bluuebunny/crossref_metadata_2025 huggingface dataset:
Nonmedical Costs in Patients Receiving Oral Cancer Surgery: Interim Analysis from the COOLS Trial
Authors: Cromwell Ian , Cressman Sonya , Poh Catherine , Rosin Miriam P. , Durham Scott , Peacock Stuart
Published: August 2013

Objectives:

1) Describe the non‐medical financial burden experienced by early‐stage oral cancer patients. 2) Analyze constituent costs and discover relevant potential policy levers.

Methods:

The pan‐Canadian Optically‐guided Oral Lesions Surgical (COOLS) Trial is a multi‐center randomized controlled trial evaluating a novel surgical staging method for the treatment of early‐stage oral cancer. A survey of 209 participants collected data at baseline, 3 months, and 12 months after surgery on time taken away from work and expenses paid out of pocket.

Results:

Participants were generally able to return to work following surgery, albeit with a slight reduction in self‐reported ability to work. Very few patients needed to take time off work or changed their working status (ie, going on medical leave, retiring) following their surgery (n = 4; 10 weeks; range = 5 ‐ 146 days). A majority of trial participants reported out‐of‐pocket spending at baseline (n = 128; $64.55; 95% confidence interval [CI] $40 ‐ $88), 3 months (n = 108; $82.44; 95% CI $56 ‐ $109), and 12 months after surgery (n = 51; $65.01; 95% CI $13 ‐ $117). Most out of pocket expenses were non‐reimbursed travel costs.

Conclusions:

Oral cancer, when treated at an early stage, was not generally a barrier to returning to work in our participant sample. Moderate out‐of‐pocket expenditure was observed in a large number of patients, mostly related to travelling. Programs to defray the cost of travel may be helpful in many cases, but broader evidence is needed.
Observation of Patients with Oral Potentially Malignant Disorders Using Autofluorescence Imaging and Spectroscopy
Authors: Gillenwater Ann M. , Howe Jana M. , Mondrik Sharon , Schwarz Richard A. , King Travis J. , Bhattar Vijayashree , Richards‐Kortum Rebecca
Published: August 2013

Objectives:

1) Describe 2 noninvasive optical techniques, widefield autofluorescence imaging (AFI) and optical spectroscopy, that may be used in conjunction with conventional oral examination (COE) for long‐term surveillance of patients with oral potentially malignant disorders (OPMD). 2) Present images and spectra collected from patients with OPMD using AFI and spectroscopy over a 33‐month surveillance period, and compare results to clinical observations and patient outcomes over that time period.

Methods:

Patients undergoing routine follow‐up surveillance for OPMD were enrolled in a longitudinal optical imaging study. The patients were monitored over time with COE, AFI, and spectroscopy. AFI was used to observe natural tissue fluorescence over a 4‐5 cm field of view. Spectroscopy was used to obtain reflectance and fluorescence spectra from selected sites within the oral cavity. The images and spectra collected from these patients were evaluated for changes over time and compared to clinical observations and (where available) histopathology results.

Results:

During the 33‐month period from May 2010 to February 2013, more than 140 patients were enrolled in the study. To date, more than 1,000 optical measurements have been performed during more than 400 clinical surveillance visits. During the surveillance period 26 patients were judged clinically to have progressed from OPMD to cancer. Representative images and spectra from some of these patients will be presented.

Conclusions:

These results indicate the potential for simple optical techniques, when used in combination with COE, to assist clinicians in monitoring patients with OPMD for early detection of cancer.
Pathologic Discordance in Skull Base Tumors
Authors: Burgin Sarah , Peress Lilia , McKean Erin M.
Published: August 2013

Objectives:

A wide range of pathologies cause skull base tumors, which require accurate diagnosis for appropriate treatment. These lesions can be difficult to biopsy in the clinic due to patient intolerance and risk of bleeding, and in the operating room due to difficulty with access. The objective of this study was to analyze diagnostic accuracy among patients with skull base tumors referred to a tertiary care center.

Methods:

We retrospectively reviewed the records of patients referred to the University of Michigan Multidisciplinary Cranial Base program over a 2 year period (July 2010‐June 2012). We excluded patients referred for pituitary lesions, for internal auditory canal/cerebello‐pontine angle lesions, and without concern for tumors (encephaloceoles, CSF leaks, fractures). We collected data regarding biopsy prior to referral, histologic diagnosis by outside pathologists, diagnosis on review by University of Michigan pathologists, and final histologic diagnosis after repeat biopsy, resection, or both.

Results:

The records of 177 patients were reviewed. Fifty‐nine (59) patients had specimens which had been reviewed by both community pathologists and University of Michigan pathologists. There was some discrepancy in histologic diagnosis in 17/59 (28.8%) of the patients. The most frequent diagnosis with discordance was squamous cell carcinoma (5/17, 29%) and sinonasal undifferentiated carcinoma (2/17, 11.8%). No patient's diagnosis was changed from benign to malignant or vice‐versa.

Conclusions:

There is a high rate of discrepancy (28.8%) in the diagnosis of skull base tumors when reviewed by community pathologists compared to specialized pathologists at a tertiary care institution.
Comparison of Complication Rates with and without Arch Bar Use in Treatment of Mandible Fractures
Authors: Archer Kaete A. , Kopp Robert , Goyal Parul , Kellman Robert M. , Suryadevara Amar C.
Published: August 2013

Objectives:

1) Explain the pros and cons of using arch bars for mandible fracture stabilization. 2) Compare and contrast the outcomes of mandible fractures treated with and without arch bars.

