Demographic and Tumor Characteristic Impact on Laryngeal Cancer Outcomes in a Minority Underserved Patient Population.

OBJECTIVE: Advanced laryngeal squamous cell carcinoma remains associated with approximately 50% mortality at 5 years. Delivery of multimodality treatment remains critical to maximizing survival for this disease, but achieving this at a national level remains a difficult undertaking, particularly in under- and uninsured patients as well as minority patients. We sought to evaluate laryngeal cancer treatment delivery and clinical outcomes in a predominantly minority and underserved cohort of largely under- and uninsured patients in a county hospital. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care county hospital in Houston, Texas. SUBJECTS AND METHODS: Patients (N = 210) with a new diagnosis of laryngeal squamous cell carcinoma treated between 2005 and 2015 were included in a retrospective analysis of patient demographics, tumor and treatment characteristics, and oncologic outcomes. RESULTS: The majority of patients presented with advanced disease (T4 = 43%, N>0 = 45%). Treatment selection was compliant with National Comprehensive Cancer Network guidelines in 81% of cases, but 76% of patients who required adjuvant radiotherapy were unable to start it within 6 weeks postsurgery. Overall survival and disease-free survival were 52% and 63% for the entire cohort, respectively. Supraglottic subsite and nodal metastases were significantly associated with decreased overall survival and disease-free survival. Race/ethnicity and insurance status were not associated with worse oncologic outcomes. CONCLUSION: Under- and uninsured patients often present with advanced laryngeal cancer. Oncologic outcomes in this cohort of patients is similar to that of other published series. Moreover, tumor characteristics rather than demographic variables drive oncologic outcomes for the predominantly minority and underserved patients seeking care in our tertiary care county hospital.

Repairing angle of the mandible fractures with a strut plate.

IMPORTANCE: Despite multiple fixation techniques, the optimal method of repairing mandibular angle fractures remains controversial. OBJECTIVE: To evaluate the outcomes when using a 3-dimensional, curved strut plate in repair of angle of the mandible fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center at an academic institution in Harris County, Texas. PARTICIPANTS: Patients with diagnostic codes involving angle of the mandible fractures that were repaired by the otolaryngology-head and neck surgery service from February 1, 2006, through February 28, 2011. EXPOSURE: Open reduction internal fixation using either a 3-dimensional curved strut plate or any other type of repair technique for angle of the mandible fractures. MAIN OUTCOMES AND MEASURES: Complication rates, postoperative complaints, and operative characteristics. RESULTS: Ninety patients underwent qualifying procedures during the study period. A total of 68 fractures (76%) were repaired using the 3-dimensional curved strut plate and 22 (24%) were repaired using other methods. The revision surgery rate was 10% for the strut plate group (7 patients) and 14% for the non-strut plate group (3 patients), with no significant differences in rates of infection (3 [4%] vs 2 [9%]), dehiscence (4 [6%] vs 2 [9%]), malunion (1 [1%] vs 2 [9%]), nonunion (3 [4%] vs 0), hardware failure (1 [1%] vs 1 [5%]), malocclusion (2 [3%] vs 2 [9%]), and injury to the inferior alveolar nerve (1 [1%] vs 1 [5%]). The most common postoperative complaints were pain (13 [19%] vs 6 [27%]), followed by numbness (5 [7%] vs 2 [9%]), trismus (4 [6%] vs 3 [14%]), edema (3 [4%] vs 3 [14%]), and bite deformity (2 [3%] vs 2 [9%]), with a mean (range) follow-up time of 54.7 (2-355) days for the strut plate group vs 46.8 (8-308) days for the non-strut plate group. CONCLUSIONS AND RELEVANCE: The 3-dimensional curved strut plate is an effective treatment modality for angle fractures, with comparable infection rates, low incidence of alveolar nerve injury, and trends for decreased length of operation, complications, and infections compared with other techniques.

Infectious Collet-Sicard syndrome in the differential diagnosis of cerebrovascular accident: a case of head-to-neck dissociation with skull-based osteomyelitis.

