obese (BMI: >30). We recorded overall survival, recurrence, and percutaneous endoscopic gastrostomy or nasogastric tube placement during treatment.
Results: Among sarcopenic patients, 2.3%, 30%, 42%, and 19% were underweight, normal weight, and obese, respectively. Among nonsarcopenic patients, 1.6%, 16%, 43%, and 39% were underweight, normal weight, overweight, and obese, respectively (P=.063). No differences were found between patients with vs without sarcopenia with respect to smoking history, p16 status, primary tumor site, chemotherapy exposure, tumor stage, or NLR. At 24-month follow-up, sarcopenia did not significantly impact overall survival (OS; 92.6% vs 91.1%, P=.790). However, age was an independent predictor of poorer OS (hazard ratio [HR], 1.1; 95% CI, 1-1.1; P=.0037), whereas greater BMI (HR, 0.57; 95% CI, 0.36-0.9; P=.015) predicted improved OS.
Conclusion: Pre-RT sarcopenia and NLR were not associated with survival and recurrence outcomes. However, pre-RT BMI was found to be of significant prognostic importance. This highlights the value of early and aggressive nutritional support for oropharyngeal cancer patients undergoing head and neck RT.
Selective Neurectomy for Postfacial Paralysis Synkinesis: A Systematic Review
Emily YiQin Cheng, Amirpouyan Namavarian, MD, Hedyeh Ziai, MD, Danny J. Enepekides, MD, FRCSC, MPH
Introduction: Selective neurectomy (SN) has been suggested as an effective alternative treatment for postfacial paralysis synkinesis (PFPS). This study aims to systematically review SN in managing PFPS.
Method: MEDLINE, Ovid Embase, PubMed, Web of Science, and CINAHL databases were searched. Original studies evaluating outcomes in patients undergoing SN for PFPS were included. Data including age, sex, PFPS etiology, grade, operative details (neurectomy, adjuvant procedure) and postoperative outcomes and complications were extracted and summarized.
Results: Database search yielded 1967 studies; 108 underwent full-text screening. A total of 10 studies with 344 patients (mean age 48.0±6.5 years; 18.3% men) were included. Three studies used neurectomy as the sole surgical treatment. The remaining 7 studies used adjuvant procedures including facial reanimation procedures using nerve-to-nerve transfer (6%), nerve-to-muscle (2%), and free muscle transplantation (24%); other interventions (69%) included myectomy, rhytidectomy, and blepharoplasty. Of the 5 studies (n=164) that measured botulinum toxin (BTX) use postoperatively, 72% had BTX cessation, while 28% (n=46/164) showed a reduction in BTX use by 38% to 50%. Three studies used the Sunnybrook Facial Grading System and found synkinesis improved postoperatively from moderate/severe to mild/none category. Similarly, 2 studies using the eFACE synkinesis score found significant improvements postoperatively from 76 to 89 (P<.001; n=46) and 52.7 to 82 (P<.001; n=7), respectively. A total of 133 complications were reported, most commonly being upper lip contracture (33%), uneven cheek surface (14%), lagophthalmos (8%), and temporary oral incompetence (8%).
Conclusion: SN improved synkinesis outcomes in patients with PFPS with a low complication rate. It may be considered for patients with PFPS, particularly those with refractory PFPS and those unable to undergo long-term management with BTX treatment. Further larger studies are required to evaluate the long-term efficacy.
Sentinel Lymph Node Biopsy for Orbital Adnexal Melanoma
Sana H. Siddiqui, MD, Zachary Elliott, Alexander Duffy, MD, Michele Fiorella, MS, Andrew Corr, Joseph Curry, MD
Introduction: Limited literature exists on the positivity and false-negative rates of sentinel lymph node biopsy (SLNB) in ocular adnexal melanoma. The positivity rate is reported between 11% and 20%. The aim of this study is to describe the findings of SLNB in this population at our institution.
Method: In this retrospective review, all cases of SLNB in patients with ocular adnexa melanoma at 1 institution from 2015 to 2021 were included. SLNB was performed following tumor resection. Positivity rate was determined, and tumor features were examined.
Results: A total of 18 patients underwent SLNB between 2015 and 2021. The average length of follow-up was 20.5 months. The most common primary site was conjunctiva (77.8%) followed by eyelid (22.2%). Primary tumors were staged T1/T2 in 5 patients (45.5%) and T3/T4 in 6 patients (54.5%). No patients had nodal or metastatic disease at the time of initial staging. Of the patients, 27.8% presented after a recurrence at the primary site. Lymphovascular invasion was positive in 12.5% of tumors (n=2) and ulceration present in 50% (n=5). Most patients had mitotic figures reported on initial pathology. The average number of nodes taken in SLNB was 3.6, with the maximum at 13 nodes. The positivity rate was 5.6% (n=1). In follow-up, recurrence at the primary site was noted in 16.7% of cases, but no patients clinically developed nodal or metastatic disease.
Conclusion: The positivity rate in our cohort was 5.6%, lower than what has been previously reported; however, the indications for SLNB in ocular melanomas remain to be defined with high-level evidence, especially in the setting of locally recurrent disease. Presence of occult nodal disease appears to be rare in this population.