Methods:

A retrospective review was performed of mandible fractures treated at a Level 1 trauma center between 2001 and 2011. Two‐hundred forty‐two patients met inclusion criteria. Patients were categorized into those treated with or without arch bars. Major complications were malocclusion, infection, and malunion. Independent variables of age, sex, trauma, and dental status were collected. Exclusion criteria included lack of follow‐up, greenstick fractures, mid‐facial fractures, and subcondylar fractures. Data were analyzed using Fisher's exact test.

Results:

Eighty‐four patients had one mandible fracture, and 158 patients had two fractures. Overall, patients treated with arch bars had a complication rate of 13%, and those treated without arch bars had a rate of 16%. This was statistically insignificant (P = 0.58). When separated by number of fractures, the differences remained insignificant (12% and 10% complication rates with and without arch bars in single fracture cases (P = 0.74); 14% and 19% in two fracture cases (P = 0.37)).

Conclusions:

The use of arch bars did not have a significant effect on major complications in this series. This trend was consistent for cases of one and two mandible fractures. These data suggest that many patients with mandible fractures may be safely treated without arch bars.
Predictors and Cost of Readmissions at an Academic Head and Neck Cancer Service
Authors: Dziegielewski Peter T. , Boyce Brian J. , Manning Amy , Agrawal Amit , Old Matthew O. , Ozer Enver , Teknos Theodoros N.
Published: August 2013

Objectives:

With healthcare reform nationally debated, surgeons are increasingly called upon to improve quality of care while lowering cost of delivery. Rate of hospital readmission within thirty days of discharge (RA30) is a quality measure monitored by CMS and will subject healthcare systems to fines if they fall outside of acceptable standards. Unfortunately, few benchmarks in head and neck surgery (HNS) exist. Our goal was to determine: 1) the rate and predictors of readmissions, and 2) a detailed cost breakdown of readmissions on an academic head and neck surgery service.

Methods:

A prospective‐cohort study at a tertiary‐care academic center was conducted. Six hundred and ninety‐four patients from 2011‐2012 underwent HNS procedures. Demographic, pathological, and follow‐up data were collected. Financial information for each admission was obtained from the hospital billing database. RA30 was the primary outcome. Multivariate analysis identified peri‐admission factors predictive of re‐admission. A cost analysis was performed.

Results:

C4QI cancer hospital‐readmission benchmarks for fiscal year 2011 were 17.29%. On the HNS service, 39 (5.6%) patients were re‐admitted to the hospital. Thirty‐six of 39 patients were admitted due to wound complications and 3/39 due to pneumonia (2) or C difficile (1) colitis. Predictors of re‐admission were age >65 years, advanced stage cancer, previous radiation therapy, multiple medical comorbidities, and high‐acuity procedures (P < 0.05). Median cost of readmission was $20,877.84 (range: $3,201.50‐$174,693.30). The highest source of readmission cost was the operating room.

Conclusions:

Readmission rates on a busy HNS service can be low, but costly. Knowing factors predictive of readmission may help create preventative and minimize excess costs.
Prognostic Factors for Survival in Human Papilloma Virus Positive Head and Neck Squamous Cell Carcinoma
Authors: Ahn Sun M. , Chan Jason Y. , Mydlarz Wojciech K. , Zhou Xian‐Chong , Richmon Jeremy D. , Agrawal Nishant
Published: August 2013

Objectives:

The TNM classification of human papillomavirus (HPV) associated tumors does not account for HPV/p16 status or that the cervical metastases tend to be cystic, which artifactually increases the size of the affected nodes. Our study objective was to review the outcomes of patients with HPV associated squamous cell carcinoma (SCC) of the oropharynx and unknown primary treated at our institution from 2008‐2011.

Methods:

A retrospective review of patients at our institution from 2008‐2011 identified 199 patients with p16 positive squamous cell carcinoma of unknown primary or of the oropharynx.

Results:

Of the 199 patients, 177 (89%) were males, 182 (92%) were Caucasian, 135 (68%) were ≤ 60 years old, 85 (43%) were non‐smokers, 187 (94%) arose from the oropharynx, 139 (70%) had T stage ≤2, 47 (24%) had N ≤1, and 20 (10.1%) were p16 positive but HPV DNA negative by in situ hybridization (ISH). On multivariate analysis of disease‐free survival (DFS), increased age (hazard ratio [HR] = 1.05 P = 0.02), ECOG status ≥1 (HR = 3.09 P = 0.002), T3/4 vs. T0/1/2 (HR 2.27 P = 0.02), N2C vs. N1/N0 (HR = 2.77 P = 0.02) and receiving induction chemotherapy versus definitive chemoradiotherapy (HR = 5.13 P = 0.02) were associated with worse DFS. p16 and HPV DNA positivity (HR 0.41 P = 0.03) was associated with improved DFS.

Conclusions:

Our data suggest that nodal size may not be as important as number of nodes in HPV positive disease. Furthermore, dual positivity of p16 and HPV DNA compared to p16 alone has a positive impact on prognosis suggesting a biologic difference between them.
Rapid Mandible Margins for Intraoperative Assessment
Authors: Taraska Allison K. , Royer Mark C. , Summerlin Don‐John , Moore Michael G. , Kokoska Mimi S.
Published: August 2013

Objectives:

1) Assess various rapid methods for processing mandible bone margins for histopathologic examination. 2) Determine the optimal method for intraoperative use.

Methods:

Multiple bone samples were collected from a fresh (<12 hours post‐mortem) human cadaveric mandible using a standard 3mm core bone biopsy trocar. The cored specimens were placed 30 minutes in 10% formalin (transport time) and then for 15‐75 minutes in 1 of 3 decalcifying solutions (Decal A, Calex, EDTA Decal). Controls were placed in 10% formalin. After each designated decalcification time period, specimens were cryosectioned or paraffin‐embedded and reviewed by a head and neck surgical pathologist blinded to the treatment groups. The specimens were assessed for overall quality, adequacy of decalcification, soft tissue quality, marrow quality, and presence of artifact.

