Feasibility and safety of Heavy Lifting Strength Training in Head and Neck Cancer survivors post-surgical neck dissection (the LIFTING trial).

BACKGROUND: Light-to-moderate intensity strength training (LMST) improves muscular strength, physical functioning, and some side effects in head and neck cancer survivors (HNCS). Heavy lifting strength training (HLST) may further improve these outcomes; however, it has not been studied in HNCS. The primary aim of the LIFTING trial was to examine the feasibility and safety of a HLST program in HNCS ≥1-year post-surgical neck dissection. METHODS: In this single-arm feasibility study, HNCS were asked to complete a twice weekly, 12-week, supervised HLST program, gradually progressing to lifting heavy loads of 80-90% of 1 repetition maximum (1RM) for barbell squat, bench press, and deadlift. The feasibility outcomes included recruitment rate, 1RM completion rate, program adherence, barriers, and motivation. The preliminary efficacy outcomes included changes in upper and lower body strength. RESULTS: Nine HNCS were recruited over an 8-month period during the COVID-19 pandemic. All 9 (100%) completed the 1RM tests and successfully progressed to heavy loads at approximately 5 weeks. The median attendance was 95.8% (range 71-100%), and few barriers were reported. Weight lifted increased for squat/leg press (median change: +34kg; 95% CI +25 to +47), bench press (median change: +6kg; 95% CI +2 to +10), and deadlift (median change: +12kg; 95% CI +7 to +24). No adverse events were reported and participants were motivated to continue HLST after the study. CONCLUSIONS: HLST appears feasible and safe for HNCS and may result in meaningful improvements in muscular strength. Future research should consider additional recruitment strategies and compare HLST to LMST in this understudied survivor population. TRIAL REGISTRATION: NCT04554667.

Head-neck dissection course during COVID-19 pandemic: challenges, adaptations and how we did it.

INTRODUCTION: Cadaveric dissection courses have come to a standstill since the onset of the COVID-19 pandemic. In addition to limited operative opportunities, cancellation of such courses has severely impacted surgical training, especially in a craft-based specialty such as head-neck surgery. The aim of this educational project was to: (1) study the feasibility of an in-person head-neck cadaveric dissection course during COVID-19 pandemic; and (2) validate the educational benefit of this teaching method to ear, nose and throat (ENT) trainees. METHODS: We developed a 2-day head-neck cadaveric dissection course for ENT trainees. The course programme covered essential head-neck open surgical procedures. Content validity (subjective feedback) was assessed using a 5-point Likert scale. Construct validity (objective usefulness) was evaluated via two pre- and post-course questionnaires, estimating knowledge of head-neck surgical anatomy and self-assessment of levels of confidence with head-neck procedures, respectively. RESULTS: A risk assessment was conducted and a protocol developed (risk was deemed to be low/tolerable). Content validity showed high satisfaction compared with a median Likert score of 3, 'average' (p=0.000002). For construct validity, the mean score per question improved significantly (p=0.001). Overall levels of confidence showed a trend towards improvement (p=0.08). There was significant improvement in laryngectomy (p=0.01) and level I dissection (p=0.01), with an indication of improvement in level II-V dissection (p=0.07). CONCLUSIONS: We demonstrated that a cadaveric dissection course, using thorough risk assessment and protocol, could be safely conducted with high content and construct validation during these unprecedented times. This is an invaluable learning environment that needs to be encouraged despite infection control restrictions.

Primary thyroid squamous cell carcinoma presenting as a left-sided neck lump.

The elderly patient presenting with a neck lump often raises concerns regarding a malignancy. Thyroid gland malignancies are well recognised and subtype characteristics thoroughly researched, whereas rarer types of thyroid carcinoma are reported infrequently and often behave more aggressively. An 83-year-old woman was referred from the general practitioner (GP) to otolaryngology due to a 7-month history of an unexplained enlarging left-sided neck swelling. A fine-needle aspiration revealed cytology consistent with squamous cell carcinoma (SCC). Staging imaging failed to reveal evidence of a primary foci elsewhere. The definitive diagnosis was that of a primary thyroid SCC: a rare entity with limited citations in the literature. Surgical resection has been found to comprise the optimal treatment for this disease. Recognition of the possibility of primary thyroid SCC in elderly patients presenting with a neck lump, with prompt referral to a head and neck specialist permits a timely progression to potentially curative surgical management, a more promising prognosis and reduced mortality rates.

