Intractable Aspiration Treated With Laryngectomy After SLAD-R Surgery: A Case Report.

A variety of surgical treatment options exist for adductor spasmodic dysphonia (ADSD) with selective adductor recurrent laryngeal nerve denervation and reinnervation (SLAD-R) being one of the more popular. We present a case of bilateral vocal fold paralysis (BVFP) for SLAD-R resulting in the need for total laryngectomy. We suggest BVFP is more common than reported and that we all must insure optimal long term follow up of our surgical patients. Laryngoscope, 2024.

Inhibitors of the CD73-adenosinergic checkpoint as promising combinatory agents for conventional and advanced cancer immunotherapy.

The cell surface enzyme CD73 is increasingly appreciated as a pivotal non-redundant immune checkpoint (IC) in addition to PD-1/PD-L1 and CTLA-4. CD73 produces extracellular adenosine (eADO), which not only inhibits antitumor T cell activity via the adenosine receptor (AR) A2AR, but also enhances the immune inhibitory function of cancer-associated fibroblasts and myeloid cells via A2BR. Preclinical studies show that inhibition of the CD73-adenosinergic pathway in experimental models of many solid tumors either as a monotherapy or, more effectively, in combination with PD-1/PD-L1 or CTLA-4 IC blockades, improves antitumor immunity and tumor control. Consequently, approximately 50 ongoing phase I/II clinical trials targeting the CD73-adenosinergic IC are currently listed on https://clinicaltrials.gov. Most of the listed trials employ CD73 inhibitors or anti-CD73 antibodies alone, in combination with A2AR antagonists, and/or with PD-1/PD-L1 blockade. Recent evidence suggests that the distribution of CD73, A2AR and A2BR in tumor microenvironments (TME) is heterogeneous, and this distribution affects CD73-adenosinergic IC function. The new insights have implications for the optimally effective, carefully tailored approaches to therapeutic targeting of this essential IC. In the mini-review, we briefly discuss the cellular and molecular mechanisms of CD73/eADO-mediated immunosuppression during tumor progression and therapy in the spatial context of the TME. We include preclinical data regarding therapeutic CD73-eADO blockade in tumor models as well as available clinical data from completed trials that targeted CD73-adenosinergic IC with or without PD-1/PD-L1 inhibitors and discuss factors that are potentially important for optimal therapeutic outcomes in cancer patients.

HPV-associated oropharyngeal Adenosquamous carcinoma with early metastatic disease detected by ctDNA.

Adenosquamous Carcinoma is a rare, aggresssive variant of squamous cell carcinoma that may HPV-driven in the oropharynx. Although it is reported to behave similar to HPV-related squamous cell carcinoma, the literature is very limited for this disease. We present a case of early T and N stage HPV + adenosquamous carcinoma of the tonsil that metastasized immediately following surgery and adjuvant therapy despite only having microscopic nodal burden. Circulating tumor DNA (ctDNA) was instrumental in recognizing and salvaging metastatic disease early with radiation.

Base of tongue neuroendocrine carcinoma: A case report.

Neuroendocrine tumors are rare entities in the head and neck and an even more rare entity in the tongue. In this case report, we describe a calcified neuroendocrine tumor of the base of tongue that was presumed to be benign and was electively excised with pathology demonstrating low-grade carcinoma with focal neuroendocrine features and extensive ossification. We then discuss the histopathology and management.

Occult Metastasis in Laryngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis.

OBJECTIVE: The incidence of occult metastasis (OM) in laryngeal squamous cell carcinoma (SCC) is still widely debated. In this systematic review, we aim to determine the rate of OM in laryngeal SCC, its impact on recurrence, and the role of elective neck dissection (END) in the management of the clinically negative neck. METHODS: A systematic review of the English-language literature in Web of Science, PubMed, MEDLINE, and Cochrane Library databases on occult metastasis in laryngeal SCC from 1977 to 2018 was conducted. Studies evaluating occult metastasis (OM) in patients with laryngeal SCC with clinically negative necks undergoing surgery were included. Studies evaluating other head and neck subsites, clinically node positive, and salvage patients were excluded. RESULTS: Twenty-one articles with a total of 5630 patients were included. The overall rate of OM was 20.5% and was 23% and 12.2% in supraglottic and glottic tumors, respectively. The OM rate in T1-T2 tumors was 13% and 25% in T3-T4 tumors. T3-T4 tumors had significantly greater odds of developing OM compared to T1-T2 tumors (Odds Ratio [OR] = 2.61, 95% Confidence Interval [CI] = 1.92-3.55, P < .00001). Patients with OM were more likely to develop distant metastasis (OR = 5.65, 95% CI = 3.36-9.51, P < .00001). CONCLUSIONS: Patients with advanced T-stage laryngeal SCC should undergo elective neck treatment. More aggressive treatment for patients with history of OM should be considered due to the risk of subsequent regional and distant metastasis. LEVEL OF EVIDENCE: II.