Results:

Bone margin specimens collected with a 3mm core bone biopsy trocar and processed with all 3 decalcifying solutions for 15 minutes yielded acceptable quality and sufficient decalcification for histopathologic assessment. In addition, the trabecular, intact soft tissue and marrow were well‐preserved with good cellular architecture.

Conclusions:

Mandible bone margins can be rapidly processed for histologic evaluation using cored specimens with only 15 minutes of decalcification, allowing for intraoperative assessment of a bone margin. A prospective clinical trial of patients with cancer invasion in the mandibular bone to confirm cancer cells are identifiable with this rapid processing method is planned.
Recurrence Patterns for Head and Neck Squamous Cell Carcinoma Treated with Cetuximab versus Non‐cetuximab Therapy
Authors: Walgama Evan S. , Sumer Baran D.
Published: August 2013

Objectives:

The respective roles of platinum‐based chemotherapy and cetuximab therapy in the treatment of head and neck squamous cell carcinoma (HNSCC) have yet to be strictly defined. This study investigates the patterns of recurrence for patients with HNSCC treated with cetuximab versus non‐cetuximab therapies.

Methods:

Retrospective case‐control study at a tertiary academic practice. Patients with recurrent HNSCC that received primary non‐surgical therapy between 2006 and 2009 were retrospectively reviewed. Patients were stratified by treatment into 2 primary groups: 14 patients who received cetuximab plus radiotherapy and 30 patients who received non‐cetuximab radiotherapies. The 2 groups were compared, and the primary endpoint was the time to locoregional recurrence. Subgroup analysis was performed for the non‐cetuximab radiotherapy group.

Results:

Overall stage (P = 0.423), T stage (P = 0.190), smoking history (P =1.000), alcohol use (P = 0.498), and comorbidity based on ASA score (P = 1.000) were not significantly different between the 2 groups. Patients in the cetuximab group were on average older; 68.9 versus 61.3 years old (P = 0.049). Median time to recurrence for the cetuximab group was 5.3 ± 3 months versus 8.7 ±6 months for non‐cetuximab patients (P = 0.020); subgroup analysis showed 10.7 ± 7.3 months till recurrence for the concurrent chemoradiotherapy subgroup (P = 0.023). None of the patients in the cetuximab group were disease‐free for one year or longer.

Conclusions:

Patients with recurrent HNSCC treated primarily with cetuximab and radiotherapy alone have a significantly shorter time to recurrence than patients treated with conventional therapies.
Re‐irradiation versus Chemo‐reirradiation for Recurrent, Unresectable Head and Neck Cancer
Authors: Tay Kaijun , Loh Kwok‐Seng , Goh Boon‐Cher , Tham Ivan W.K. , Lim Chwee Ming
Published: August 2013

Objectives:

Both chemo‐reirradiation and reirradiation alone have been shown to be feasible treatment options for recurrent, unresectable head and neck cancer in an irradiated field. However, no randomized controlled studies have been performed to compare their efficacy. Our goal was to compare the survival and toxicity rates among patients treated with chemo‐reirradiation and reirradiation.

Methods:

A Pubmed search was performed using the search terms: re irradiation, previously irradiated, reirradiation, re‐irradiation and head and neck neoplasms[Mesh]. Two observers identified the full manuscripts which fulfilled the inclusion criteria: recurrent or second primary head and neck cancer, prior irradiation, no surgery, and no targeted therapy. Median overall survival (OS), 1‐year OS, and toxicity between reirradiation alone and chemo‐reirradiation groups were compared using Mann‐Whitney‐U test.

Results:

Of 473 papers identified, 15 papers were included: 11 papers (n = 567) reported median OS, and 13 papers (n = 601) reported 1‐year OS. Median age of the patients and radiation dosage delivered were similar between the groups. Average 1‐year OS was 44.1% (n = 214) in the reirradiation group and 47.2% (n = 387) in the chemo‐reirradiation group (P = 0.42). Average median OS was 12 months in the reirradiation group (n = 162) and 10.6 months in the chemo‐reirradiation group (n = 405) (P = 0.32). Average incidence of Grade‐3/4 Mucositis was 21.5% (n = 118) in the reirradiation group and 18.1% (n = 396) in the chemo‐reirradiation group (P =0.46). Chemotherapy‐related‐hematology toxicity was 24.2% (n = 353).

Conclusions:

This analysis involving more than 600 patients shows that, compared to reirradiation alone, chemo‐reirradiation has no discernable difference in OS or local toxicity but poses additional hematological toxicity. Optimal treatment remains to be defined.
Results after U‐shaped Pectoralis Major Myocutaneous Flap Reconstruction of Circumferential Pharyngeal Defects
Authors: Malard Olivier , Ferron Christophe , Durand Nicolas , De Montreuil Claude B. , Cassagnau Elisabeth , Espitalier Florent
Published: August 2013

Objectives:

Evaluate surgical, functional, carcinologic results after circumferential pharyngolaryngectomy and reconstruction with U‐shaped pectoralis major myocutaneous flap.

Methods:

Forty‐one patients in a retrospective case series spanning a 6‐year period.

Results:

General and local complications occurred in 10% and 22% of patients respectively, without early death. Swallowing and vocal functions were satisfactory for 82% and 43% of patients respectively, despite 39% of neopharynx stricture and 22% of pharyngocutaneous fistula. With a 20‐month mean follow‐up, cancer recurrence was present in 58% of patients. The overall survival rate was 29% at 3 years.