Concomitant malignancies in the neck: follicular dendritic cell sarcoma; a rare tumour presenting as a right-sided neck nodal mass and papillary carcinoma thyroid.

Follicular dendritic cell sarcoma is a rare low-grade sarcoma of mesenchymal origin. It involves the lymph nodes more commonly and rarely extranodal sites. The most common lymph node is cervical and usually presents as a painless asymptomatic mass. More often, it is a misdiagnosis, and there is a delay in treatment. It is rarely associated with Castleman disease, myasthenia gravis. Diagnosis of this condition is by histopathology and immunochemistry. Surgery is the primary modality of treatment, and adjuvant therapy has been tried with no definite trials due to the rarity of the disease. Here, we report a case of concomitant follicular dendritic sarcoma of the right cervical lymph node and papillary carcinoma of the thyroid managed in our institute. There was a line of investigations approaching towards a diagnosis, and she underwent total thyroidectomy and right modified radical neck dissection.

Getting Recovery Right After Neck Dissection (GRRAND-F): mixed-methods feasibility study to design a pragmatic randomised controlled trial protocol.

INTRODUCTION: We will evaluate the feasibility of a randomised controlled trial to estimate the effectiveness and cost-effectiveness of a rehabilitation intervention on pain, function and health-related quality of life following neck dissection (ND) after head and neck cancer (HNC). METHODS AND ANALYSIS: This is a pragmatic, multicentred, feasibility study. Participants are randomised to usual care (control) or usual care plus an individualised, rehabilitation programme (Getting Recovery Right After Neck Dissection, GRRAND intervention). Adults aged over 18 with HNC for whom ND is part of their care will be recruited from specialist clinics. Participants are randomised in 1:1 ratio using a web-based service. The target sample size is 60 participants. Usual care will be received by all participants during their postoperative inpatient stay consisting standard National Health Service care supplemented with a booklet advising on postoperative self-management strategies. The GRRAND intervention programme consists of usual care plus up to six individual physiotherapy sessions including neck and shoulder range of motion (ROM) and progressive resistance exercises, advice and education. Between sessions participants will be advised to complete a home exercise programme. The primary outcome is to determine recruitment and retention rates from study participants across sites. Outcomes will be measured at 6 and 12 months. Participants and physiotherapists will be invited to an optional qualitative interview at the completion of their involvement in the study. The target qualitative sample size is 15 participants and 12 physiotherapists. Interviews aim to further investigate the feasibility and acceptability of the intervention and to determine wider experiences of the study design and intervention from patient and physiotherapist perspectives. ETHICS AND DISSEMINATION: Ethical approval was given on 29 October 2019 (National Research Ethics Committee Number: 19/SC/0457). Results will be reported at conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: ISRCTN11979997. STATUS: Trial recruitment is ongoing and is expected to be completed by 30 August 2021.

Patient-Directed Home Drain Removal in Head and Neck Surgery.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to evaluate the efficacy and safety of at home drain removal in head and neck surgery patients. METHODS: The study population included patients who underwent head and neck surgery at an academic tertiary care center between February 2020 and November 2020 and were discharged with one to four drains with instructions for home removal. Prior to discharge, patients received thorough drain removal education. Patients were prospectively followed to evaluate for associated outcomes. RESULTS: One hundred patients were evaluated in the study. There was record for ninety-seven patients receiving education at discharge. The most common methods of education were face-to-face education and written instructions with educational video link provided. Of 123 drains upon discharge, 110 drains (89.4%) were removed at home while 13 (10.6%) were removed in office. Most drains were located in the neck (86.4%). There was one seroma, two hematomas, two drain site infections, and five ED visits; however, none of these complications were directly associated with the action of drain removal at home. Calculated cost savings for travel and lost wages was $259.82 per round trip saved. CONCLUSIONS: The results demonstrate that home drain removal can provide a safe and efficacious option for patients following head and neck surgery. This approach was safe and associated with patient cost savings and better utilization of provider's time. Furthermore, patients and healthcare providers avoided additional in-person encounters and exposures during the COVID-19 pandemic. Our findings warrant further investigation into cost savings and formal patient satisfaction associated with home drain removal. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2471-2477, 2021.