18F-fluorodeoxyglucose positron emission tomography/computed tomography in predicting overall survival of oral cavity squamous cell carcinoma: Ongoing controversy.

We aimed to retrospectively determine if initial staging 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/ CT) can predict overall survival (OS) in oral cavity squamous cell carcinoma (OCSCC), which is currently a source of ongoing controversy in the literature. Forty-six consecutive patients with nonmetastatic (Stage M0) OCSCC had 18F-FDG PET/CT prior to definitive surgical treatment followed by observation or adjuvant treatment at our institution between 2006 and 2012. The median follow-up time was 18 months (range 0.1-76 months). Univariate and multivariate analysis were used to determine the ability of imaging, pathologic, and demographic factors to predict OS. 18F-FDG PET/CT parameters were standardized uptake value (SUV) maximum and mean, metabolic tumor volume, and total lesional glycolysis (TLG) of primary tumor and regional nodes. Significant predictors of OS in the multivariate analysis were primary tumor SUV mean, nodal TLG, and age. Two-year OS of patients with primary tumor SUV mean below and above the median of 6.26 was 68% and estimated 28%, respectively. Two-year OS of patients with nodal TLG below and above median of 7.9 was 69% and 34%, respectively. Two-year OS of patients younger and older than median age of 57 was 60% and 43%, respectively. Our results suggest that 18F-FDG PET/CT may be a valuable addition to multifactorial models predicting outcome for OCSCC. Thus, continued research aiming to incorporate 18F-FDG PET/CT parameters in risk-stratification algorithms for OCSCC is warranted and should be conducted using more standardized prognostic models driven by a specific clinical question.

Implementation of an interdisciplinary tracheostomy care protocol to decrease rates of tracheostomy-related pressure ulcers and injuries.

OBJECTIVES: Tracheostomy-related pressure injuries (TRPI) have been demonstrated to occur in approximately 10% of tracheostomy patients. In this study, we present TRPI outcomes after implementation of a standardized tracheostomy care protocol. METHODS: A tracheostomy care protocol was developed by an interdisciplinary quality improvement program and implemented on July 1, 2016. The protocol was designed to minimize factors that contribute to the development of TRPI. Rates of TRPI over the subsequent 20 months were compared to the year before implementation. RESULTS: 9 out of 85 patients (10.6%) developed TRPI in the pre-protocol cohort compared to 0 of 137 (0%) in the post-protocol cohort, which was a statistically significant decrease by Fisher's exact test with a p-value of 0.0001. Pearson's correlation coefficient demonstrated a negative correlation between age and post-operative day of diagnosis (r = -0.641, p = 0.063), indicating that older patients develop TRPI more quickly. CONCLUSIONS: Interdisciplinary peri-operative tracheostomy care protocols can be effective in decreasing rates of TRPI.

Preoperative Stellate Ganglion Block for Perioperative Pain in Lateralized Head and Neck Cancer: Preliminary Results.

Patients with head and neck cancer represent a vulnerable population at particular risk of opioid dependence due to frequent histories of substance abuse, requirement of extensive surgery, and the synergistic toxicity of multimodal therapy. Regional anesthetic techniques have been used by other surgical disciplines to facilitate early recovery after surgery and decrease postoperative patient narcotic requirements. This pilot study investigates the efficacy of a preoperative regional analgesia using stellate ganglion block in lateralized head and neck cancer surgery. From our early results, stellate ganglion blockade may hold promise as an effective preoperative intervention for controlling early postoperative pain, lessening narcotic requirements, and improving quality of life.

Recurrence Rate after Endoscopic vs. Open Approaches for Juvenile Nasopharyngeal Angiofibroma: A Meta-analysis.