Sialendoscopy in Major Salivary Glands Disease: A Methodological Quality Analysis of Published Systematic Reviews
Lucas Kallás Silva, Maria Fernanda Dias Azevedo, Fátima Cristina Mendes de Matos, MD, PhD, Silvia Picado Petrarrolha, MD, Rogério Aparecido Dedivitis, MD, PhD, Marco Aurélio Vamondes Kulcsar, MD, PhD, Leandro Luongo Matos, MD, PhD
Introduction: Many systematic reviews and meta-analyses have been conducted in sialendoscopy for treatment of major salivary glands disease, with different populations and outcomes. With a large heterogeneity of results, it is important to define which studies should be used for clinical guidance. With the present study, we intend to assess the methodological quality of systematic reviews and meta-analyses conducted in sialendoscopy for treatment of lithiasic and alithiasic major salivary glands disease in adults, children, and adolescents.
Method: This is a methodological quality assessment of systematic reviews and meta-analyses. We conducted a comprehensive systematic literature search in 4 databases. We included systematic reviews and meta-analyses of lithiasic and alithiasic obstructive salivary gland diseases (OSGDs). After study screening, the selected studies underwent data extraction for study characteristics and results. We assessed the methodological quality of the included studies using the AMSTAR 2 (a critical appraisal tool to assess systematic reviews and meta-analyses) tool.
Results: We identified 13 systematic reviews and meta-analyses of patients who underwent therapeutic sialendoscopy for treatment of major salivary gland disease. Nine were in adults, and 4 were in children and adolescents. Studies evaluated a large range of outcomes, with important clinical and statistical heterogeneity. Most studies evaluated only retrospective data with low quality and high risk of bias. Assessment of methodological quality of studies showed critically low quality of evidence in all systematic reviews and meta-analyses.
Conclusion: The majority of the studies demonstrates the efficacy of sialendoscopy in the treatment of different diseases of the major salivary glands. However, all systematic reviews and meta-analyses conducted up to now have presented critically low quality of evidence, with high clinical and statistical heterogeneity and inclusion of mostly retrospective study of high risk of bias.
Site-Specific and Pathologic Predictors of Occult Metastasis in Head and Neck Squamous Cell Carcinoma
Benjamin Liba, MD, Jeffrey C. Liu, MD
Introduction: Cervical lymph node metastases are among the most important prognostic factors in head and neck squamous cell carcinoma (HNSCC) outcomes. To our knowledge, no large database studies including all head and neck subsites together have evaluated parameters predictive of occult metastasis (OM) in HNSCC.
Method: A retrospective review of the National Cancer Database was performed. Patients with cN0 HNSCC of the oral cavity, oropharynx, larynx, and hypopharynx managed with primary surgery and neck dissection from 2009 to 2019 were included. Patients with distant metastases were excluded. Oropharynx was separated by human papillomavirus (HPV) status.
Results: We identified 27,526 patients with cN0 necks who underwent neck dissection and had pathologic data available for review. Of patients, 7393 (26.9%) were found to have occult lymph node metastasis. Early-stage tumors (T1/T2) were found to have OM at a rate of 24.5% compared with late stage (T3/T4) with a rate of 31.6% (odds ratio [OR] 1.42; 95% CI, 1.34–1.50; P<.001). Lymphovascular invasion (LVI) had a strong association with the presence of OM (OR 5.28; 4.9–5.6; P<.001). Histologic grade was also associated with OM (OR 1.85; 1.73–1.98; P<.001). In a multivariate analysis of early/late stage, LVI, and grade, all these remained significant. Occult metastasis rates differed by subsite. When compared with oral cavity (OM rate 25%), a statistically significant increased rate of OM was noted only for HPV-positive oropharyngeal squamous cell carcinoma (SCC), with a reported OM rate of 40% (OR 1.97; 1.78–2.18; P<.001) compared with oral cavity. Glottic and supraglottic SCC were not significantly different than oral cavity with rates of 23% and 30%, respectively. Glottic cancers specifically were significantly lower than oral cavity (OR 0.61; 0.53–0.71; P<.001).
Conclusion: Occult lymph node metastasis is a common occurrence in HNSCC. LVI and advanced T stage predict an increased likelihood of OM. These data can be used to better aid in the decision-making process for HNSCC and better personalize treatment.
Socioeconomic Impact on Voice and Speech Rehabilitation After Laryngectomy
Luke Stanisce, MD, Mick McGlone, Yekaterina Koshkareva, MD, Ian Lawrence, MS, CCC-SLP, Gregory J. Kubicek, MD, Nadir Ahmad, MD
Introduction: Vocal and speech rehabilitation after laryngectomy significantly affects patient quality of life. Prosthetic voice restoration provides optimal outcomes; however, the long-term maintenance of these devices carries considerable financial costs that are not universally covered by insurance. This investigation aimed to analyze associations between socioeconomic factors and differences in postlaryngectomy speech rehabilitation outcomes.
Method: We conducted a retrospective review of a prospectively maintained database capturing patients undergoing total laryngectomy at our single-center, academic institution from May 2014 to October 2021. Differences in vocal and speech rehabilitation outcomes, including the incidence of indwelling voice prostheses (VP) placement, were compared among various patient-reported demographic factors. Wald χ2, Fisher exact, and Wilcoxon rank sum testing were used to estimate differences.