Outcomes of major head and neck reconstruction during the COVID-19 pandemic: The St. Andrew's centre experience.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. METHODS: A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri­operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. RESULTS: Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36-92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. CONCLUSION: Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri­operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

Hypofractionated chemoradiation for head and cancer: Data from the PET NECK trial.

There has been increased interest in hypofractionated accelerated chemoradiation for head and neck cancer during the recent first peak of the COVID-19 pandemic. Prospective data regarding this approach from randomised trials is lacking. In the PET NECK study, 564 patients with squamous cell carcinoma of the head and neck receiving definitive chemoradiation were randomised to either planned neck dissection or PET CT scan guided surveillance. In this surgical trial, three radiotherapy fractionation schedules delivered over 7, 6 or 4 weeks were permitted with synchronous chemotherapy. The purpose of this study was to determine efficacy and quality of life outcomes associated with the use of these schedules. Primary local control and overall survival in addition to quality of life measures at immediately post treatment and 6, 12 and 24 months post-treatment were compared between the three fractionation cohorts. In the 525 patients where fractionation data was available, 181 (34%), 288 (55%) and 56 (11%) patients received 68-70 Gy in 34-35 fractions (#), 60-66 Gy in 30# and 55 Gy in 20# respectively. At a minimum follow up of two years following treatment there was no significant difference between the three fractionation schemes in local control, overall survival or any quality of life measure. Despite the obvious limitations of this study, some data is provided to support the use of hypofractionated accelerated chemoradiation to avoid delays in cancer treatment and reduce hospital visits during the peak of a pandemic. Data from on-going randomised trials examining hypofractionated chemoradiation may be useful for selecting fractionation schedules during future pandemics.

Head and neck surgery during the coronavirus-19 pandemic: The University of California San Francisco experience.

BACKGROUND: Guidelines regarding head and neck surgical care have evolved during the coronavirus-19 (COVID-19) pandemic. Data on operative management have been limited. METHODS: We compared two cohorts of patients undergoing head and neck or reconstructive surgery between March 16, 2019 and April 16, 2019 (pre-COVID-19) and March 16, 2020 and April 16, 2020 (COVID-19) at an academic center. Perioperative, intraoperative, and postoperative outcomes were recorded. RESULTS: There were 63 operations during COVID-19 and 84 operations during pre-COVID-19. During COVID-19, a smaller proportion of patients had benign pathology (12% vs 20%, respectively) and underwent thyroid procedures (2% vs 23%) while a greater proportion of patients underwent microvascular reconstruction±ablation (24% vs 12%,). Operative times increased, especially among patients undergoing microvascular reconstruction±ablation (687 ± 112 vs 596 ± 91 minutes, P = .04). Complication rates and length of stay were similar. CONCLUSIONS: During COVID-19, perioperative outcomes were similar, operative time increased, and there were no recorded transmissions to staff or patients. Continued surgical management of head and neck cancer patients can be provided safely.

Assessment of YouTube as an Educational Tool in Teaching Key Indicator Cases in Otolaryngology During the COVID-19 Pandemic and Beyond: Neck Dissection.

