Supraorbital Neuralgia Associated With Thyroid Eye Disease.

PURPOSE: To identify the relationship between thyroid eye disease (TED) and supraorbital neuralgia (SON) and establish a reliable approach to the diagnosis and management of TED-associated SON. METHODS: This retrospective study included 1,126 patients. Demographics, active and inactive phase status and duration, and reactivation rate were noted. TED clinical activity was determined using the vision, inflammation, strabismus, and appearance assessment system, and TED severity was classified using the European Group of Graves' Orbitopathy system. Subtypes of periorbital pain were identified, and suspected SON was confirmed by supraorbital nerve block. RESULTS: Of the study's 1,126 patients, 935 (83%) were deemed "active" at some point during the follow up and 34 (3%) remained "active" at the study's conclusion. Of the 2,251 eyes studied, 1,193 (53%) underwent orbital decompression. Of the 1,126 patients, 946 (84%) reported a retrobulbar "pressure" or "aching," but a distinct, more debilitating pain suggestive of SON was reported in 91 (8%). All 91 patients were given a supraorbital nerve block, and all had complete pain resolution lasting from hours to weeks. Eighty-eight (97%) of the 91 patients with SON-type pain underwent orbital decompression compared to 496 (48%) of the 1,035 without SON-type pain (p < 0.00001). A difference was found in the rate of TED reactivation between those with SON-type symptoms (8%) as compared to those without (2%), p = 0.01. CONCLUSIONS: SON of uncertain etiology appears to be a previously underreported but significant pain associated with TED. Paradoxically, although the SON does not appear to be related to the type or severity of TED on standard rating scales, the presence of SON was found to be associated with increased likelihood of both orbital decompression and TED reactivation.

Early glottic cancer in a veteran population: Impact of race on management and outcomes.

OBJECTIVES: Multiple population studies have shown racial discrepancies in head and neck cancer treatment and outcomes. We sought to characterize the impact of race on clinical outcomes for patients with early glottic squamous cell carcinoma (SCC) in a tertiary institution which provides equivalent access to care. METHODS: We retrospectively reviewed all early glottic (T1-T2) squamous cell carcinoma at a single institution, the Michael E. DeBakey Veterans' Administration Medical Center (MEDVAMC). Data collected included demographic information, primary and adjuvant treatment modalities, time to diagnosis, time to treatment, recurrences, recurrence treatment modality, secondary malignancies, recurrence-free survival (RFS), and overall survival (OS). RESULTS: One hundred seventeen patients with a primary diagnosis of T1-T2 glottic squamous cell carcinoma were included. Black and white patients demonstrated equivalent rates of recurrence, RFS, and OS. There was no significant difference in treatment delivery by race for all recorded parameters. T1b tumors were associated with an increased risk of recurrence which did not translate into a statistically significant decrease in RFS or OS. Surgical treatment was associated with increased recurrence but similar RFS and OS compared to radiation-based treatment. Secondary malignancies were common; 12% of patients were diagnosed with a second primary lung cancer during the study period. CONCLUSION: At our institution, race did not impact survival when access to care, treatment selection, and delivery are equivalent for early glottic SCC. Secondary lung cancer is a critical risk factor for mortality in this patient group and requires long-term surveillance and monitoring. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1733-1739, 2020.

Gastrostomy Utilization by Oropharyngeal Cancer Patients Is Partially Driven by Swallowing Function.