Results: Seventy patients were included in the study cohort. Forty-two (60%) underwent indwelling VP placement (39 primary). Of subjects, 88% with self-reported annual household incomes greater than $50k elected for VPs compared with only 38% with incomes less than $50k/year (P<.001). All patients with private primary insurance elected for VP placement compared with 67% with Medicare, 44% with Medicaid, and 25% with no insurance (P=.001). Twenty-one patients expressed financial concerns regarding VP maintenance during prelaryngectomy speech and language pathology counseling: 80% had annual incomes less than $50k (P=.001), and none had private insurance (P=.01). After censoring for lost to follow-up, 11 patents were unable to pay for supplies within the first year of treatment, with significant differences among insurance status (P=.013) and household incomes (P≤.001).
Conclusion: Disparities in vocal and speech rehabilitation after laryngectomy may disproportionally affect underserved patients.
Spondylodiscitis and Spinal Epidural Abscess After Transoral Robotic Surgery Radical Tonsillectomy
Jacquelyn K. Callander, MD, Aaron J. Clark, MD, PhD, William Dillon, MD, William R. Ryan, MD
Introduction: While the range of typical complications after transoral robotic surgery (TORS) is well reported in the literature, we describe a rare case of spondylodiscitis and spinal abscess treated successfully with computed tomography (CT)–guided needle aspiration and antibiotics.
Method: A 65-year-old man with a cT1N1M0 left tonsil human papillomavirus–associated squamous cell carcinoma underwent a TORS-assisted left radical tonsillectomy, left selective neck dissection and excision of a single retropharyngeal lymph node seen on CT, and ligation of left facial and lingual arteries. Surgical pathology showed negative margins, a positive retropharyngeal lymph node, and 3/32 positive neck lymph nodes without extranodal extension. Four weeks postoperatively, a CT neck demonstrated a C2–C3 epidural abscess. Magnetic resonance imaging (MRI) showed prevertebral phlegmon, C2–3 spondylodiscitis, and epidural abscess spanning C1–C3. His neurologic examination was intact. A small fistulous tract between the oropharynx the prevertebral site of the infection was identified on MRI.
Results: An anterior neck approach for drainage with cervical discectomy, debridement, and fusion was considered, as is customary for spinal epidural abscesses. Given the mucosal surgical defect would likely expand to a more extensive pharyngospinal fistula, this approach was thought to be unfavorable. Instead, a CT-guided aspiration of the abscess was performed followed by a culture-driven 6-week course of intravenous (IV) antibiotics with clinical improvement on MRI 16 weeks later.
Conclusion: On review of the literature, we identified 1 case report and 1 series of 7 cases of spondylodiscitis with and without abscess after TORS radical tonsillectomy, the latter of which also reported 43% mortality. Studies have suggested CT-guided diagnostic fine needle aspiration biopsy to guide antibiotic choice with open surgical drainage or debridement of an epidural abscess in the setting of clinical signs of neural compression. We propose therapeutic CT-guided drainage of epidural abscess even in the absence of clinical signs of compression, followed by culture-directed IV antibiosis.
Tinnitus Changes After Hearing Implants
Piotr Skarzynski, MD, PhD, MSc, Danuta Raj-Koziak, Henryk Skarżyński, Justyna Kutyba, MSc, Katarzyna Cywka, Elżbieta WŁodarczyk
Introduction: Surgical interventions aimed at implanting a hearing implant are one of the most effective methods of improving hearing. They are used by people with hearing loss for whom conventional hearing aids do not bring any results or cannot be used. Among this group of patients, in addition to hearing loss, there is also tinnitus, which additionally impedes communication and reduces the quality of life. Research conducted at the Institute of Physiology and Pathology of Hearing on various groups of implanted patients showed that the use of an audio processor not only improved hearing but also significantly reduced the perceived nuisance caused by the presence of tinnitus. This study aims to present the results obtained from the research on the impact of various types of hearing implants on the annoyance of tinnitus.
Method: The study involved 1100 adult patients who had been implanted with 1 of 3 types of implants: cochlear implant, Vibrant Soundbridge, or Bonebridge. In addition, these subjects had to have tinnitus. Tinnitus annoyance was assessed using the questionnaires Tinnitus Functional Index and Tinnitus Handicap Inventory. Tinnitus annoyance was monitored before and 3 months after implantation.
Results: Based on the results of both questionnaires, a significant reduction in tinnitus annoyance was observed after hearing implant placement in all groups of patients. Tinnitus annoyance decreased from catastrophic and severe tinnitus to moderate and light tinnitus.
Conclusion: Hearing implants are the hope of thousands of patients to improve communication abilities and quality of life. Our study has shown that an additional benefit of implantation can also be a reduction in tinnitus annoyance and, in individual cases, a complete resolution of the condition.
Tongue Base Palpation Practice Among Oral Health Care Professionals: A Cross-sectional Survey
Angelica Nieves-Rivera, MD, Krystal Kan, MD, Steven Tucker, DMD, Michael Johnson, DMD, Heather A. Edwards, MD
Introduction: Many oral cancers are detected by dentistry professionals during oral cancer screening (OCS) examinations. However, it is unknown what proportion of oral health professionals (OHPs) include assessment of the oropharynx in routine cancer screening exams. Palpation of the tongue base is a simple technique that can detect early oropharyngeal cancers prior to the development of symptoms.