OBJECTIVES: YouTube has become the preferred resource for trainees in otolaryngology to prepare for surgery. This study aimed to compare the evaluation by 2 attending physicians and 2 resident physicians of the quality of videos on YouTube on neck dissection, a key indicator case in head and neck surgery. The authors aimed to assess the quality and quantity of YouTube videos available for development of a virtual surgical educational curriculum for trainees in otolaryngology. METHODS: Using the YouTube search feature, the top 10 videos by relevance and view count were compiled using the following search terms: radical neck dissection, selective neck dissection, modified radical neck dissection, lateral neck dissection, levels I-III neck dissection, levels II-IV, left neck dissection, right neck dissection, cervical nodal dissection, and supraomohyoid neck dissection. A total of 37 videos on neck dissection were identified and analyzed using the LAP-VEGaS criteria as well as author-specific modified LAP-VEGaS criteria. RESULTS: The mean comprehensive LAP-VEGaS score was 8.74 (SD 3.10). The majority of videos (24/37) were designated as medium quality; 10 of 37 videos were low quality and 3 of 37 videos were high quality. In the total group analysis, there was excellent inter-rater reliability between attending physicians (Cohen's kappa coefficient of 0.84) and good inter-rater reliability between resident physicians (Cohen's kappa coefficient of 0.58). There was no correlation between total view count, video age, or number of likes/dislikes and the overall LAP-VEGaS score. The presence of audio or written commentary had a moderate positive correlation with LAP-VEGaS score (adjusted R2 of 0.36). There was no statistically significant difference in video quality between videos posted by US and non-US based physicians (95% confidence interval -0.10 to 4.10; p = 0.06). However, videos made by an otolaryngology-trained physician had a LAP-VEGaS score that was 3.93 points higher (95% confidence interval 2.34-5.52; p < 0.001) than that of videos made by a nonotolaryngology-trained physician. CONCLUSIONS: Online videos of neck dissection represent an increasingly ubiquitous and appropriate resource for trainees in learning otolaryngology key indicator cases. While free-to-access video repositories, such as YouTube, have become increasingly popular among trainees as a primary resource for learning and preparing for surgical cases, they lack consistent quality and as such, global efforts should be taken to improve the breadth and depth of educational video content in otolaryngology.

Impact of COVID-19 on thyroid cancer surgery and adjunct therapy.

COVID-19 has profoundly modified the way healthcare is delivered. Jordan imposed lockdown and restrictive policies between March 17 and May 20, 2020. We aimed to assess the impact of such measures on thyroid cancer treatment plans. In the specified period, 12 patients were scheduled for surgery. Since papillary carcinoma was the preoperative diagnosis in all cases, radioactive iodine ablation (RIA) therapy was also planned 3-4 weeks following surgery after withdrawing thyroxine and achieving a thyroid stimulating hormone (TSH) level > 30 mU/L. Thyroxine withdrawal is the routine method applied for RIA in Jordan as it is less costly compared to the rapid method of exogenous stimulation using recombinant TSH. All surgical procedures were performed without delay since all patients were asymptomatic per flu-like illness and came from a region of low COVID-19 prevalence. These included total thyroidectomy (n = 11), bilateral therapeutic central compartment neck dissection (n = 7), lateral compartment neck dissection (n = 5). However, the RIA treatment plan was altered considerably according to the period in which they were operated. 6 out of the 7 patients operated in March changed to the stimulated method of RIA at a considerable additional extra cost. The seventh patient and the April patient opt to delay RIA until after lockdown. The remaining cases (operated in May) followed the usual withdrawal method as restrictions were due to an end. The restrictive measures applied during COVID-19 did not affect the safe and timely delivery of surgical care. However, it added a financial and psychological burden to the entire cancer management plan.

Self-removing passive drain to facilitate postoperative care via telehealth during the COVID-19 pandemic.

BACKGROUND: Telehealth postoperative visits are an attractive strategy to minimize exposure, especially during the SARS-CoV-2 (COVID-19) pandemic. The use of a surgical drain often prevents this minimal-exposure approach in that patients return to the outpatient clinic for drain removal. METHODS AND RESULTS: Following unilateral neck dissection, the customary closed-suction drain was replaced with a self-removing, passive drain dressing to facilitate same-day discharge and telehealth postoperative follow-up. The patient removed the dressing and drain at home during a telehealth visit on postoperative day 4 and she healed favorably without any signs of infection or seroma. CONCLUSIONS: When thoughtfully applied in the appropriate clinical context, small practice adaptations like this can facilitate telehealth solutions that diminish unnecessary exposure for patients, their caregivers, and health care staff.

Major head and neck reconstruction during the COVID-19 pandemic: The University of Pittsburgh approach.

The 2019 novel coronavirus (COVID-19) pandemic has created significant challenges to the delivery of care for patients with advanced head and neck cancer requiring multimodality therapy. Performing major head and neck ablative surgery and reconstruction is a particular concern given the extended duration and aerosolizing nature of these cases. In this manuscript, we describe our surgical approach to provide timely reconstructive care and minimize infectious risk to the providers, patients, and families.