OBJECTIVE: Oropharyngeal squamous cell carcinoma (OPSCC) incidence is rapidly increasing, as are survival rates, in large part due to the human papillomavirus (HPV). Treatment intensity, however, has remained unchanged, making treatment-related toxicity (i.e., dysphagia) a critical problem for an increasing number of patients. The primary objective of this study was to determine whether pretreatment objective swallowing measures can predict percutaneous fluoroscopic guided gastrostomy tube (PFG) utilization during OPSCC treatment. METHODS: Forty-one newly diagnosed OPSCC patients treated with radiation underwent evaluation of swallow function with modified barium swallow study (MBSS) prior to and at completion of radiation treatment using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST); a subset of patients were evaluated using the MD Anderson Dysphagia Inventory (MDADI). RESULTS: Patients were male (100%), primarily Caucasian (85.4%) and p16 positive (85.4%) with mean age of 65.7 years. PFG were placed in 70.7% patients (n = 29) and used by 63.4% (n = 26). Pre- and post-treatment DIGEST scores were associated with T-classification (t = -2.9, p = .001, t = -2.7, p = .01) and indicated deteriorating swallow function during treatment (mean change = 0.46 [t = -2.7, p = .01]). DIGEST and MDADI scores were generally not associated with patient PFG utilization. DIGEST and MDADI scores were significantly correlated prior to, but not following completion of treatment. CONCLUSION: Pre-treatment DIGEST and patient reported swallowing outcomes (MDADI) can be useful in identifying patients with unsafe and/or grossly inefficient swallowing function. However, objectively measured swallow function was not associated with PFG utilization. Development of PFG placement algorithms (reactive vs. prophylactic) therefore require additional inputs/metrics. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2153-2159, 2020.

Swallowing Function in Survivors of Oropharyngeal Cancer Is Associated With Advanced T Classification.

OBJECTIVES: The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing in the United States. The aim of this study was to characterize the functional status of OPSCC survivors to identify predictors of swallowing dysfunction in this patient population. METHODS: OPSCC survivors (n = 81) treated at the Michael E. DeBakey Veterans Affairs Medical Center between 2005 and 2015 with at least 2 years of clinical follow-up were reviewed. Functional status was ascertained using (1) gastrostomy and tracheostomy placement and retention, (2) gastrostomy use at last follow-up, (3) patient-reported diet, and (4) modified barium swallow. RESULTS: Median follow-up duration was 5.6 years; 67% of patients had ≥10-pack-year tobacco exposure; 96% of tumors for which p16 data were available were p16 positive. At last follow-up, 82% of patients reported a regular diet, and only 9 patients required gastrostomy use. Gastrostomy use at last follow-up was higher in patients with T3 and T4 tumors compared with those with T1 and T2 tumors (P = .01). The relationship between T classification and gastrostomy use persisted even when the analysis was limited to p16+ tumors and p16+ tumors with ≥10-pack-year history of tobacco exposure. CONCLUSIONS: Advanced T classification at presentation is a critical predictor of gastrostomy use in long-term OPSCC survivors irrespective of p16 status or tobacco exposure history. LEVEL OF EVIDENCE: 2b.

Treatment Patterns in Veterans with Laryngeal and Oropharyngeal Cancer and Impact on Survival.

OBJECTIVES: Veterans with laryngeal and oropharyngeal cancer remain an understudied patient population despite a high incidence of disease and decreased survival compared to the general population. Our objective was to evaluate treatment patterns for laryngeal and oropharyngeal cancer in patients treated at one of the Veterans Health Administration's busiest cancer centers in order to generate some basic benchmarks for treatment delivery in the veteran population. METHODS: We reviewed 338 patients treated at the Michael E. DeBakey Veterans Affairs Medical Center between 2000 and 2012. RESULTS: Oropharyngeal site and advanced age were associated with worse overall and disease-free survival. Treatment periods (mean) were as follows: 1) referral-diagnosis, 26 days; 2) diagnosis-surgery, 29 days; and 3) diagnosis-radiation, 58 days. Adjuvant radiation was initiated within 6 weeks of surgery in 42% of patients and 68% of patients had a total treatment package time ≤100 days. Time from diagnosis to treatment initiation, surgery to adjuvant radiation interval and total treatment package time did not impact survival. CONCLUSIONS: This study establishes basic benchmarks for laryngeal and oropharyngeal cancer treatment delivery in veterans. Additional efforts are warranted to improve consistency and provide treatment in line with NCCN recommendations and literature consensus. LEVEL OF EVIDENCE: 2b.

Minor salivary gland basal cell adenocarcinoma: a systematic review and report of a new case.

