African American race as a risk factor associated with a second primary lung cancer after initial primary head and neck cancer.

BACKGROUND: Initial primary head and neck cancer (IPHNC) is associated with second primary lung cancer (SPLC). We studied this association in a population with a high proportion of African American (AA) patients. METHODS: Patients with IPHNC and SPLC treated between 2000 and 2017 were reviewed for demographic, disease, and treatment-related characteristics and compared to age-and-stage-matched controls without SPLC. Logistic and Cox regression models were used to analyze the relationship of these characteristics with the development of SPLC and overall survival (OS). RESULTS: Eighty-seven patients and controls were compared respectively. AA race was associated with a significantly higher risk of developing SPLC (OR 2.92, 95% CI 1.35-6.66). After correcting for immortal time bias, patients with SPLC had a significantly lower OS when compared with controls (HR 0.248, 95% CI 0.170-0.362). CONCLUSIONS: We show that AA race is associated with an increased risk of SPLC after IPHNC; reasons of this increased risk warrant further investigation.

Flipping the Classroom: An Evaluation of Teaching and Learning Strategies in the Operating Room.

OBJECTIVES: With increasing restraints on resident's experiences in the operating room, with causes ranging from decreased time available to increasing operating room costs, focus has been placed on how to improve resident's education. The objectives of our study are to (1) determine barriers in education in the operating room, (2) identify effective learning and teaching strategies for residents in the operating room with a focus on the tonsillectomy procedure. METHODS: An online survey was sent to all otolaryngology residents and residency programs for which contact information was available from January 2016 to March 2016 with 139 respondents. The 12-question survey focused on information regarding limitations to learning how to perform tonsillectomies as well as difficulties with teaching the same procedure. Resident responses were separated based on PGY level, and analysis was performed using t-tests and Chi squared analysis. RESULTS: Common themes emerged from responses for both teaching and learning how to perform tonsillectomies. A significant limitation in learning the procedure was lack of visualization during the surgery (57% learning vs 60% teaching). For both learners and teachers, the monopolar cautery instrument was found to be the most preferred instrument to use during tonsillectomy (80% each). The majority of resident respondents (93%) felt that an instructional video would be beneficial for both learning and teaching the procedure. CONCLUSIONS: Significant limitations for learning and teaching in the operating room were identified for performing tonsillectomies. Future endeavors will focus on resolving these limitations to improve surgical education. EVIDENCE LEVEL: Level IV.

Anti-PD-1 therapy using cemiplimab for advanced cutaneous squamous cell carcinoma in HIV patient: A case report.

This is a case of a 60-year-old man living with HIV who presented with advanced cutaneous squamous cell carcinoma. After workup, medical and surgical treatment, and disease recurrence, he achieved a complete response with no unexpected toxicities after immunotherapy with cemiplimab.

Tracheal Resection in the Management of Thyroid Cancer: An Evidence-Based Approach.

OBJECTIVE: Determine the effect of patient demographics and surgical approach on patient outcomes after tracheal resection in the management of thyroid cancer. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Systematic review of literature was performed using PubMed, Embase, and Cochrane Library to identify patients with thyroid carcinoma who underwent tracheal resection. Pooled estimates for patient demographics, presenting findings, complications, and outcomes are determined using random-effects meta-analyses. RESULTS: Ninety-six relevant studies encompassing 1,179 patients met inclusion criteria. Meta-analysis pooled rates of complications: 1.7% (confidence interval [CI] 0.8-2.5; P < .001; I2 = 1.85%) airway complications, 2.8% (CI 1.6-3.9; P < .001; I2 = 13.34%) bilateral recurrent laryngeal nerve paralysis, 2.2% (CI 1.2-3.1; P < .001; I2 = 6.72%) anastomotic dehiscence. Circumferential resection pooled estimates major complications, locoregional recurrence, distal recurrence, overall survival: 14.1% (CI 8.3-19.9; P < .001; I2 = 35.26%), 15% (CI 9.6-20.3; P < .001; I2 = 38.2%), 19.7% (CI 13.7-25.8; P < .001; I2 = 28.83%), 74.5% (CI 64.4-84.6; P < .001; I2 = 85.07%). Window resection estimates: 19.8% (CI 6.9-32.8; P < .001; I2 = 18.83%) major complications, 25.6% (CI 5.1-46.1; P < .014; I2 = 84.68%) locoregional recurrence, 15.6% (CI 9.7-21.5; P < .001; I2 = 0%) distal recurrence, 77.1% (CI 58-96.2; P < .001; I2 = 78.77%) overall survival. CONCLUSION: Management of invasive thyroid carcinoma may require tracheal resection to achieve locoregional control. Nevertheless, postoperative complications are not insignificant, and therefore this risk cannot be overlooked when counseling patients perioperatively. Laryngoscope, 131:932-946, 2021.

