Head & neck melanoma: A 22-year experience of recurrence following sentinel lymph node biopsy.

OBJECTIVE: To examine the clinicopathologic factors that contribute to regional and distant recurrence in intermediate to high risk head and neck melanoma patients after sentinel lymph node biopsy (SLNB). METHODS: This study is a retrospective review from an academic tertiary care center. Patients treated with SLNB for head and neck melanoma from 1997 to 2019 were reviewed and characterized by sentinel lymph node (SLN) status. Clinical variables were examined for the impact on regional and distant recurrence in SLNB-negative patients using univariable and multivariable Cox regression analysis. RESULTS: One hundred and fifty four patients were included. Of note, 127 (82.5 %) were men, and the average age was 61.3 years. Median follow-up was 68.6 weeks. Pathologic review of SLNs found 3.9% positive for metastatic melanoma; 96.1% were negative. Regional recurrence was significantly associated with tumor stage and age on multivariate analysis. A total of 4.5% of patients recurred in a previously labeled negative basin. Scalp subsite accounted for 30.5% of primary tumors and was more likely to yield a positive SLN on univariate analysis (P = .023). Tumor stage and age were significantly associated with distant metastasis on multivariable analysis (P = .026, P < .001 respectively). CONCLUSION: We report a number of prognostic trends in head and neck melanoma. SLN positivity was found more often in patients with a primary tumor of the scalp. Regional recurrence was significantly associated with age and tumor stage, whereas distant recurrence was significantly associated with tumor staging and scalp subsite. Scalp subsite was associated with an increased risk for nodal metastasis and distant recurrence. LEVEL OF EVIDENCE: 3.

Standardization of thyroid ultrasound reporting in the community setting decreases biopsy rates.

OBJECTIVE: With the rising incidence of thyroid cancer, a standardized approach to the evaluation of thyroid nodules is essential. Despite the presence of multiple national guidelines detailing evaluation and management of these nodules, significant variability exists in the information that is collected and reported to clinicians from diagnostic imaging. The aim of this study was to evaluate the impact of thyroid ultrasound standardization on thyroid cancer detection in a community practice setting. DESIGN: As part of a physician-driven quality improvement project, a multidisciplinary team created an electronic worksheet to be utilized by sonographers to capture suspicious findings based on societal guidelines and agreed on institutional criteria for recommending fine needle aspiration (FNA) of thyroid nodules. PATIENTS: For a one-year period prior to and after the intervention, all ultrasounds performed for suspected thyroid pathology, excluding patients undergoing follow-up imaging, were reviewed at two affiliated community hospitals served by a single radiology and pathology group. MEASUREMENTS: The number of fine needle biopsies recommended and performed, as well as the percentage of FNAs positive for malignancy were evaluated. RESULTS: A total of 608 and 675 ultrasounds were reviewed in pre- and post-standardization periods, respectively. Following standardization, there was a similar percentage of FNAs recommended (35% vs. 37%, p = .68), fewer FNAs per total ultrasounds performed (36% vs. 31%, p = .03), fewer FNAs performed when FNA was not explicitly recommended (9.9% vs. 2.8%, p = .000046) and an increased detection of cytology consistent with, or suspicious for, malignancy (5% vs. 11.5%, p = .0028). CONCLUSIONS: Standardization of thyroid imaging protocol and management recommendations can reduce the number of FNAs performed and increase the percentage of positive tests in a community setting.

Safety of fibula free flap in patients following total knee replacement.

BACKGROUND: Fibula free flap (FFF) is the preferred osteocutaneous flap for reconstruction of large head and neck composite defects. There is a paucity of data whether FFF can be performed safely in patients with knee replacement (total knee arthroplasty [TKA]). METHODS: Multi-institutional review of outcomes following FFF in patients who had prior TKA. RESULTS: Ten surgeons reported successful FFF in 53 patients with prior TKA. The most common preoperative imaging was a CT angiogram of the bilateral lower extremities. There was no evidence of intraoperative vascular abnormality. Physical therapy began between postoperative day 1 to postoperative day 3. At 1 month postoperatively, 40% of patients were using a cane or walker to ambulate, but by 3 months all had returned to baseline ambulatory status. At >1 year, there were no gait complications. CONCLUSION: FFF appears safe in patients with prior knee replacement without an increased risk of complications compared to baseline.

Effect of defensins-containing eye cream on periocular rhytids and skin quality.

BACKGROUND: Defensins are peptides shown to activate LGR6 stem cells to stimulate the production of new basal stem cells in the epidermis. Use of topical definsin-containing products has been shown to address signs of global skin aging including decrease of wrinkles and increase of epidermal thickness. AIMS: To investigate the ability of a topical defensin-containing skincare product in improving the structure and function of aging periocular skin using objective and subjective outcome measures. PATIENTS/METHODS: A prospective pilot trial of a defensin-containing eye cream was performed in patients with periocular rhytids over 6 weeks. Subjective changes in skin quality and aging characteristics were compared using a patient survey tool. Objective changes in periocular skin quality were analyzed using the QuantifiCare imaging system and the DermLab ultrasound scanner by blinded reviewers. RESULTS: A total of eight patients completed treatment; two were male, and six were female. The average age was 51 years (range 37-63). Compliance with product application as reported on the participant application log was over 90%. Overall, there was an average 2.1 point improvement in subjective measures of skin quality on the consumer questionnaire (P = .002). QuantifiCare imaging of pores, wrinkles, and oiliness showed 370% improvement, 55% improvement, and 12% improvement, respectively. DermaLab noninvasive measurements of elasticity, skin thickness, and hydration showed improvement of 120%, 28%, and 6%, respectively. CONCLUSION: The use of topical formulations of definsin-containing eye cream statically improves patient-reported outcomes of skin quality, especially redness, sensitivity to weather, age spots, and crow's feet.