Conclusions:

This flap is simple, reliable, and allows adequate reconstruction of the hypopharynx. However, the neopharynx stricture rate is high and the quality of voice rehabilitation is poor when compared with free flaps. This procedure, which is an option for the reconstruction of circumferential pharyngeal defects, must be considered in selected cases.
Salvage Surgery for Locally Recurrent Pharyngeal Squamous Cell Carcinoma after Definitive Radiotherapy or Chemoradiotherapy
Authors: Omura Go , Kobayashi Kenya , Saito Yuki , Ebihara Yasuhiro , Ando Mizuo , Asakage Takahiro , Yamasoba Tatsuya
Published: August 2013

Objectives:

A local recurrence of pharyngeal carcinoma (PC) after definitive radiotherapy (RT) or chemoradiotherapy (CRT) is correlated to a poor prognosis. Therefore, the objective of the current study was to analyze the efficacy of salvage surgery for patients with locally recurrent PC after RT or CRT.

Methods:

We retrospectively reviewed the clinical charts of patients with PC treated between 2001 and 2011 at the University of Tokyo Hospital and enrolled 222 patients, including 106 with oropharyngeal carcinoma (OPC) and hypopharyngeal carcinoma (HPC) who received definitive RT or CRT. Local recurrence developed in 63 patients (26 OPC and 37 HPC), of whom 44 (18 OPC and 26 HPC) underwent salvage surgery. Initial treatments were radiotherapy, radiotherapy with induction chemotherapy, and concurrent chemoradiotherapy in 13, 11, and 20 patients, respectively. The median radiation dose was 70 Gy.

Results:

Resection of the local recurrence was combined with free or pedicle flap reconstruction in 38 patients and was performed without reconstruction in 8. Twenty‐eight patients simultaneously underwent laryngectomy and resection. The median overall survival (OS) and median disease‐free survival (DFS) after salvage surgery was 16 and 10 months, respectively. The DFS of HPC patients (median, 15 months; 2‐year OS rate, 43%) was significantly longer than that of OPC patients (median, 7 months; 2‐year OS rate, 12%; P = 0.01).

Conclusion:

The prognosis of locally recurrent PC remains poor despite the technical feasibility of salvage surgery, with the prognosis for HPC being significantly better than that for OPC.
Secondary TEP Placement in Office
Authors: Britt Christopher J. , Lippert Dylan C. , Hartig Gregory K.
Published: August 2013

Objectives:

Evaluate the use and outcomes of in‐office secondary tracheoesophageal puncture (TEP) technique using trans‐nasal esophagoscopy (TNE) and the Seldinger technique for placement, in a large series of patients having undergone laryngectomy and laryngopharyngectomy.

Methods:

A retrospective chart review at a single institution was performed on 83 subjects who underwent in‐office secondary TEP procedure. Variables that were examined included disease site, staging, histology, extent of resection and reconstruction, chemoradiation, functional voice status (as assessed by speech pathologist in most recent note), and complications directly related to the procedure.

Results:

83 individuals from our institution met our criteria for in‐office secondary TEP placement from 2006 to 2012. The overall complication rate was 2.4% (2/83). Complications included one patient with bleeding from the puncture site, and another who had closure of puncture site before initial TEP placement. At the time of most recent follow‐up, voicing was achieved in 91% of all patients with a TEP (74/81) with 75.3% (61/81) having a fully functional voice as defined as regular use of their TEP for conversational speech.

Conclusions:

These results justify the regular use of in‐office TEP performed using TNE and the Seldinger technique. This technique avoids the need for a general anesthetic and has results which compare favorably with other methods of placement.
Sialendoscopy for Dysfunction of Salivary Gland after Radioactive Iodine Therapy
Authors: Choi Jeong‐Seok , Lim Jae‐Yol , Kim Young‐Mo
Published: August 2013

Objectives:

Ablation of the thyroid remnants using radioactive iodine (RI) after total thyroidectomy of well differentiated thyroid cancer could induce dysfunction of salivary gland. The purpose of this study is to review our experience with sialendoscopy for dysfunction of salivary gland after RI therapy.

Methods:

We reviewed medical charts of all patients treated with sialendoscopy due to RI induced salivary dysfunction. The study included 30 patients who underwent sialendoscopy for the treatment of RI induced salivary dysfunction after failing conservative management.

Results:

30 patients (23 women, 7 men) with a mean age of 45.2 years (range, 25~71) underwent sialendoscopy for the treatment of RI‐induced salivary dysfunction that is unresponsive to conservative management. Symptoms arising from the parotid gland were seen in 26 (87%) of patients, whereas symptoms arising from the submandibular gland were seen in 4 (13%). Fifteen patients (50%) presented symptoms in bilateral parotid or submandibular glands. The mean dose of RI was 203.5 mCi (range, 150 ~ 500) received as a single dose. The mean duration from RI ablation therapy to sialendoscopy was 13.2 months (range, 0.5 ~ 32). Sialendoscopy was possible in all patients. Ductal stenosis and mucous plugs and debris were the most common types of ductal pathology. Sialendoscopy improved the symptoms in 80% (24/30) of patients, with no serious complications reported in mean follow‐up of 12 months(range, 1 ~ 24).

Conclusions:

Sialendoscopy is an effective tool for improving symptoms due to RI‐induced salivary dysfunction in patients who are unresponsive to conservative managements.
Six‐Year Experience with Video‐Assisted Thyroidectomy: Outcomes and Safety Profile
Authors: White Jennifer R. , Singer Michael C. , Duke William S. , Chin Edward , Terris David J.
Published: August 2013

Objectives:

1) Review complication profiles among various thyroidectomy techniques, including conventional, minimally invasive non‐endoscopic, minimally invasive video‐assisted (MIVAT), and robotic approaches. 2) Analyze factors contributing to the safety profile of MIVAT. 3) Describe potential steps to implement MIVAT in a surgical practice.