Novel Changes in Resident Education during a Pandemic: Strategies and Approaches to Maximize Residency Education and Safety

Abstract Introduction The COVID-19 pandemic has led to a reduction in surgical and clinical volume, which has altered the traditional training experience of the otolaryngology resident. Objective To describe the strategies we utilized to maximize resident education as well as ensure patient and staff safety during the pandemic. Methods We developed a system that emphasized three key elements. First and foremost, patient care remained the core priority. Next, clinical duties were restructured to avoid unnecessary exposure of residents. The third component was ensuring continuation of resident education and maximizing learning experiences. Results To implement these key elements, our residency divided up our five hospitals into three functional groups based on geographical location and clinical volume. Each team works for three days at their assigned location before being replaced by the next three-person team at our two busiest sites. Resident teams are kept completely separate from each other, so that they do not interact with those working at other sites. Conclusions Despite the daily challenges encountered as we navigate through the COVID-19 pandemic, our otolaryngology residency program has been able to establish a suitable balance between maintenance of resident safety and well-being without compromise to patient care.

Novel Changes in Resident Education during a Pandemic: Strategies and Approaches to Maximize Residency Education and Safety.

Introduction The COVID-19 pandemic has led to a reduction in surgical and clinical volume, which has altered the traditional training experience of the otolaryngology resident. Objective To describe the strategies we utilized to maximize resident education as well as ensure patient and staff safety during the pandemic. Methods We developed a system that emphasized three key elements. First and foremost, patient care remained the core priority. Next, clinical duties were restructured to avoid unnecessary exposure of residents. The third component was ensuring continuation of resident education and maximizing learning experiences. Results To implement these key elements, our residency divided up our five hospitals into three functional groups based on geographical location and clinical volume. Each team works for three days at their assigned location before being replaced by the next three-person team at our two busiest sites. Resident teams are kept completely separate from each other, so that they do not interact with those working at other sites. Conclusions Despite the daily challenges encountered as we navigate through the COVID-19 pandemic, our otolaryngology residency program has been able to establish a suitable balance between maintenance of resident safety and well-being without compromise to patient care.

The role of immune checkpoint inhibitors in anaplastic thyroid cancer (Case Series).

Anaplastic thyroid carcinoma (ATC) is a rare type of thyroid neoplasm. However, it is one of the most aggressive forms of malignancy accounting for approximately 50% of mortality associated with all thyroid cancers. Here we report two cases of ATC treated with immune checkpoint inhibitors. Next generation sequencing identified BRAFV600E mutation in one of the patients who also derived benefit from BRAF targeted therapy. We here discuss these cases highlighting the importance of expert pathological review, utilizing molecular testing to identify the underlying genetic targets for personalized therapy, and the potential role of PD-1 inhibitors for the treatment of ATC.

Survival, Outcomes, and Use of Acuity Scoring Systems Following Tracheotomy in Veteran Patients.