IMPORTANCE: Basal cell adenocarcinoma (BCAC) of the minor salivary gland is an extremely rare disease: the most recent substantive literature review reports only 25 cases. Owing to the rarity of this disease, it has not yet been well characterized in the literature. OBJECTIVE: We sought to expand the knowledge of minor salivary gland BCAC by performing an exhaustive literature review and adding to it a new case that is rare owing to the tumor's size, aggressive nature, and mixed histologic pattern. The review emphasizes epidemiologic patterns, diagnostic characteristics, treatment patterns, and expected prognosis for minor salivary gland BCAC. EVIDENCE ACQUISITION: In June 2012, PubMed was queried using the term "salivary gland basal cell adenocarcinoma," and the resultant articles were reviewed. Those specifically mentioning a minor salivary gland BCAC were included in this study. Those that did not differentiate minor salivary gland BCAC from major salivary gland BCAC were excluded. The search was not limited by language and included articles from North America, Europe, Africa, and Asia from 1978 to June 2012. RESULTS: The PubMed search resulted in 195 articles, of which 33 articles reported at least 1 case of minor salivary gland BCAC. We report herein 72 cases of minor salivary gland BCAC (71 cases from the literature review and 1 new case reported herein). The mean patient age at the time of presentation was 56 years (range, 24-90 years), and the disease showed no sex predilection. The most common location was the palate, and the average lesions size was 2.4 cm (range, 0.7-4.2 cm). The treatment modality of choice was wide local excision (n = 57; 79%). There was a high local recurrence rate (n = 30; 41%) but a low rate of distant metastasis (n = 8; 11%). CONCLUSIONS AND RELEVANCE: We present a comprehensive review of minor salivary gland BCAC, describing nearly 3 times as many cases as has been previously reported. This review characterizes a rare disease and increases awareness of the disease among otolaryngologists. Minor salivary gland BCAC is similar to major salivary gland BCAC and minor salivary gland tumors in general with regard to patient age, sex, tumor site, treatment modality, recurrence, metastasis, and mortality.

Traumatic optic neuropathy and second optic nerve injuries.

IMPORTANCE: Current controversy about the primary treatment of traumatic optic neuropathy (TON) has anchored on final vision following injury, but, to our knowledge, no study has examined the effect of different treatments on regaining and protecting optic nerve reserve or on the outcome of second optic nerve injuries. OBJECTIVE: To assess vision improvement in patients treated by various methods who have a second incidence of TON. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 12 patients with a second TON seen in an 18-year period (mean follow-up, 11.3 months) at a single tertiary care oculoplastic practice. INTERVENTIONS: Observation, high-dose corticosteroids, optic nerve decompression, or high-dose corticosteroids plus optic nerve decompression. MAIN OUTCOMES AND MEASURES: Change in vision on the Snellen eye chart. RESULTS All second TON events involved the same-side optic nerve as initially injured, and with observation alone, corticosteroids, or corticosteroids and partial optic canal decompression, all patients had vision improvement after their initial injury (P = .004). However, following the second optic nerve injury, most patients' vision fell to the pretreatment level of the first injury, and subsequent management of the second injury with corticosteroids and/or optic canal decompression provided little or no vision return (P = .05). In contrast, optic canal decompressions performed for 91 primary TON injuries resulted in 82.4% having some degree of vision improvement. CONCLUSIONS AND RELEVANCE: Patients with TON may have a second optic nerve insult, and vision recovery from the second event may be limited regardless of primary treatment choice.

An unusually large granular cell tumor of the pharynx: a case report and literature review.

We report a granular cell tumor of the pharynx in a 53 year-old woman who presented with a large retropharyngeal mass. Surgical excision revealed a 5.5 cm tan rubbery unencapsulated but circumscribed mass. Histologically, the tumor is composed of diffusely arranged oval and spindle cells with abundant eosinophilic granular cytoplasm and mildly pleomorphic nuclei without necrosis or mitoses. Immunostains show the tumor cells to be positive for S-100, vimentin, non-specific esterase and focally positive for inhibin. In addition to its unusual location, this tumor is extremely large while most granular cell tumors are small (<2 cm). This case represents a unique example of a large granular cell tumor at a rare location: the pharynx.