Methods:

The largest single series of MIVAT in North America was reviewed to explore its safety profile. An institutional review board (IRB)‐approved prospectively maintained database was queried for all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011. Demographic information, surgical and pathologic data, and post‐operative outcomes were analyzed.

Results:

A total of 1,132 consecutive thyroidectomies were identified. MIVAT was incorporated beginning in 2005. There were 249 MIVATs (164 hemi, 85 total), 399 minimally invasive non‐endoscopic thyroidectomies, 441 conventional thyroidectomies, and 43 robotic thyroidectomies. Two hundred twenty‐eight MIVATs were accomplished on an outpatient basis. MIVAT patients were predominantly young (46.8 ± 14.8 years old) and female (89%). The mean incision length was 2.3 ± 0.4 cm. No cases of permanent hypoparathyroidism or permanent true vocal fold paralysis occurred. Observed complications included transient vocal fold dysfunction (n = 10; 4.0%), cellulitis (n = 1, 0.4%), and temporary hypocalcemia (n = 5; 2.0%). The overall complication rate for MIVAT was lower than the combined overall complication rate for minimally invasive non‐endoscopic, conventional, and robotic thyroidectomy (6.8% vs. 14.8%; P = 0.001).

Conclusions:

MIVAT can be performed safely with a low complication profile in a high‐volume practice. The safety of MIVAT represented by this experience may support expanded implementation.
Swallowing Outcomes for T1‐T4 Oropharyngeal Cancers Treated with TORS: Preliminary Experience
Authors: Ghanem Tamer A.H. , Fei Naomi , Simmerman Erin , Lindholm Jamie M.
Published: August 2013

Objectives:

1) Assess swallowing function longitudinally using standardized questionnaires in a cohort of oropharyngeal cancer patients treated with transoral robotic surgery (TORS). 2) Compare the effect of tumor T‐stage on swallowing outcomes.

Methods:

A prospective, institutional review board (IRB)‐approved database of all patients undergoing TORS for oropharyngeal cancer at a tertiary‐care academic institution was queried from November 2010‐October 2012. Demographic data as well as longitudinal assessment of swallowing outcomes were collected. Standardized questionnaires included: University of Washington Quality of Life question 5 (UW‐QOLq5), MD Anderson Dysphagia Inventory (MDADI), and Functional Oral Intake Scale (FOIS). Two‐sided Wilcoxon signed‐rank tests were used to compare baseline values with corresponding 1, 3, 6, and 12 months post‐surgery. Two‐sided Wilcoxon rank‐sum tests were used to test for differences between T‐stages.

Results:

Thirty‐nine patients were studied with a mean age of 60.7 (42‐92). T‐stages included: T1 n = 14, T2 n = 15, T3 n = 6, T4 n = 4. No significant differences were detected at any time between patients with T1‐T2 and T3‐T4 stage disease on UW‐QOLq5, MDADI, or FOIS. Compared to baseline, UW‐QOLq5 measures were significantly lower at 1 month (P = 0.0156), but not at 3 or 6 months. MDADI overall scores were significantly lower than baseline at 1 month (P = 0.0134), but not at 3, 6, or 12 months. Compared to baseline, FOIS measures were significantly lower at 1 month (P <.0001), and remained significantly lower at 3 (P <.0001), 6 (P <.0001), and 12 months (P = 0.0039).

Conclusions:

Results suggests that while swallowing status declines immediately after TORS, it can be expected to approach baseline within 3 months post‐surgery.
T4 Oropharyngeal Squamous Cell Carcinoma: Primary Management Outcomes
Authors: Van Abel Kathryn M. , Moore Eric J. , Price Daniel L. , Oldenburg Michael , Kasperbauer Jan L. , Olsen Kerry D.
Published: August 2013

Objectives:

1) Describe T4a and T4b oropharyngeal squamous cell carcinoma (OPSCC) and its management. 2) Analyze morbidity, functional and oncologic outcomes, and survival associated with four major treatment strategies.

Methods:

We retrospectively reviewed functional, clinical, and oncologic outcomes for patients diagnosed with T4 OPSCC at a tertiary institution from 1990‐2010. Patients underwent primary 1) surgery + chemoradiation (Group 1), 2) surgery + radiation (Group 2), 3) chemoradiation (Group 3), or 4) chemoradiation + neck dissection (Group 4). Preliminary analysis of ongoing study (N = 120).

Results:

47 patients were included (32% female, 68% male; mean age 58.8 years, range 43‐82). Groups 3 and 4 had a higher preoperative nodal stage (P = 0.02). Complications and PEG placement/dependence were similar across groups. Groups 2 and 4 had higher rates of surgical airway dependence at last follow up (P =0.05). Average follow up was 43 months (median 26, range 2‐167). Two/five year overall survival was 83%/54% for Group 1, 60%/40% for Group 2, 64%/32% for Group 3, and 80%/30% for Group 4 (P =0.82). Disease specific survival at two/five/ten years was 83%/63%/31% for Group 1, 70%/58%/44% for Group 2, 68%/60%/48% for Group 3, and 80%/40 %/40% for Group 4 (P =0.97). Progression free survival at two/five years was 80%/80% for Group 1, 57%/57% for Group 2, 68%/58% for Group 3, and 40%/40% for Group 4.