OBJECTIVES: To determine whether established prognosis tools used in the general population of critically ill patients will accurately predict tracheotomy-related outcomes and survival outcomes in critically ill patients undergoing tracheotomy. METHODS: Retrospective chart review of 94 consecutive critically ill patients undergoing isolated tracheotomy. RESULTS: Logistic Organ Dysfunction System (LODS) and sepsis-related organ failure assessment (SOFA) scores, 2 validated measures of acuity in critically ill patients, were calculated for all patients. The only tracheotomy-related outcome of significance was the finding that patients with an LODS score ≤6 were more likely to become ventilator independent (P < .015). Higher LODS or SOFA scores were associated with in-house death (LODS, P = .001, SOFA, P = .008) and death within 90 days (LODS, P = .009, SOFA, P = .031), while death within 180 days was associated only with a higher LODS score (LODS, P = .018). When controlling for age, there was an association between both LODS (P = .015) and SOFA (P = .019) scores and death within 90 days of tracheotomy. CONCLUSIONS: The survival outcome for critically ill patients undergoing tracheotomy seems accurately predicted based on scoring systems designed for use in the general population of critically ill patients. Logistic Organ Dysfunction System may also be useful to predict the likelihood of the tracheotomy-related outcome of ventilator independence. This suggests that LODS scores may be helpful to palliative care clinicians as part of a shared decision-making aid in critically ill, ventilated patients for whom tracheotomy is being considered.

Complete response with neoadjuvant avelumab in Merkel cell carcinoma - A case report.

Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine skin malignancy. We report here a case of localized MCC achieving pathologic complete response upon treatment with avelumab in the neoadjuvant setting. Preclinical and clinical studies have revealed a close relationship between MCC and the immune system, thus supporting a role for PD-1/PD-L1 inhibitors in MCC. This neoadjuvant use of PD-1/PD-L1 inhibitors can avoid potentially disfiguring surgery in MCC. As the incidence of MCC is rising, clinical trials are needed to evaluate the efficacy and safety of immunotherapy in resectable disease.

Development and Assessment of a Novel Composite Pathologic Risk Stratification for Surgically Resected Human Papillomavirus-Associated Oropharyngeal Cancer.

Importance: Human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) is a distinct form of head and neck squamous cell carcinoma (HNSCC) with its own American Joint Committee on Cancer staging system. However, pathologic risk stratification for HPV+ OPSCC largely remains based on the experience with HPV-unassociated HNSCC. Objective: To compare the survival discrimination of traditional pathologic risk stratification for both HPV+ OPSCC and HPV-unassociated HNSCC and derive a novel pathologic risk stratification system for HPV+ OPSCC with improved survival discrimination. Design, Setting, and Participants: In this retrospective cohort study, we used the National Cancer Database to identify 15 324 patients diagnosed with nonmetastatic HNSCC between January 1, 2010, and December 31, 2013, who were treated with upfront surgery and neck dissection. We compared traditional pathologic risk stratification for HPV+ OPSCC and HPV-unassociated HNSCC and then derived a novel pathologic risk stratification system. Analyses were performed from July 1, 2018, to January 31, 2019. Exposures: Definitive primary surgical resection and neck dissection. Main Outcomes and Measures: Survival discrimination of pathologic risk stratification systems measured with concordance indices. Results: This retrospective cohort study included 15 324 patients (10 779 men and 4545 women; mean [SD] age, 59.9 [11.8] years) with surgically treated nonmetastatic HNSCC. Separation of survival curves for HPV-unassociated HNSCC using traditional pathologic risk stratification (5-year overall survival for the low-, intermediate-, and high-risk groups) were 76.2%, 54.5%, and 40.9%, respectively. Separation curves for HPV+ OPSCC were 93.2%, 88.9%, and 83.7%, respectively. Human papillomavirus-unassociated HNSCC had a concordance index of 0.68, whereas HPV+ OPSCC had a concordance index of 0.58. A novel risk stratification system for HPV+ OPSCC that more closely fits actual survival rates for HPV+ OPSCC was derived. The system incorporated the composite number of pathologic adverse features. This composite risk stratification system was associated with an improved concordance index of 0.67 for HPV+ OPSCC. Adjuvant treatment with radiation was not associated with improved survival for patients categorized as low risk according to the new risk stratification system, but this treatment was associated with improved survival for patients in the intermediate- and high-risk groups. Conclusions and Relevance: Traditional pathologic risk stratification shows poor survival discrimination for HPV+ OPSCC and classifies many patients with an excellent prognosis as high risk. We derived a novel composite pathologic risk stratification system for HPV+ OPSCC that may be associated with improved survival discrimination.