Tracheostomy Considerations during the COVID-19 Pandemic.

OBJECTIVE: To compile current best practices regarding tracheostomy decision making, care, and technical performance during the global COVID-19 pandemic. DATA SOURCES: Articles listed in PubMed and Google sources for up-to-date information. REVIEW METHODS: All sources presenting objective evidence related to the topic were reviewed and distilled. CONCLUSIONS: Tracheostomy in patients with coronavirus disease should be a rare event yet one that requires significant decision making and procedural deliberation. Indications for surgery must be balanced by risk of disease transmission to health care workers. Considerations are given to personal protective equipment, viral testing, and alternatives. IMPLICATIONS FOR PRACTICE: Otolaryngologists worldwide must be aware of these considerations to provide safe patient care without undue risk to themselves or their hospital coworkers.

Merkel Cell Carcinoma: A 28-Year Experience.

OBJECTIVE: To evaluate the management and recurrence outcomes of head and neck Merkel cell carcinoma (HN-MCC) at a single institution. STUDY DESIGN: A retrospective review of outcomes in patients with HN-MCC. SETTING: A tertiary center from May 1990 to December 2018. SUBJECTS AND METHODS: Electronic medical records of patients with HN-MCC were reviewed. RESULTS: Sixty cases were included, with 67% (40 of 60) males and a mean age of 73.3 years. Imaging had a moderate sensitivity and specificity for detection of occult disease when compared with histopathologic analysis. Forty-two percent (25 of 60) of patients underwent neck dissection, and 12% (7 of 60) had a sentinel lymph node biopsy (SLNB). There was a high rate of negative SLNB findings. The majority of patients were treated with surgery alone (29 of 60), followed by a cohort (21 of 60) treated with surgery plus adjuvant treatment, and 10 of 60 patients were treated with radiation therapy with or without chemotherapy. Recurrence-free survival was 50%, 45%, and 42% at 1, 2, and 5 years. CONCLUSIONS: We report higher recurrence rates and higher negative SLNB result rates than other studies. Our results affirm that imaging may not be a substitute for SLNB and that it had an intermediate ability to identify the occult disease. Traditional predictors, including SLNB and cervical node pathology, may not identify patients at risk for recurrence in HN-MCC. We report similar recurrence rates in patients who had treatment of the cervical nodes by radiation therapy or neck dissection as compared with those who did not receive neck treatment.

Drug-Induced Sleep Endoscopy Performed in the Endoscopy Suite: A Resource Utilization Analysis.

OBJECTIVES: To analyze the resource utilization of performing drug-induced sleep endoscopy (DISE) procedures in an endoscopy suite (ES) setting as compared with the operating room (OR). STUDY DESIGN: A retrospective review of DISE procedures performed by a single attending surgeon from 2016 to 2018. SETTING: Tertiary hospital. SUBJECTS AND METHODS: All patients undergoing sleep endoscopy without concurrent surgical procedures were included. No exclusion criteria were incorporated. Analysis assessed for differences in procedure-related expenditures, patient characteristics, anesthesia and surgeon time, and access to care. RESULTS: A total of 87 sleep endoscopies were included: 65 (74.7%) performed in the ES and 22 (25.3%) in the OR. Patient groups were similar in age and apnea-hypopnea index severity (P > .05). Patient body mass index was significantly higher for the ES group (P = .03). Total facility time, postoperative recovery time, anesthesia care time, and time in the surgical room were significantly decreased in the ES setting (P < .01). Surgical time was similar between the groups (P > .05). For ES procedures, total cost was reduced by 74% (P < .01). DISE in the ES resulted in a mean $5080 less in health system charges versus the OR group (P < .01). There were no treatment-related complications in either setting. CONCLUSION: The resource utilization profile of performing DISE can be significantly improved by transferring these procedures from the OR to the ES setting.

It Takes Two: One Resects, One Reconstructs.

Care of patients with advanced head and neck cancer is a multidisciplinary effort through all phases of care. Head and neck cancer surgery involves balancing oncologic control, functional preservation, and aesthetics. Given the advances in free tissue reconstruction, the majority of defects can be reconstructed using free tissue transfer flaps. A 2-team approach allows for early, continual communication and meticulous operative planning. Operations can be combined into a single effort. This approach maximizes efficiency and enables multidisciplinary collaboration for comprehensive surgical treatment. We present our experience and an outline of how responsibilities between the ablative and reconstructive teams are shared.