Context The effect on recurrence rate between patients with juvenile nasopharyngeal angiofibroma (JNA), treated by an endoscopic versus open approach, has not been well established. Objective A meta-analysis of the available literature concerning recurrence rate in patients who underwent surgery for JNA. Methods A retrospective meta-analysis of studies analyzing recurrence rate after endoscopic or open surgery for patients with JNA was performed using the DerSimonian-Laird random-effects method. English and non-English articles were reviewed using Embase, Medline, and Cochrane databases. Results Among nine studies, including 362 patients from 1981 to 2015, with a mean follow-up of 49.4 months, a total of 89 patients (24.5%) had recurrence. Our analysis revealed a total effect size of -0.16 in favor of endoscopic approach (-0.25 to -0.06, CI [confidence interval] 95%). When analyzing tumor by stage (Radkowski's IA-IIIB n = 299), the endoscopic approach proved to be superior independent of tumor stage (2 vs. 17% for tumors stage IA-IIA, and 26 vs. 32% for tumor stage IIB-IIIB for endoscopic and open approaches respectively; p < 0.05). The endoscopic approach has a statistical significant lower recurrence rate in patients without intracranial compromise when compared with the open approach (13 vs. 28%; p < 0.02). No statistical difference was seen in patients with intracranial compromise ( p = 0.5) Conclusion The use of an endoscopic approach to treat JNA has a significantly lower recurrence rate when compared with open approaches. Independent of disease stage, an endoscopic approach should be the standard of care to surgically treat JNA. For cases with intracranial compromise, either approach can be used for surgical resection.

Tumefactive fibroinflammatory lesion successfully treated with Rituximab.

Skull base pseudotumors, or tumefactive fibroinflammatory lesions (TFIL), are tumors characterized by local destruction with benign histopathology. Treatment includes surgery and steroids with varying degrees of symptom relief. A 45-year-old female presented with right otorrhea and middle ear effusion, which progressed to CN V3 pain/numbness, trismus, headache, and autophony. MRI showed a diffuse infiltrating mass in the right infratemporal region involving the trigeminal ganglion. Biopsy revealed benign fibromuscular and adipose tissue with lymphoplasmacytic infiltrate, giving a diagnosis of TFIL. Resection would be very difficult given tumor location. Initial treatment included an extended course of steroids without response, and interval disease progression. Two courses of rituximab 375 mg/m2 weekly × 4 given 3 months apart were then completed with excellent tolerance. With sixteen months following induction, the patient reports minimal symptoms with radiographic findings confirming continued disease regression. Rituximab is a potential treatment option for patients with TFIL without response to steroids.

Salivary Gland Cancers of the Nasopharynx: A Population-Based Analysis of 383 Cases.

OBJECTIVES/HYPOTHESIS: Salivary gland nasopharynx cancers (SGNPCs) are rare malignancies with few cases discussed in the literature. This study represents the largest cohort of SGNPC to date. STUDY DESIGN: Retrospective population-based analysis. METHODS: The Surveillance, Epidemiology, and End Results registry from 1973 to 2015 was utilized to extract 383 cases of SGNPC. Data were analyzed for demographic characteristics, incidence, clinicopathologic traits, and outcome prognosticators. RESULTS: White female patients aged >40 years were most commonly affected. The incidence was measured as 0.019 per 100,000 people. The majority of tumors presented at advanced stages (stage III/IV, 60.8%). Adenoid cystic carcinoma, adenocarcinoma, and mucoepidermoid carcinoma were the most commonly encountered histologies (43.1%, 31.6%, 13.3%, respectively). Cervical node involvement and distant metastasis were measured at 23% and 11.9%, respectively. Mucoepidermoid carcinomas presented with the best disease-specific survival at 5 and 10 years. Asian ethnicity, age <80 years, and earlier American Joint Committee on Cancer stages were positive prognostic factors. The inclusion of surgical therapy improved 5-year outcomes among the most common histologies, except for mucoepidermoid carcinoma. CONCLUSIONS: Salivary gland nasopharyngeal cancer represents a group of rare histologies with similar outcomes as squamous cell carcinomas. However, prognosis is primarily dependent on histologic subtype, race, age, and American Joint Committee on Cancer stage.

Salivary Clear Cell Carcinoma Clinicopathologic Characteristics and Outcomes: A Population-Based Analysis.

BACKGROUND: Salivary clear cell carcinoma is an uncommon, low-grade malignancy for which limited data describing predictive clinicopathologic factors and treatment outcomes exist because of rarity. METHODS: The authors queried the Surveillance, Epidemiology, and End Results database from 1982 to 2014. Multivariate Cox and Kaplan-Meier analyses were performed to determine disease-specific survival (DSS) and predictive clinicopathologic factors. RESULTS: One hundred ninety-eight patients with salivary clear cell carcinoma were included. Overall incidence was 0.011 per 100 000 individuals, with no significant annual percentage change across years (-0.93%, P = .632). Five-, 10-, and 20-year DSS rates were 81.3% (n = 117), 69.6% (n = 94), and 55.3% (n = 68), respectively. Men (hazard ratio, 4.74; P = .0087) and patients with regional (hazard ratio, 5.59; P = .018) or distant (hazard ratio, 8.9; P = .01) metastases carried a worse prognosis. Five-year DSS was greater in patients with localized disease (96.36%, P < .0001) than those with regional or distant metastases. Treatment with surgery alone had better 10-year DSS (86.3%) compared with treatment with combination radiation and surgery (57.6%) or radiation monotherapy (18.75%, P < .0001). CONCLUSIONS: Salivary clear cell carcinoma carries an overall good prognosis. Patients with localized disease and those treated with surgery alone have more favorable prognoses. Male patients and those with regional or distant metastatic disease at time of presentation carry a worse prognosis. LEVEL OF EVIDENCE: N/A.