Submandibular Gland Invasion by Oral Cavity Cancers: A Systematic Review.

OBJECTIVE: The submandibular gland (SMG) is typically included in level I neck dissection specimens despite limited data demonstrating SMG invasion. The main objective of this article is to determine the rate and pathways of SMG invasion by squamous cell carcinoma of the oral cavity and oropharynx. DATA SOURCES: A systematic review of relevant studies was performed, evaluating articles identified via the PubMed, Cochrane, and Medline databases. REVIEW METHODS: Descriptive features of primary tumors, primary treatment modalities, the rate and pathway of SMG invasion, and survival outcomes, if present, were reported following the PRISMA guidelines. RESULTS: The initial literature search yielded 273 articles, of which 17 met inclusion criteria. A total of 2306 patients with 2792 SMG resections were analyzed. Fifty-eight resections (2.0%) were revealed to have tumor involvement. Among patients with SMG tumor involvement, the most common invasion pathway was direct SMG invasion by primary tumor (43 of 58, 74.1%). The second-most common mode of SMG invasion was from involved adjacent lymph nodes (10 of 58, 17.2%). Only 3 SMG resections out of 2792 (0.1%) had isolated metastatic parenchyma without evidence of direct tumor invasion or invasion by involved lymph nodes. CONCLUSION: Given this rarity of SMG involvement, preservation of SMG might be feasible in selected patient population. However, additional studies need to examine the functionality of preserved SMGs among patients who receive postoperative adjuvant radiation therapy.

Transoral robotic resection of a retropharyngeal parathyroid adenoma: a case report.

Transoral robotic surgery (TORS) has become an increasingly popular option for early malignancies of the oropharynx. It offers superior visualization and has been proven to have acceptable functional and oncologic outcomes. Additionally, indications in head neck have expanded to manage tumors of the thyroid, neck, parapharyngeal space and salivary glands. A 58-year-old female had an incidental finding on CT imaging of a retropharyngeal mass at the level of the hyoid bone. She was referred to a tertiary medical center for further workup and removal of this mass. Due to the midline position of the mass, favorable access and potentially decreased surgical morbidity, TORS excision of the mass was performed for diagnosis and treatment. Histopathology confirmed this to be a hypercellular parathyroid mass consistent with parathyroid adenoma. We report a relatively unusual location of parathyroid adenoma in an asymptomatic patient with normal parathyroid and calcium levels. TORS proves to be a feasible and safe method for complete surgical excision of retropharyngeal parathyroid adenoma without tumor spillage or violation.

Osteoradionecrosis of the Temporal Bone: An Evidence-Based Approach.