Method: An anonymous online 9-item survey was distributed (January–June 2021) to dentists, oral and maxillofacial surgeons (OMFSs), and otolaryngologists with practices in Massachusetts and Connecticut through the mailing lists of professional societies. The survey assessed providers’ attitudes and practice patterns regarding OCS. Responses about cancer screening clinical practices, use of adjuncts, and attitudes toward OCS usefulness to detect asymptomatic malignant lesions were compared using χ2 tests. Correlations between palpation of the tongue base and digital palpation of 12 other intra- and extraoral anatomical sites were computed. For all questions, statistically significant levels were established at P<.050.
Results: A total of 171 responses were collected (dentists [n=91], OMFSs [n=42], and otolaryngologists [n=38]). Most respondents reported performing a routine OCS exam twice a year (41%), rather than annually (6.4%). Tongue base palpation was performed as part of a routine cancer screening exam by 55% of otolaryngologists, 34% of dentists, and 29% of OMFSs (P=.030). Providers who palpated the tongue base were also more likely to use palpation as an exam technique in the tonsils (r=0.52; 95% CI, 0.40–0.62; P<.001), dorsal tongue (r=0.36; 95% CI, 0.23–0.49; P=.001), lateral tongue borders (r=0.31; 95% CI, 0.17–0.44; P<.001), and soft palate (r=.31; 95% CI, 0.17–0.44; P<.001).
Conclusion: While tongue base palpation can detect oropharyngeal cancers in a presymptomatic stage, it is underutilized during routine cancer screening exams. Considering the rising incidence of oropharyngeal cancer, tongue base palpation should be established as a routine part of cancer screening by OHPs.
Total Laryngectomy for Management of Anaplastic Thyroid Carcinoma
Alexandra Rose, MBBS, Anne C. Kane, MD, Gina D. Jefferson, MD, Kacie R. Oglesby, MD
Introduction: Anaplastic thyroid carcinoma (ATC) is a highly aggressive disease with disease-specific mortality near 100%. Median survival ranges from 3 to 7 months.
Method: Data were obtained via electronic medical records and a literature search performed on anaplastic carcinoma. A 71-year-old man with a history of untreated papillary thyroid carcinoma presented intubated secondary to airway obstruction from an enlarging left neck mass. Computed tomography (CT) imaging demonstrated a 6.1-cm thyroid mass involving the larynx, left thyroid, and cricoid cartilage, which was deemed surgically resectable with total thyroidectomy and total laryngectomy. CT imaging of the chest revealed bilateral pulmonary lesions that were biopsied as metastatic anaplastic and papillary thyroid carcinoma. Final pathology revealed anaplastic carcinoma arising from papillary thyroid carcinoma of the left thyroid with thyroid and cricoid cartilage invasion. Final staging was pT4bN0M1 (stage IVC) ATC with confirmed BRAFV600 mutation. Recommendations by the Multidisciplinary Head and Neck Tumor Symposium were for the patient to receive adjuvant chemotherapy and radiation.
Results: Although the 2021 American Thyroid Association guidelines for management of patients with ATC do not recommend surgery for stage IVC disease, palliative total thyroidectomy and laryngectomy were necessary to secure this patient’s airway. With R1 resection, the patient was able to be discharged home and receive combination external beam radiation and immunotherapy. Tracheostomy tube placement was risky and unsafe secondary to risk of hemorrhage and risk of dislodgement. Total laryngectomy was surgically feasible and allowed resection of disease and a safe airway. The patient was ultimately able to live 9 months postresection exceeding the median survival for patients diagnosed with anaplastic carcinoma.
Conclusion: Management of ATC is often a difficult challenge regarding airway management. While total laryngectomy is not the formal recommendation, our patient demonstrates that in certain circumstances this surgery may result in quality of life extension.
Transfer Status and Free Flap Surgery Postoperative Outcomes
Mehdi S. Lemdani, BA, David A. Cohen, BA, Hannaan S. Choudhry, BA, Sudeepti Vedula, BS, Prayag S. Patel, MD, Jean Anderson Eloy, MD
Introduction: Patients transferred in from different entry points of care typically have complex comorbidities and complications that require higher level of care and management. However, the impact of patient transfer has not been examined in free flap surgery outcomes. Our study seeks to understand the impact of transfer status on postoperative outcomes in patient undergoing free flap surgery.
Method: A retrospective database review was performed on the National Surgical Quality Improvement Program database by querying for patients with known transfer status who underwent free flap surgery performed by an otolaryngologist between 2011 and 2018. Multivariable analyses were conducted to investigate the association between transfer status and postoperative comorbidities and complications.
Results: Included were 2074 patients. The mean age was 62.9 years. The majority of patients were White (64.7%), male (81.1%), and nonobese (54.9%). Of patients, 140 (6.8%) were transferred from other health care facilities rather than being directly admitted to the hospital where they underwent free flap surgery. Univariate analysis showed that transferred patients were more likely to experience postoperative deep vein thrombosis (P=.036), sepsis (P=.013), wound disruption (P=.001), reintubation (P<.001), extended ventilator use (P=.010), urinary tract infection (P<.001), blood transfusion (P<.001), and any complication (P<.001). Multivariable analysis associated transfer status with surgical complication (odds ratio [OR] 1.466; 95% CI, 1.084-1.982; P=.013) and any complication (OR 1.439; 95% CI, 1.072-1.931; P=.015).