Radiation Therapy Impact on Lymph Node Yield in Patients With Laryngeal Squamous Cell Carcinoma.

BACKGROUND: A lymph node yield (LNY) over 20 is considered a quality metric for lateral neck dissection to ensure an oncologic representative sample. Anecdotally, however, LNY in patients undergoing neck dissection after radiation therapy (RT) is lower due to atrophy and fibrosis. OBJECTIVE: To determine whether preoperative RT decreases LNY in patients with laryngeal cancers undergoing surgery. METHODS: Medical record database was queried for patients presenting between 2006 and 2015 with laryngeal cancer. Tabulation was made for location (glottic/supraglottic), stage, and side for the total number of lymph nodes between primary surgery and RT (salvage surgery) groups. Descriptive analysis and a paired Student t test were used for statistical analysis. RESULTS: Fifty-nine patients were included in the study for a total of 98 neck dissections. Twenty-six (44%) patients had primary surgery, and 33 (56%) patients had salvage surgery. The mean left and right total LNY in the salvage surgery group was 27.6 and 29.5, respectively, and 32.2 and 33.7 for the primary surgery group. A difference of 4.5 (left) and 4.3 (right) in LNY between the salvage surgery and primary surgery group was found. A Student t test showed no statistically significant difference in LNY between both groups when analyzed per site (glottic and supraglottic), side, and stage (III-IV). CONCLUSION: Although patients with prior RT had a lower mean of LNY, our results did not demonstrate a statistically significant difference. Further studies with a larger number of patients are recommended.

Workup of Suspected Chest Metastases on 18F-FDG-PET/CT in Head and Neck Cancer: Worth the Wait?

The objective of our study is to assess the impact of equivocal or positive positron emission tomography combined with low-dose noncontrast computed tomography (PET/CT) findings in the chest on treatment for head and neck cancer (HNC). We reviewed charts of patients presented at Augusta University's Head and Neck Tumor Board (AUTB) between 2013 and 2016 with the following exclusion criteria: <18 years, Veterans Affairs patients, those with incomplete data, and those without a history of head and neck squamous cell carcinoma. The lung/thorax sections of the radiologists' PET/CT reports were graded as "Positive, Equivocal, or Negative" for chest metastases. Patients who underwent workup for suspected chest metastases were assessed for treatment delays, changes in treatment plans, and complications. In addition, we evaluated the time between AUTB presentation and peri-treatment PET/CT to primary treatment initiation were calculated between groups. There was a total of 363 patients with PET/CT prior to treatment, the read was "Negative" in 71.3% (n = 259), "Equivocal" in 20.9% (n = 76), and "Positive" in 5.8% (n = 21). Of 272 patients with complete treatment data, 22 underwent workup for suspected chest metastases. Mean time from PET/CT to treatment initiation was 27.5 days without workup and 64.9 days with workup ( P < .0001), and from AUTB presentation was 29.1 days without workup and 62.5 days with workup ( P < .0001). Five (19.2%) patients experienced a complication from workup. Twenty (76.9%) patients had no changes in their treatment plan after workup. In conclusion, our results for potential chest metastases on PET/CT in patients with HNC are often not clear-cut. Workup of suspected chest metastasis based on PET/CT findings significantly delays primary treatment initiation and may cause serious complications.

Conversion to Chronic Invasive Fungal Sinusitis From Allergic Fungal Sinusitis in Immunocompetence.

A review of the treatment of allergic and invasive fungal sinusitis, as well as a presentation of the first recorded case of a conversion from allergic fungal sinusitis (AFS) to chronic granulomatous invasive sinusitis and the fourth case of invasive fungal sinusitis associated with Curvularia. This immunocompetent patient suffering from chronic AFS converted after repeated high-dose steroid tapers and noncompliance. AFS may present atypically and should be suspected even in immunocompetent patients with sinus disease who report new onset pain and neurologic symptoms. Clinicians should consider the potential complications associated with repeated systemic steroid administration. Laryngoscope, 129:2447-2450, 2019.

Cervical nodal metastasis after malignant conversion of sinonasal inverted papilloma: Report of a rare case and literature review.