Conclusions:

For a disease in which improved survival and oncologic outcomes are measured in months, primary surgery followed by chemoradiation may achieve this goal without sacrificing morbidity or functional outcomes.
Transoral Robotic Surgery and the Unknown Primary: A Highly Effective Technique for Identifying the Tumor
Authors: Byrd James K. , Albergotti William G. , Davis Kara , Kim Seungwon , Ferris Robert L. , Johnson Jonas T. , Duvvuri Umamaheswar
Published: August 2013

Objectives:

1) Describe the use of transoral robotic surgery (TORS) in the management of patients with unknown primary carcinoma of the head and neck. 2) Report the efficacy of TORS for patients with unknown primaries in our updated series, the largest reported series of such patients.

Methods:

A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with non‐diagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Tumor identification rate and characteristics were analyzed.

Results:

206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. Of these, 11 had bilateral base of tongue resection, 3 had unilateral base of tongue resection, and the remainder had a combination of base of tongue procedures and tonsillectomy. The primary tumor was located in 19/22 (86.4%) patients. Mean tumor size was 1.03 cm +/‐ 0.66 cm and 9/22 (40.9%) patients had negative resection margins after the primary procedure.

Conclusions:

TORS is an effective procedure to locate the primary tumor in patients with cervical lymph node metastases and no obvious source. Bilateral base of tongue resection should be considered as part of the exam under anesthesia for these patients, particularly if the palatine tonsils have already been removed.
Using Sentinel Lymph Node Biopsy for Thick (>4 mm) Head and Neck Melanoma
Authors: Pattisapu Prasanth , Monroe Marcus M. , Myers Jeffrey N. , Kupferman Michael E.
Published: August 2013

Objectives:

Sentinel lymph node biopsy (SLNB) has become standard practice for intermediate‐thickness head and neck melanoma (HNM) but remains controversial for melanomas >4 mm thick. The objectives of this study were to evaluate the diagnostic accuracy and the prognostic value of SLNB in patients with thick HNM.

Methods:

Retrospective cohort study of patients undergoing SLNB for thick HNM at a large cancer center between June 2000 and December 2012. Univariate and multivariate analysis of prognostic factors was performed. False negative SLNB was defined as recurrence within a previously identified negative nodal basin.

Results:

A total of 107 patients with thick HNMs were identified, of which 77 met inclusion criteria. Population characteristics included a mean patient age of 62.9 (range 4‐87) with a male predominance (82%). Mean Breslow thickness was 6.04 mm (range 4‐21 mm). Of the 77 patients undergoing attempted SLNB, 7 had no identifiable SLN (9%). For the remaining 91% with identifiable SLN(s), the mean number of nodes identified was 3.3 (range 1‐13). The SLN positivity rate was 24%. A false‐negative SLNB occurred in two patients (3.8%). With a median follow‐up of 36 months, the estimated 5‐year disease‐free, disease‐specific and overall survival rates were 47%, 80%, and 71%, respectively. A positive SLN was significantly linked to shortened DFS (35% v. 51%, P = 0.028) and DSS (65% v. 85%, P = 0.04) and trended towards significance for OS (59% v. 76%, P = 0.09).

Conclusions:

SLNB provides accurate staging of the regional node basin and important prognostic information for patients with thick HNM.
What Is the Learning Curve of Sialoendoscopy?
Authors: Steck Jose H. , Bertelli Hallan D. , Hoeppner Catarine A. , Volpi Erivelto , Vasconcelos Evandro C.
Published: August 2013

Objectives:

Sialoendoscopy is becoming the gold standard method for diagnosis and treatment of Salivary gland inflammatory diseases (SGID). Our objectives are:1) Analyze our initial experience with sialoendoscopy. 2) Measure the learning curve to implement this technique.

Methods:

We reviewed the data from 113 consecutive sialoendoscopies from September 2010 to January 2013. These procedures were performed for diagnosisor intervention in 82 patients (62% female), with mean age 46.4 (4 to 83). They were divided into 2 groups: A, with the first 60 exams, and B, with the last 53 exams. We compared the following outcomes in the 2 groups: failure in papilla catheterization, failure to complete the exam, complication rates and need to repeat exams in the same patient. The most common diagnoses were lithiasis, stenosis, scars, radiodine sialoadenitis, Sjogren Disease.

Results:

In Group A, failure to catheterize papilla were 18.3%, versus 3.7% in Group B (95% CI, 3.58 to 25.62), P = 0.016 (statistically significant‐SS). Failure to complete the examination was 21.6% in Group A versus 7.5% in Group B (95% CI 1.52 to 26.68), P = 0.036 (SS), and need to repeat exams was 23.3% in Group A versus 3.7% in Group B (95% CI 7.78 to 31.42), P = 0.0027 (SS). The overall complication rate was 11.2%, 15% in Group A, 7.5% in Group B, P = 0,23 (not SS).

Conclusions:

Sialoendoscopy is a challenging procedure. In our experience we found statistically better outcomes for the exam after 60 procedures. The complication rate was statistically the same.
Acute Contained Ruptured Aortic Aneurysm Presenting as Left Vocal Cord Paralysis
Authors: Gnagi Sharon H. , Howard Brittany E. , Lott David G.
Published: August 2013

Objectives:

Recognize intrathoracic abnormalities, including expansion or rupture of aortic aneurysms, as a source of acute onset vocal cord paralysis.

Methods:

Case report and review of the literature.