Conclusion: This study found an association between transfer status and postoperative surgical complication or any complication. Transferred patients undergoing free flap surgery may be at increased risk for complications, though results suggest postoperative mortality is not a significant concern.
Treatment Delay and Its Impact on Human Papillomavirus–Positive and Negative Oropharyngeal Squamous Cell Carcinoma
Elaine Martin, MD, Milind Vasudev, Yarah M. Haidar, MD
Introduction: Treatment delay, including diagnosis to treatment initiation (DTI), surgery to radiotherapy initiation (SRT), and total treatment time (TTT), have been associated with worse overall survival in head and neck squamous cell carcinoma. However, data on the impact of treatment delay in human papillomavirus (HPV)–positive(+) and negative(–) oropharyngeal squamous cell carcinoma (OPSCC) are mixed, and further study is required.
Method: Patients >18 years old with squamous cell carcinoma of the oropharynx with known HPV status who were treated surgically were identified from the 2010–2017 National Cancer Database. This retrospective cohort study analyzes the effect of treatment delay as well as other relevant factors on overall survival of patients with HPV+ and HPV– OPSCC.
Results: A total of 1643 patients with HPV+ OPSCC and 391 patients with HPV− OPSCC were included in this study. Tumor size >2 cm and lymphovascular invasion were significantly associated with worse overall survival in both HPV+ and HPV− groups (all, P<.05). Involvement of >4 lymph nodes was associated with worse survival in HPV− patients (hazard ratio [HR] 2.64, P<.001), but regional lymph node involvement was not significantly associated with worse survival in the HPV+ group (P=.21). Robotic surgery was associated with significantly improved survival in the HPV+ group (HR 0.425, P<.001). On multivariate analysis, diagnosis to treatment initiation was not associated with overall survival. However, increasing interval between surgery and initiation of radiotherapy was associated with decreased overall survival in the HPV− group (HR 1.71 for 42–66 days, P=.021; HR 2.69. for ≥67 days, P<.0001).
Conclusion: An increased interval between surgery and initiation of radiotherapy was associated with decreased overall survival in the HPV− group. Treatment delay, as measured by diagnosis to treatment initiation and surgery to radiation initiation, does not appear to be associated with overall survival in HPV+ OPSCC on multivariate analysis. These findings add to the current understanding of OPSCC and can guide providers in management decisions and patient counseling.
Treatment Outcomes for Recurrent Head and Neck Cancer
Morcos Nakhla, MS, Kelly J. Pettijohn, MD, Hassan Nasser, MD, William Lorentz, Marilene B. Wang, MD
Introduction: Despite high cure rates for early-stage disease, 50% to 60% of patients with locally advanced head and neck cancer develop locoregional recurrence within 2 years of treatment, presenting a challenge for clinicians. We describe outcomes for a cohort of patients who underwent retreatment for head and neck cancer recurrence to help identify optimal salvage treatments.
Method: A retrospective review of 50 patients with recurrent squamous cell carcinoma in the head and neck from 2009 to 2014 at a US Veterans Affairs medical center was conducted. Demographic, tumor, and treatment characteristics, which included re-irradiation, salvage surgery, and supportive care, were collected. Univariate and multivariate analyses were performed to assess variables associated with improved outcomes, including survival and re-recurrence.
Results: All patients were male with an average age at diagnosis of 64±9 years. Of patients, 12% drank >14 alcohol drinks weekly, and 76% were smokers, with an average 36±21 pack-year history. Patients were initially treated with chemoradiation (CRT; 54%), surgery (12%), radiation (XRT; 12%), or a combination. Cancer recurrence was diagnosed on average 18 months after initial treatment completion. Twenty-two percent received supportive care alone and survived on average 8 months, while 14% received chemotherapy alone and survived 14 months with no re-recurrences. Eighteen percent received surgery alone and survived on average 27 months, though 2 of these patients had a re-recurrence within 2 years. Of the patients, 44% were re-irradiated, whether XRT or CRT alone or combined with surgery, and survived an average of 18 months. On multivariate analysis, salvage surgery was independently associated with increased overall survival (β=15 months; P=.003). Furthermore, each additional 5 pack-years of smoking was associated with a 1-month decrease in overall survival after adjusting for patient, tumor, and treatment factors (β=−0.2; P=.048).
Conclusion: Our results suggest that surgical resection when feasible and re-irradiation, with or without chemotherapy when surgery is not an option, are associated with improved overall survival.
Treatments and Survival in Human Papillomavirus–Positive and Human Papillomavirus–Negative Metastatic Oropharyngeal Carcinoma
Ryan S. Ziltzer, Ruben Ulloa, Mark S. Swanson, MD
Introduction: Oropharyngeal squamous cell carcinoma (OPSCC) is among the most common head and neck cancers with growing incidence in the era of rising human papillomavirus (HPV)–related cancers. However, there are few studies describing outcomes for treatment in advanced HPV-positive(+) and HPV-negative(–) OPSCC with distant metastasis. This study aims to examine the effects of various therapies and HPV status on survival in OPSCC patients with distant metastasis.