Malignant conversion of sinonasal inverted papilloma (SNIP) occurs in approximately ten percent of cases. These tumors are classically described as locally destructive, but without metastatic potential. Only four cases of malignant conversion with cervical nodal metastases have been described in the English literature. We present the rare case of a 61-year-old Caucasian male with a nasopharyngeal recurrence of malignant SNIP with cervical and retropharyngeal nodal metastases. The patient underwent endoscopic transpterygoid with nasoseptal flap reconstruction, followed by staged bilateral and retropharyngeal node dissection. Histopathology of the specimens demonstrated poorly differentiated invasive nonkeratinizing squamous cell carcinoma with inverted-type features. Three months after surgery, the patient suffered from C1-C2 fractures consistent with osteoradionecrosis and expired. Although the rate of malignant conversion of SNIP is low, this case highlights the need for aggressive, definitive treatment and surveillance.

Clear Cell Myoepithelial Carcinoma Arising from the Hard Palate with Metastasis to the Lungs.

Myoepithelial carcinoma is an uncommon tumor of the salivary glands, most commonly the parotid gland. Clear cell myoepithelial carcinoma is a rare variant with an aggressive behavior. Here, we describe a case of clear cell myoepithelial carcinoma arising from the hard palate in an elderly male who underwent resection of the tumor and postop radiation. Posttreatment imaging demonstrated bilateral pulmonary nodules and a C2 body lesion concerning for metastasis. Biopsy of the lung lesions revealed a monomorphous population of optically clear cells with hyperchromatic and pleomorphic nuclei which were morphologically similar to the prior resection specimen. There are few reported cases of clear cell myoepithelial carcinoma arising from the hard palate, and there are even fewer reports on metastases to the lungs. Due to the low number of reported cases, prognosis and treatment of this neoplasm is not well defined.

Basaloid nasopharyngeal carcinoma: A population-based analysis of a rare tumor.

OBJECTIVES: Basaloid nasopharyngeal carcinoma (BNPC) is an extremely rare malignancy with a paucity of cases reported in the literature. This analysis represents the largest cohort of BNPC to date. STUDY DESIGN: Retrospective population-based analysis. METHODS: The Surveillance, Epidemiology, and End Results registry from 2001 to 2015 was utilized to extract a total of 82 cases of BNPC. Data were analyzed for incidence trends, demographic, and tumor characteristics, as well as potential outcome prognosticators. RESULTS: White male patients between the ages of 40 to 79 years were most commonly affected. The incidence was measured at 0.06 per 100 thousand people. The majority of tumors were considered high grade (grade III/IV; 92.2%). At presentation, patients were most commonly advanced stage (American Joint Committee on Cancer [AJCC] stage IV) at 29.3%, followed by AJCC stages II and III (20.7%, respectively). T2 tumors were most common at 28.8%. Cervical node involvement and distant metastasis were measured at 53.7% and 10.4%, respectively. One-year, 5-year, and 10-year disease-specific survival was 87.7%, 60.7%, and 29.8%, respectively. No prognostic factors were identified in this study. CONCLUSION: Basaloid squamous cell carcinoma represents a histologic subtype of nasopharyngeal carcinoma with excellent short-term outcomes but poor survival at 10 years when compared to conventional squamous cell carcinomas. LEVEL OF EVIDENCE: NA Laryngoscope, 129:2727-2732, 2019.

Outcomes of reapplication to otolaryngology residency: A prospective cohort study.

Although the field of otolaryngology has experienced a decline in the number of applicants to our residency programs, otolaryngology remains a highly competitive field with an extremely strong applicant pool. Many highly qualified candidates cannot obtain a position in our field each year, and many of these candidates choose to reapply the next year. Data are lacking regarding reapplicants' success rate and the best gap year employment and training options for these reapplicants. Reapplicants were studied prospectively via a two-stage survey during the 2014-2015 and 2015-2016 application cycles. Success rates for the overall group were compared to those from published data, and success rates between subgroups were also compared. First-time reapplicants in the study performed extremely well. Their match rate (19/22) was not significantly different from that of traditional otolaryngology applicants (551/619, p = 0.73) and was significantly higher than that of nontraditional applicants not in our cohort (23/62, p < 0.001). No significant difference was found between applicants by employment/training activities, with both researchers (11/12) and surgical interns (8/10, p = 0.57) performing well. Predictors of reapplicant success could not be assessed because only 3 reapplicants in the cohort were unsuccessful. First-time otolaryngology reapplicants remain a highly competitive group of applicants to our field, regardless of employment/training activities undertaken after graduating medical school.