OBJECTIVES: To perform a systematic review evaluating etiologies, associated complications, and management of osteoradionecrosis of the temporal bone (ORNTB). METHODS: The authors searched the PubMed, Embase, and Cochrane Library databases for relevant literature. Patient demographics, etiologies, treatments, and other clinical characteristics were obtained. Treatment success was defined as resolution of symptoms at last follow-up. Results were reported using the preferred reporting systems for systematic reviews and meta-analysis (PRISMA) guidelines. RESULTS: Thirty-eight studies encompassing 364 patients with ORNTB were identified. The most common etiologies necessitating radiotherapy included: nasopharyngeal carcinoma (n = 133 [36.8%]), parotid tumors (n = 73 [20.2%]), and external auditory canal pathology (n = 59 [16.3%]). The mean dose of radiation was 58.0 Gy. The mean lag time between radiotherapy and osteoradionecrosis (ORN) symptoms was 7.9 years. The most common presenting symptoms were purulent otorrhea (33.3%), hearing loss (29.1%), and otalgia (17%). ORNTB complications included tympanic membrane perforation (n = 102 [63.8%]) and chronic otitis media (n = 16 [10%]). Treatments included lateral temporal bone resection (n = 99 [28.3%]), conservative treatment (n = 92 [26.3%]), and mastoidectomy (n = 82 [23.5%]) with 90.9, 89.13, and 59.76% considered successful, respectively. CONCLUSIONS: ORNTB is a rare complication of radiotherapy that may present years after initial radiation exposure. Management should be aimed at relief of presenting symptoms and treatment of ORNTB associated complications. Both conservative and surgical measures may adequately control the disease process and symptomatology; however, randomized controlled studies comparing treatments would serve to further corroborate these findings.

Medicolegal Issues in Endoscopic Sinus Surgery and Complications.

Complications occur during and after endoscopic sinus surgery. Complications leading to temporary or most commonly permanent injury often are involved in litigation for malpractice. This article concentrates on areas of importance that are considered during medicolegal deliberations.

Otologic complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

This case report demonstrates the otologic complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS/TEN). A five year-old male was admitted to the burn unit with the diagnosis of SJS/TEN believed secondary to acetaminophen use. After resolution of the acute phase, the patient was left with a severe auricular deformity with scarring and complete occlusion of the right external auditory canal (EAC). The patient underwent meatoplasty, canaloplasty, and tympanoplasty with subsequent placement of a molded stent in order to maintain patency of his EAC. Four years later, the patient has a patent right EAC with adequate hearing.

Optical stimulation of auditory neurons: effects of acute and chronic deafening.

In developing neural prostheses, particular success has been realized with cochlear implants. These devices bypass damaged hair cells in the auditory system and electrically stimulate the auditory nerve directly. In contemporary cochlear implants, however, the injected electric current spreads widely along the scala tympani and across turns. Consequently, stimulation of spatially discrete spiral ganglion cell populations is difficult. In contrast to electrical stimulation, it has been shown that extremely spatially selective stimulation is possible using infrared radiation (e.g. [Izzo, A.D., Su, H.S., Pathria, J., Walsh Jr., J.T., Whitlon, D.S., Richter, C.-P., 2007a. Selectivity of neural stimulation in the auditory system: a comparison of optic and electric stimuli. J. Biomed. Opt. 12, 1-7]). Here, we explore the correlation between surviving spiral ganglion cells, following acute and chronic deafness induced by neomycin application into the middle ear, and neural stimulation using optical radiation and electrical current. In vivo experiments were conducted in gerbils. Before the animals were deafened, acoustic thresholds were obtained and neurons were stimulated with optical radiation at various pulse durations, radiation exposures, and pulse repetition rates. In one group of animals, measurements were made immediately after deafening, while the other group was tested at least four weeks after deafening. Deafness was confirmed by measuring acoustically evoked compound action potentials. Optically and electrically evoked compound action potentials and auditory brainstem responses were determined for different radiation exposures and for different electrical current amplitudes, respectively. After completion of the experiments, the animals were euthanized and the cochleae were harvested for histology. Acoustically evoked compound action potential thresholds were elevated by more than 40 dB after neomycin application in acutely deaf and more than 60 dB in chronically deaf animals. Compound action potential thresholds, which were determined with optical radiation pulses, were not significantly elevated in acutely deaf animals. However, in chronically deaf animals optically evoked CAP thresholds were elevated. Changes correlated with the number of surviving spiral ganglion cells and the optical parameters that were used for stimulation.