Endoscopic management of Zenker's diverticulum: factors predictive of success or failure.

OBJECTIVES: We review our experience with endoscopic management of Zenker's diverticulum. We sought to analyze and determine risk factors for success or failure of endoscopic diverticulum treatment. METHODS: We performed a retrospective review of 72 consecutive patients who underwent attempted endoscopic management of a Zenker's diverticulum between January 2000 and April 2006. The procedures were performed by either of 2 otolaryngologists. There were 50 men and 22 women ranging in age from 44 to 93 years. A total of 85 procedures were performed. The medical records were reviewed for preoperative diverticulum size (small, 1 to 2 cm; moderate, 2.1 to 3.0 cm; and large, more than 3.0 cm), intraoperative diverticulum characteristics, patient anatomic limitations that prevented adequate endoscopic visualization, surgical complications, and management of recurrences. RESULTS: Of our 72 patients, 61 (85%) were able to undergo endoscopic cricopharyngeal myotomy with diverticulum elimination. Of the 61 endoscopic procedures, 47 (77%) resulted in complete symptom resolution. The most common risk factors for recurrence were diverticulum size (more than 3 cm) and amount of redundant mucosa. Of the 14 patients with a recurrence, 10 (71%) underwent a repeat procedure. Six of the 14 (43%) had a successful excision via a cervical approach, and 4 of the 14 (29%) underwent a repeat endoscopic myotomy. There was 1 major complication (esophageal tear), and there were 3 minor complications (mucosal abrasions). CONCLUSIONS: Most patients with a Zenker's diverticulum are good candidates for endoscopic management. In our series, 84% of those who underwent endoscopic treatment ultimately achieved relief of symptoms. The patient morbidity is minimal. A large diverticulum with redundant mucosa is a risk factor for recurrence after endoscopic treatment.

Diagnosis of laryngopharyngeal reflux disease with digital imaging.

OBJECTIVE: The study goal was to assess the use of digital laryngeal videostroboscopy (LVS) in the detection of objective improvement of the larynx after 6 weeks of proton pump inhibitor (PPI) therapy and to evaluate a clinical grading scale for findings of laryngopharyngeal reflux disease (LPRD). STUDY DESIGN AND SETTING: We conducted a prospective analysis of digital LVS examinations from a tertiary referral center for laryngology by 3 independent blinded examiners. RESULTS: The mean score on the Laryngopharyngeal Reflux Disease Index for experimental patients was significantly higher than that for control patients (9.50 versus 2.92, P < 0.001), and posttreatment scores were significantly lower than pretreatment scores (7.35 versus 9.50, P < 0.001). Useful items on the grading scale for assessing the presence of LPRD and improvement in LPRD included supraglottic edema and erythema, glottic edema and erythema, and subglottic edema and erythema. Nonuseful items included the presence of pachydermia, granulomas, nodules, leukoplakia, and polyps. CONCLUSION: Objective improvement of signs of LPRD can be detected after 6 weeks of PPI therapy using digital LVS. The Laryngopharyngeal Reflux Disease Index is a useful valid clinical tool for following treatment response to PPI therapy.

Using technology to decrease xerostomia for head and neck cancer patients treated with radiation therapy.

The treatment of head and neck cancer has evolved from conventional fields encompassing large volumes of normal tissue to focused treatment aimed at conforming the dose around the target while avoiding normal tissue. Intensity modulated radiation therapy has changed the way radiation oncologists think about head and neck cancer. Using the concepts of conformal treatment and avoidance, the therapeutic ratio can be improved and technology exploited to the patients' advantage. This is particularly evident with head and neck irradiation, where a common side effect is xerostomia. By decreasing xerostomia through conformal avoidance of the parotid glands, we can improve patient satisfaction and quality of life. In this study, xerostomia is assessed through a subjective salivary gland function questionnaire. This article examines the use of intensity modulated radiation therapy in the treatment of head and neck cancer to decrease xerostomia. The purpose of this article is to evaluate the significance of parotid gland dosimetry in relation to subjective salivary gland function.