Comparative cost of transoral robotic surgery and radiotherapy (IMRT) in early stage tonsil cancer.

PURPOSE: To compare treatment costs and cost-effectiveness for transoral robotic surgery (TORS) and definitive intensity-modulated radiotherapy (IMRT) in managing early stage tonsil cancer. MATERIALS AND METHODS: Direct treatment costs for surgery and IMRT were calculated from SEER-Medicare data for a cohort with clinically early stage (cT1/2N0) p16+ tonsillar squamous cell carcinoma from Kaiser Permanente Southern California Health Plan between 2012 and 2017. A Markov decision tree model with a 5-year time horizon was then applied to the cohort which incorporated costs associated with treatment, surveillance, and recurrence. RESULTS: IMRT cost up to $19,000 more (35%) than TORS in direct treatment costs. When input into the Markov model, TORS dominated IMRT with lower cost and better effectiveness over a range of values. CONCLUSION: TORS is a more cost-effective treatment method than IMRT in early stage (cT1/2N0) tonsil cancer.

Prevalence, Characteristics and Impact of Dysphonia in US Marine Corps Drill Instructors.

IMPORTANCE: Prior studies have evaluated various populations at increased risk of voice impairment. However, minimal data is available for military Drill Instructors, a population known to have significant vocal demands. OBJECTIVE: The purpose of this study was to determine the prevalence of subjective, perceptual, and objective dysphonia in this population and to evaluate contributing factors and impact on job performance. DESIGN: Cross-sectional analysis. SETTING: United States Marine Corps base (Marine Corps Recruit Depot, San Diego, California). PARTICIPANTS: Active US Marine Corps Drill Instructors. INTERVENTIONS: A survey was administered investigating subjective measures of dysphonia and its impact on occupational function. Standardized voice samples were recorded for objective and perceptual voice analysis. MAIN OUTCOMES AND MEASURES: Prevalence of subjective (Voice Handicap Index-10 and Glottal Function Index scores), perceptual (CAPE-V score), and acoustic (Cepstral-spectral index of dysphonia) measures of dysphonia. RESULTS: Subjective dysphonia was present in 47.7% by the Voice Handicap Index-10 and 70.2% by the Glottal Function Index. 51% of subjects reported periods of aphonia, while 47% reported voice problems limiting job function in the month prior to being surveyed. The Cepstral-Spectral Index of Dysphonia Mean was abnormal in 95.3% and CAPE-V overall severity score was abnormal in 94%. There was significant improvement in subjective, perceptual, and acoustic voice outcomes as the amount of time since last training cycle (ie, relative voice rest) and as experience as a Drill Instructor increased, however the VHI-10 was the only measure that normalized. CONCLUSION AND RELEVANCE: There is a very high prevalence of self-reported dysphonia in Drill Instructors, with near-universal prevalence of some degree of objectively and perceptually-rated dysphonia. Nearly half of those surveyed reported that dysphonia limited their job performance. Relative voice rest and experience seem to mitigate severity, but normal ratings were rare. While objective and perceptually-rated dysphonia are persistent and highly prevalent, it does not necessarily translate into a perceived impairment in this population. For these reasons and considering the importance of extraordinary vocal function in this occupation, Drill Instructors appear to be in dire need of proper voice care to both maximize job performance and mitigate long-term voice-related problems.

Mucoepidermoid Carcinoma: A 23-Year Experience with Emphasis on Low-Grade Tumors with Close/Positive Margins.

Objective Describe outcomes for mucoepidermoid carcinoma by histologic grade and evaluate outcomes for patients with low-grade tumors with close/positive margins after initial surgical resection. Study Design Cohort study. Setting Kaiser Permanente Southern California Medical Group from 1993 to 2016. Subjects and Methods Retrospective review of 154 patients with major and minor salivary gland mucoepidermoid carcinoma of the head and neck. Disease-specific and recurrence-free survival were stratified by tumor grade. Subgroup analysis of recurrence-free survival in patients with low-grade disease with close or positive margins was also performed. Results Five-year recurrence-free and disease-specific survival were excellent for both low- and intermediate-grade tumors, while there was there was a high rate of recurrence and mortality among patients with high-grade tumors. Patients with low-grade tumors with close or positive margins who were observed had no difference in recurrence-free survival compared to those who underwent revision surgery and/or adjuvant radiotherapy. Conclusions High-grade mucoepidermoid carcinoma has poor outcomes despite aggressive treatment. Among patients with low-grade tumors with close or positive margins on initial resection, additional treatment had no impact on survival or recurrence. Observation may be a reasonable alternative to additional treatment in this select group of patients.

Staging Neck Dissection and Transoral Robotic Surgery Treatment Algorithm in Palatine Tonsil Cancer.

Objective This study introduces a treatment algorithm based on staging neck dissection to identify patients with palatine tonsil squamous cell carcinoma who can be effectively treated with single-modality transoral robotic surgery while maintaining quality of life. Study Design Retrospective case series. Setting Kaiser Permanente Southern California Medical Group from 2012 to 2017. Subjects and Methods Patients with early-stage (T1/2) palatine tonsil squamous cell carcinoma with clinically and radiographically N0 necks underwent staging neck dissection. Those with pN2/3 disease or extracapsular extension on final pathology were triaged to definitive chemoradiation treatment. Patients with confirmed pN0/1 necks without extracapsular extension were treated definitively with transoral robotic surgery. Results Nineteen patients with cN0 disease underwent selective neck dissection. All were p16 positive. Of these, 14 had pathologically confirmed N0/1 necks without extracapsular extension and were treated with primary surgical resection via transoral robotic surgery. Clear margins were obtained on all patients. There were no significant intra- or postoperative complications. No patients required gastrostomy tube or tracheostomy placement. Mean and median follow-up was 28 months with no recurrences to date. Conclusion Up-front staging neck dissection accurately triages low-risk patients, determining candidates for single-modality definitive treatment with transoral robotic surgery. This approach provides excellent survival outcomes and minimal morbidity and maintains quality of life among appropriately selected patients with palatine tonsil cancer.

Facial trauma caused by electronic cigarette explosion.

Electronic cigarettes are increasingly popular as a supposed safer alternative to tobacco cigarettes or a smoking cessation tool. Research and debate have focused primarily on possible adverse effects caused by the inhaled aerosol produced by electronic cigarettes and on smoking cessation efficacy. Few reports in the medical literature describe injuries secondary to device malfunction. We present a case of electronic cigarette explosion, with a projectile fracturing the patient's right naso-orbital-ethmoid complex and anterior and posterior frontal sinus tables, with frontal sinus outflow tract involvement. The patient underwent combined open and endoscopic repair, including open reduction internal fixation, with reconstitution and preservation of the frontal sinus and frontal sinus outflow tract. Additionally, we review the available data on electronic cigarette malfunction-including fires, explosions, associated injuries, and possible reasons for device malfunction-and discuss new 2016 U.S. Food and Drug Administration regulations pertaining to electronic cigarettes.