Results:

An 85‐year‐old female with prior history of an aortic aneurysm status post‐endovascular repair presented to a tertiary care laryngology clinic with a history of sudden onset hoarseness that began two months prior with no subsequent improvement. On laryngoscopy, the left vocal cord was seen in the midline position. A computed tomography (CT) scan obtained that day revealed a new, large acute 4.6 cm hematoma surrounding the upper descending aortic stent graft consistent with an acute contained ruptured aortic aneurysm. She was subsequently referred to the Emergency Department for further evaluation and treatment by the vascular surgery team. She was counseled regarding surgical options and ultimately decided not to pursue further treatment. Her vocal cord paralysis was subsequently treated via office‐based injection medialization two weeks after presentation and again 5 months after the initial injection which dramatically improved her voice. Follow‐up CT scan at 8 months after diagnosis demonstrated a slight decrease in the size of the hematoma and the development of a pseudoaneurysm within it. The left vocal cord remains immobile to date.

Conclusions:

Ortner's syndrome, or cardiovocal syndrome, is hoarseness secondary to left recurrent laryngeal nerve palsy caused by cardiovascular pathology. It is a rare condition, and while typically presenting gradually, may also present with acute symptomatology.
Adult Supraglottic Rhabdomyoma with Extralaryngeal Extension: Surgical Excision and Reconstruction with Aortic Homograft
Authors: Gnagi Sharon H. , Cain Rachel B. , Lott David G.
Published: August 2013

Objectives:

1) Review the presentation, pathology, and treatment of rhabdomyomas. 2) Recognize the potential need for open resection with reconstruction as a treatment of benign laryngeal lesions in rare cases.

Methods:

A 67‐year‐old female presented with dyspnea and hoarseness. On examination she had a soft, mobile, centrally‐located neck mass. Fiberoptic laryngoscopy revealed a large, submucosal supraglottic mass. Computed tomography (CT) showed a 3‐cm supraglottic tumor with extralaryngeal extension. Needle aspiration suggested rhabdomyoma, confirmed by direct laryngoscopy with biopsy. She subsequently underwent awake tracheostomy, hemilaryngectomy, and reconstruction with aortic homograft. Pathology showed adult rhabdomyoma with representative large, polygonal cells with abundant cytoplasm, focal cross‐striations, and occasional “strap” cells. Three weeks postoperatively she was decannulated and found to have a functional voice and swallow. After six months of follow‐up she is without evidence of recurrence.

Conclusions:

Laryngeal rhabdomyoma is a rare benign clinical entity, which may present with airway distress and extralaryngeal extent. Treatment is complete surgical excision, possibly requiring open surgery with reconstruction. Aortic homograft reconstruction is safe, is technically straight‐forward, and has good postoperative results.
Chronic Pepsin Exposure Increases Cell Proliferation and Promotes Tumor Growth of Hypopharyngeal Cells
Authors: Kelly Elizabeth A. , Samuels Tina L. , Johnston Nikki
Published: August 2013

Objectives:

1) Investigate the role of reflux, specifically pepsin, in laryngopharyngeal carcinogenesis. 2) Evaluate effects of chronic pepsin exposure on cell proliferation, apoptosis, and colony forming ability in hypopharyngeal cells.

Methods:

Human hypopharyngeal squamous cell carcinoma FaDu cells were chronically exposed to nonacidic porcine pepsin (exposed for 24 hours, 4 times over 2 weeks at the following concentrations: 0.01mg/ml, 0.1 mg/ml, and 1mg/ml). Precise wounds were created in confluent cell plates. Rates of cell invasion into wounds were quantified. Separately, cell viability of chronic pepsin exposed FaDu cells acutely treated with paclitaxel was measured. Finally, a clonogenic assay was performed on these cells to measure effects of chronic pepsin exposure on colony forming ability.

Results:

In the invasion assay, an increased rate of relative wound density was observed in pepsin treated (0.01mg/ml, 0.1mg/ml) cells compared to control (P = 0.003, P < 0.001), suggesting greater rates of cell proliferation. Pepsin treated (0.1 mg/ml) cells had a greater cell viability compared to control after exposure to paclitaxel (P < 0.03) demonstrating greater apoptosis resistance. Chronic pepsin exposure (0.1mg/ml, 1mg/ml) was associated with dose dependent increase in colony forming ability relative to control (P < 0.001), supporting the role of pepsin as a tumor promoter.

Conclusions:

Hypopharyngeal cells chronically exposed to pepsin demonstrated an enhanced rate of cell proliferation and increased resistance to apoptosis and colony forming ability relative to control cells. These experiments indicate that chronic pepsin exposure acts as a tumor promoter in cellular transformation of airway epithelium, suggesting a role for pepsin in laryngopharyngeal carcinogenesis attributed to gastric reflux.
CO2 Laser versus Stapler‐Assisted Endoscopic Zenker's Diverticulotomy: A Systematic Review
Authors: Parker Noah P. , Misono Stephanie
Published: August 2013

Objectives:

To evaluate outcomes following endoscopic Zenker's diverticulotomy using a carbon dioxide (CO2) laser or stapler‐assisted technique.

Methods:

Systematic review and meta‐analysis of retrospective studies comparing CO2 laser and stapler‐assisted endoscopic Zenker's diverticulotomy were performed. PubMed, Scopus (Embase), and United States and United Kingdom clinical trial registries were searched. References were cross‐checked.

Results:

No randomized controlled trials were identified. Six studies were included: 2 retrospective reviews of consecutive patients, 3 retrospective reviews with unknown consecutive status, and 1 case series totaling 379 procedures (219 laser, 160 stapler). Individual study outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status and hospital stay (4 studies), as well as fewer postoperative fevers and abnormal chest x‐rays (1 study). Individual study outcomes favoring the laser technique included greater improvement in postoperative dysphagia and regurgitation scores and a lower revision rate (1 study). Random effects meta‐analysis of 2 appropriate studies demonstrated a greater duration of NPO status (weighted mean difference (WMD): 1.14, 95% confidence interval [0.46‐1.81]) and hospital stay (WMD: 2.84 [2.10‐3.58]) for the laser technique. Mantel‐Haenzel fixed effects meta‐analysis of all studies suggested a greater rate of non‐dental complications (odds ratio (OR): 2.32 [0.87‐6.20]) and revision surgery (OR: 1.27 [0.68‐2.36]) for the laser technique, but differences were not statistically significant.