Method: Patients with metastatic (clinical M1) OPSCC diagnosed from 2010 to 2017 with known HPV status and treated with surgery, chemotherapy (including immunotherapy), and/or radiation were identified in the National Cancer Database (NCDB). Kaplan-Meier log-rank tests and restricted mean survival time with Scheffé-adjusted multiple comparisons were used to compare 2-year and 5-year survival across various treatment combinations. Survival in HPV+ and HPV– OPSCC were then compared for each treatment modality individually.
Results: A total of 1243 cases were analyzed, 603 (48.5%) HPV+ and 640 (51.5%) HPV− cases. The 3 most frequent treatments were chemoradiation (49.1%), chemotherapy alone (21.9%), and surgery with chemoradiation (10.7%). Two-year and 5-year mean survival were greatest for surgery with chemoradiation, chemoradiation, and surgery with chemotherapy, both overall and in HPV+ and HPV– groups. Survival was comparable between these top 3 modalities (adjusted P>.05). Comparing by HPV status, patients treated with chemotherapy (P=.0002) or chemoradiation (P<.0001) as well as metastatic OPSCC patients overall (P<.0001) had better 2-year and 5-year survival if their OPSCC was HPV+.
Conclusion: Chemotherapy is an important component of combination therapy for maximizing survival in OPSCC with metastasis to distant sites. HPV status impacts short-term and overall survival in metastatic OPSCC, particularly for patients receiving chemotherapy or chemoradiation.
Trends in Oral Cancer Mortality in Guayaquil, Ecuador
Marcos Zambrano, MD
Introduction: The incidence and mortality from carcinoma of the tongue has increased in recent decades.
Method: An observational, retrospective, descriptive, and cross-sectional study was carried out at the National Oncology Institute of SOLCA Guayaquil (Ecuador) and included patients with tongue cancer diagnosed between 2011 and 2020.
Results: The prevalence of tongue cancer in the population diagnosed with cancer during this period is 0.006%. Of the patients, 45.7% (n=80) were men and 54.3% (n=95) were women. The average age was 59 years, with 48.3% under 65 years of age. The most prevalent tumor location was at the edge of the tongue (71.4%), followed by the base of the tongue (24.6%) and 4% of the sample presented the lesion at the tip of the tongue. According to the Karnofsky scale, 51% (89) of the patients obtained a score greater than 80 and 49% (86) obtained less than 80. Of the patients, 78% presented stage II to IVa, occupying the first place stage III with 33% (n=58).
Conclusion: Patients’ habits, histopathology of the lesion, type of therapeutic approach, stage, recurrences, and Karnofsky scale are determining factors at the time of evaluating the prognosis of patients with tongue cancer.
Trial in Progress: Preliminary Data on Impact of a Virtual Reality 3D-Modeling Protocol on Surgeon Task Load Burden
Richard Wu, MPH, Michele Fiorella, MS, Victor Jegede, Ayan Kumar, MD, Sana H. Siddiqui, MD, Joseph Curry, MD
Introduction: A randomized, prospective trial using virtual reality case enhancement protocol was developed at our institution to provide a suitable platform for virtual surgical planning and to determine its impact on surgeon task load burden.
Method: Patients diagnosed with head and neck squamous cell carcinoma (HNSCC) were recruited from clinic and randomized into 1 of 2 arms. In the virtual reality (VR) arm, surgeons preoperatively utilized a virtual reality radiologic imaging software on the Oculus Rift using a patient’s computed tomography or magnetic resonance imaging. In the control arm, surgeons reviewed preoperative imaging in their typical manner. In both arms, postoperative surveys and a NASA-TLX, a validated workload assessment tool, were completed by the surgeon. An additional post-VR survey was completed for cases in the VR arm.
Results: At the time of this submission, 12 of 40 patients have been enrolled and completed the study; 6 patients were randomized to the VR planning arm, and 6 were randomized to control. On preliminary analysis, all surgeons surveyed in the VR arm found the VR platform useful for surgical planning (100%, n=6). In 2 cases (33.3%), surgeons reported that the use of VR changed their original surgical resection plan. Intraoperatively, 1 of 6 cases planned with VR and 3 of 6 control cases required re-resection at the primary site. Five of 6 VR cases (83.3%) and all control cases (n=6, 100%) sent specimens for frozen section examination. Intraoperatively, none of the 5 cases planned with VR and 2 of 6 controls demonstrated positive margins on frozen section examination (0.0% vs 33.3%). Mean NASA-TLX score was 45.8 for the VR arm and 63.7 for the control arm (P=.036).
Conclusion: These preliminary results demonstrate the potential utility of VR for planning surgical resections for HNSCC. Enrollment is ongoing with anticipated short term completion of enrollment and data analysis.
TrkB-BDNF and Perineural Invasion in Oral Squamous Cell Carcinoma
Carlos L. Green, MD, Carly Misztal, MD, Olena Bracho, BS, Zoukaa B. Sargi, MD, Donald T. Weed, MD, Christine T. Dinh, MD
Introduction: Perineural invasion (PNI) is a poor prognostic indicator associated with higher local recurrence and disease-specific mortality in oral squamous cell carcinoma (OSCC). Brain-derived neurotrophic factor (BDNF) and its receptor tyrosine kinase B (TrkB) are found to be over expressed in OSCC and associated with Schwann cells and perineural invasion in other solid tumors. Here, we aim to determine the role of TrkB-BDNF in Schwann cell–mediated perineural invasion in vitro.