Conclusions:

The stapler‐assisted technique may shorten duration of NPO status and hospital stay, while decreasing complication and revision rates compared to the laser technique for endoscopic Zenker's diverticulotomy; however, the best available evidence is Level 4.
Does Perception of Nasal Patency Correlate with Mucosal Cooling after Surgery for Nasal Obstruction?
Authors: Sullivan Corbin D. , Garcia Guilherme , Kimbell Julia S. , Frank Dennis O. , Rhee John S.
Published: August 2013

Objectives:

1) Quantify heat fluxes (ie, mucosal cooling) spatially in the nasal passages of nasal airway obstruction (NAO) patients before and after surgery using computational fluid dynamics (CFD). 2) Develop methods to correlate heat fluxes with patient‐reported symptoms, as measured by the nasal obstruction symptom evaluation (NOSE) and the visual analog score (VAS).

Methods:

Computed tomography (CT) scans of 10 patients were obtained before and after surgery to relieve NAO. Three‐dimensional models of each patient's nasal anatomy were used to run steady‐state CFD simulations of airflow and heat transfer during inspiration. The importance of anatomic location for perception of nasal patency was evaluated by comparing heat fluxes in the nasal vestibule vs. the entire nasal cavity, and by evaluating the percentage of nasal mucosa exposed to heat fluxes greater than 500 W/m2.

Results:

Post‐operatively, heat fluxes were statistically higher on the pre‐operative most obstructed side, for the nasal vestibule alone and the entire nasal cavity (p values < 0.01). A larger area of nasal mucosa was exposed to heat fluxes > 500 W/m2 after surgery than before. The best correlation between subjective and objective measures of nasal patency was obtained for NOSE against heat flux in the entire most obstructed nasal cavity (r = −0.81).

Conclusions:

A significant increase in heat fluxes (ie, mucosal cooling) correlates well with patients’ perception of better nasal patency after NAO surgery. CFD‐derived heat fluxes may prove to be a valuable predictor of success in NAO surgery.
Does Presence of Laryngotracheal Pepsin Increase Severity of Symptoms in Patients with Laryngotracheal Stenosis?
Authors: Khan Aayesha M. , Simpson C. Blake
Published: August 2013

Objectives:

Extraesophageal reflux has been implicated in the development of laryngotracheal stenosis, and presence of pepsin has been reported in up to 59% of patients with idiopathic subglottic stenosis. The objective of this study was to determine 1) the incidence of a positive pepsin biopsy in patients with laryngotracheal stenosis (LTS) and 2) if presence of laryngotracheal pepsin increases the severity of symptoms as perceived by the patients.

Methods:

A retrospective cohort was conducted on 24 patients with LTS who underwent pepsin biopsy. Severity of symptoms was determined by using Reflux Symptom Index (RSI), Voice Handicap Index‐10 (VHI‐10), and Glottal Function Index (GFI) scores on initial presentation. Student T‐test was used for statistical analysis.

Results:

The incidence of positive pepsin biopsy was 37.5% (9/24). Three patients were tracheostomy tube dependent and were excluded from further analysis, which resulted in 8 pepsin positive and 13 pepsin negative patients. The mean RSI, VHI‐10, and GFI scores were higher in the pepsin positive group; only the GFI scores were statistically significant (P = 0.034) between the two groups.

Conclusions:

In this cohort only 37.5% of patients with laryngotracheal stenosis tested positive for pepsin. Our study did not show a correlation of presence of pepsin with RSI or VHI‐10 scores but was statistically significant for GFI scores. This suggests that higher GFI scores may predict presence of pepsin at the site of stenosis. Larger studies are needed to determine if presence of pepsin plays a role in the severity of laryngotracheal stenosis.
Etiology and Presentation Time of Unilateral Vocal Fold Paralysis
Authors: Paniello Randal C. , Grindler David J.
Published: August 2013

Objectives:

1) Determine the etiology of unilateral vocal fold paralysis (UVFP) at a tertiary care institution over 10 years. 2) Determine the length of time between onset of symptoms and presentation/diagnosis of UVFP by an otolaryngologist at a tertiary medical center.

Methods:

Retrospective review of medical records of patients with UVFP between 2002 and 2012 in a tertiary care institution. Patients were seen and evaluated over 10 years by the Department of Otolaryngology at the Washington University School of Medicine. Medical records were reviewed for information relating to diagnosis, initial presentation date, date of onset of symptoms, and etiology of UVFP.

Results:

938 patients were included in the study. 621 (66.2%) patients had left sided UVFP. 581 (61.9%) patients had UVFP due to iatrogenic effects related to surgery. 158 (27.2%) of these were related to thyroid/parathyroid surgery. 357 patients had UVFP due to reasons not related to surgery. 124 (34.7%) patients had idiopathic UVFP. The median time to presentation from symptom onset until presentation to any otolaryngologist was 2 months. There was a significant delay of 3.33 months between mean time to presentation to a community otolaryngologist and subsequent referral and evaluation at a tertiary medical center, P < 0.01.

Conclusions:

Iatrogenic injury related to surgery is the most common cause of UVFP. Thyroidectomy remains the leading cause of surgically related UVFP. Patients are typically seen within 4 months; however, a significant delay exists between diagnosis and referral to a specialist.