Method: Pharmacodynamic studies were conducted for TrkB inhibitor (ANA12) on Schwann cells, neurons, and OSCC cells to validate drug concentrations for subsequent experiments. Migration assays were performed using a transwell migration design with OSCC cells in inserts and conditioned media from Schwann cell-alone or Schwann-and-neuronal cocultures in wells. Experiments were performed with 0.005% DMSO (control), BDNF, or ANA12.
Results: We validated the use of ANA12 as an inhibitor of TrkB in OSCC in vitro. We noted that conditioned media from Schwann cells treated with BDNF significantly increased the number of migrated oral SCC. ANA-12 did not inhibit Schwann cell–mediated cancer migration.
Conclusion: The BDNF-TrkB signaling pathway may play a significant role in PNI in OSCC. Understanding the mechanisms of PNI can lead to new therapies to address PNI in OSCC and improve disease-free progression and survival.
Use of a Rescue Flap After Initial Flap Loss in Salvage Laryngectomy: Feasibility and Outcome
Mohamed A. Zahran, MD, PhD, Ahmed Youssef, MD, PhD (ORL)
Introduction: The wide adoption of a larynx preservation chemoradiation therapy protocol was noticed in recent years. As a result, there has been a dramatic rise in the rate of salvage laryngectomy. Salvage laryngectomy poses challenges for the head and neck surgeon. The poorly vascularized irradiated tissue increases the rate of wound dehiscence and fistula.
Method: The aim of the current study is to describe the feasibility and outcome of using a second (rescue) flap in salvage laryngectomy after initial flap loss. The study was conducted at a tertiary referral head and neck cancer center between August 2019 and August 2021. Retrospective data for a total of 17 salvage laryngectomy cases were included in this study.
Results: Seventeen patient candidates for salvage laryngectomy were included in the study. Salvage total laryngectomy with pectoralis major (PM) flap was done in all cases (17/17). PM flap loss/failure was observed in 7/17 patients. A second (rescue) flap either PM flap (from the other side) or supraclavicular artery island flap (SCAIF) was done in case of initial flap failure. All 7 patients had good wound healing, normal oral intake with no pharyngocutaneous fistula.
Conclusion: The use of PM flap is crucial in all cases of salvage laryngectomy. A second (rescue) flap should also be available in case of initial flap loss. The use of a rescue flap either second pectoralis major myocutaneous flap or SCAIF proved to be a reliable option with excellent outcome.
Use of CO2 Laser and Coblation in Head and Neck Surgery: A Double-Blinded Histopathological Comparative Study
Vinusree Karakkandy, MBBS, MS-ENT, Preetam Chappity, MBBS, MS, DNB, MNAMS, MBA, Aswathi K V, MBBS, MS-ENT, Pritinanda Mishra, Susama Patra, Pradipta Parida, MBBS, MS-ENT, DNB
Introduction: CO2 laser and radiofrequency coblation are commonly used in head and neck surgeries. Their use is guided by the surgeon’s preference and equipment availability, as no definitive guidelines exist for their use. This study compares the tissue changes induced by CO2 laser and coblation procedures in head and neck surgery histopathologically.
Method: Benign and malignant pathology in the oral cavity, oropharynx, and larynx in which total excision was planned were included in the study. The study participants were stratified at the beginning of the recruitment into benign and malignant lesions. Further, they were randomized into coblation and CO2 laser groups according to surgical site and pathology. A primary specimen and a separate specimen from the base of the excised specimen were sent for histopathological analysis for all patients. Histological evaluation is based on criteria that has been established.
Results: Fifty patients were included in the study: 30 in the CO2 laser group and 20 in the coblation group. On histopathological examination after analyzing thermal effects of both the groups according to the established criteria, epithelial, connective tissue, and vascular changes produced by thermal injury in both groups were comparable. Quality of incision was more regular in the CO2 laser group (73%) than in the coblation group (55%) but was not statistically significant (P<1.80). Overall depth of thermal injury, which is measured in micrometer, was more with coblation; both instruments had less collateral injury.
Conclusion: This is the first kind of study in the literature comparing the thermal effects of coblation and laser histopathologically. Both coblation and laser can be used effectively in head and neck cases. However, CO2 laser, when available, is a better option because of its precise excision, better coagulative property, and less collateral tissue damage compared with coblation.
Use of Intraoperative Computed Tomography for Localization and Removal of Oral Tongue Foreign Body
Christopher Weeks, MD, N. Eddie Liou, MD
Introduction: Grill brushes that are popularly used to clean outdoor grills contain metal bristles that can become dislodged from the brush and implanted in food. Individual bristles are difficult to see, and their rigidity and small caliber allow them to be easily imbedded in the upper aerodigestive tract when inadvertently consumed. We present a particularly difficult case that required the use of intraoperative computed tomography (CT) for localization and removal of the oral tongue foreign body.
Method: A 40-year-old woman presented for possibly swallowing a toothpick while eating a sandwich. Odynophagia and dysphagia were still present 2 days later, and she presumed it to be a toothpick. CT revealed a radio-opaque linear foreign body in the posterior right paramedian oral tongue, just deep to the mucosa. Foreign body was not visible on physical exam or flexible laryngoscopy. The foreign body was unable to be localized with palpation or direct laryngoscopy in the operating room even with the assistance of intraoperative fluoroscopy. At this time, the decision was made to abort and seek other consultation.
Results: The patient was taken back to the operating room by the head and neck surgery team. Two localizing needles were placed orthogonally near the foreign body using transoral ultrasound. Intraoperative CT was then performed and demonstrated the exact location of the foreign body in relationship to the localization needles. A longitudinal incision was then made using electrocautery, and the foreign body was successfully identified and removed. The foreign body was in fact not a toothpick but a bristle from a wire grill brush.
Conclusion: Bristles from wire brushes are foreign bodies that otolaryngologists can encounter. Due to their thin and sharp nature, they can become buried in the submucosal tissue and surrounding musculature. Swallowing and removal attempts can lead to increased difficulty in finding and removing these foreign bodies and may result in delayed retrieval. Intraoperative CT guidance provides a fast and accurate localization technique that should be considered when these foreign bodies are not visible on endoscopy or direct palpation.
Using Extracorporeal Membrane Oxygenation for COVID-Positive Urgent Tracheostomy
Adrian Chow, MD, Neil N. Chheda, MD, Nikolaus Gravenstein, MD, Mindaugas Rackauskas, MD, PhD, Brian B. Hughley, MD
Introduction: Extracorporeal membrane oxygenation (ECMO) can be used during difficult airway surgery because it provides an unobstructed operative field while ensuring adequate oxygenation without need for ventilation. We present a case of utilizing ECMO to perform urgent tracheostomy on a COVID-positive patient with a large oropharyngeal mass causing critical airway narrowing.
Method: A 62-year-old man presented with 6 months of worsening dyspnea. Computed tomography imaging and flexible laryngoscopy showed a large oropharyngeal mass extending into the nasopharynx and larynx causing critical airway narrowing and severely distorted upper airway anatomy. Traditional methods to secure the airway including transnasal vs transoral intubation vs awake tracheostomy were considered inadequate due to tumor location/friability, trismus, inability to lie flat, and unclear tracheal landmarks on palpation. In addition, on the day of surgery, the patient tested positive for COVID. We decided ECMO was the safest method to safely perform tracheostomy while minimizing COVID aerosolization.
Results: The thoracic surgery team proceeded with bifemoral cannulation, and ECMO was initiated in less than 30 minutes. Standard tracheostomy was performed, and biopsies of the oropharyngeal mass were obtained. The patient was weaned off ECMO after <1 hour and awakened without any issues. There were no complications from bi-femoral venous access.
Conclusion: Multiple methods to secure this patient’s difficult airway were considered. Fiber-optic nasal intubation would require navigating the bronchoscope around the large tumor partially obstructing the nasopharynx and larynx. Awake tracheostomy was considered risky due to his large neck circumference, significant coughing episodes, and inability to lay supine. Both of these options would also be associated with high levels of COVID aerosolization. The use of ECMO allowed for apneic tracheostomy while minimizing the risk of COVID infection to all operating room personnel. In the era of COVID, ECMO is an unconventional but powerful tool that should be added to the armamentarium of high-risk airway surgery.
Using the Social Vulnerability Index to Assess Social Determinants of Head-Neck Cancer Care and Prognosis in the US
David J. Fei-Zhang, BA, Daniel C. Chelius, MD, Urjeet Patel, MD, Stephanie Smith, MD, Anthony Sheyn, MD, Jeffrey C. Rastatter, MD, MS
Introduction: Prior investigations in social determinants of health (SDH) in head-neck cancer (HNC) are limited by the narrow scope of HNC and SDH while lacking inquiry on the interrelational impact of SDH on disparities. Using the US Centers for Disease Control and Prevention Social Vulnerability Index (SVI), our study aims to assess the impact of a variety of SDH and their amalgamated influence on adults with HNC while identifying which SDH contribute more to HNC disparities in the US.
Method: Our retrospective cohort study assessed 1,277,301 HNC adult (20+ years) patients from 1975 to 2017 in the SEER database and matched SVI scores based on county of residence at time of diagnosis. Patients were assessed by univariate linear regression and violin-box plots for care (months of follow-up/surveyed) and prognosis (months survival) disparities across varied SDH in socioeconomic status, minority-language status, household composition, housing-transportation, and their total composite by SVI scores.
Results: With increasing total SVI (ie, increased overall social vulnerability), significant decreases in months of follow-up were observed for many HNC-primary sites and disease classes (P<.001 for both), ranging from 10.92% to 55.27% decreases in mean lengths of care when comparing the lowest with highest vulnerability cohorts. For months survival, increasing total SVI showed significant decreases with many primary sites and disease classes (P<.001 for both), ranging from 6.3% to 47.1% decreases in the mean survival period when comparing the lowest with highest vulnerability cohorts. Increasing SVI theme subscores (ie, increased social vulnerability within a specific SDH category) contributed significantly to the total SVI trends in months surveyed and survival, with socioeconomic status, minority-language status, household composition, and housing-transportation showing differential magnitudes of impact across primary sites and disease classes.
Conclusion: Our results show significant decreases in care and prognosis of adult HNC patients in the US, with increasing overall social vulnerability, and identify which SDH themes contribute more to disparities.
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