BACKGROUND CONTEXT: Collet-Sicard syndrome (CSS) is a rare condition that includes palsies of cranial nerves IX, X, XI, and XII. There are multiple reported causes in the literature, although infection is particularly unusual. PURPOSE: To report an unusual case of CSS as a result of infection causing head-to-neck dissociation with involvement of the upper cervical spine. STUDY DESIGN: Case report. METHODS: A 56-year-old male with medical comorbidities developed a cranial-based infection secondary to initial incomplete treatment of otitis media. The mass effect of the infection resulted in multiple cranial nerve palsies and extremity symptoms initially confused with a cerebrovascular accident. Clinical course of the patient and a review of CSS are presented. RESULTS: With progression of the disease, further evaluation revealed a disseminated upper cervical and skull-based infection causing destructive head-to-neck infectious instability. This was treated with posterior occipitocervical debridement, fixation, and fusion and appropriate long-term antibiotics. Over the course of several months, the infection resolved and there was a significant improvement in his dysphagia, dysarthria, and hearing. CONCLUSIONS: Delay in diagnosis of CSS is common, and this syndrome should be considered in patients who present with a constellation of lower cranial nerve palsies. Early recognition and treatment should result in successful recovery, but even in cases of delayed detection, suitable intervention can result in substantial clinical improvement.

Skin cancer prevention counseling and clinical practices of pediatricians.

Little is known about pediatricians' counseling and clinical practices to reduce skin cancer risk among their patients. Thus our objectives were to characterize skin cancer preventive counseling and clinical practices in a sample of pediatricians and identify correlates of these practices. Physicians practicing general pediatrics in Harris County, Texas, received a mail survey that assessed their sun protection recommendations and skin cancer preventive counseling and clinical practices. Pediatrician, patient, and medical practice variables were assessed as correlates. Most (76%) pediatricians routinely recommended sunscreen; however, relatively few (24%) suggested reapplying it after prolonged periods outside. About half routinely recommended protective clothing (53%), shade (47%), or limiting midday sun exposure (46%). Even fewer pediatricians routinely discussed skin cancer risk factors, passed out sunscreen samples, made educational materials available, took a family history of skin cancer, or documented risk factors in a patient's chart. More than half reported that they routinely performed full-body skin examinations during a first visit (65%) and annually (56%). Perceived barriers, perceived relevance of skin cancer prevention, and personal sun protection practices were important factors associated with professional practices in this sample. Interventions are needed to increase pediatricians' counseling and clinical practices to reduce skin cancer risk among patients.

XPD/ERCC2 EXON 8 Polymorphisms: rarity and lack of significance in risk of squamous cell carcinoma of the head and neck.

BACKGROUND: Inherited polymorphisms of DNA repair genes may contribute to genetic susceptibility to squamous cell carcinoma of the head and neck (SCCHN). The objective was to assess whether two polymorphisms in the nucleotide excision repair gene XPD (ERCC2) are markers of SCCHN risk. METHODS: We performed a hospital-based case-control study of 180 SCCHN patients and 400 cancer-free controls frequency matched on age, sex, smoking, and alcohol use. All subjects were non-Hispanic whites. XPD alleles 23047 and 23051 were assessed by digestion with the restriction enzymes XhoII and SphI after PCR amplification. RESULTS: The XPD 23047 G and XPD 23051 T alleles were extremely rare among both the cases and controls (allele frequencies<1.0%), and not statistically different between groups (P>0.6). CONCLUSIONS: The 23047 and 23051 variants of the DNA repair gene XPD are extremely rare and do not contribute significantly to the risk of SCCHN in the non-Hispanic white population.

Expression of nucleotide excision repair genes and the risk for squamous cell carcinoma of the head and neck.

BACKGROUND: Phenotypic differences in the ability to repair genetic damage induced by tobacco carcinogens may reflect genetic differences in susceptibility to squamous cell carcinoma of the head and neck (SCCHN). The objective of this study was to assess the variation in baseline expression of five nucleotide excision repair genes between individuals with SCCHN and cancer free controls. METHODS: The authors conducted a hospital-based case-control study of 57 SCCHN patients and 105 cancer free controls. Using peripheral blood lymphocytes, a multiplex reverse transcriptase-polymerase chain reaction assay was used to quantitate in vitro the mRNA levels of five genes (ERCC1, XPB/ERCC3, XPG/ERCC5, CSB/ERCC6, and XPC) involved in the nucleotide excision repair pathway. RESULTS: The levels of ERCC1, XPB/ERCC3, XPG/ERCC5, and CSB/ERCC6 transcripts were lower in cases than in controls (P =0.0001, 0.096, 0.001, and 0.0001, respectively). In multivariate logistic regression analysis (adjusting for age, gender, race, smoking status, and alcohol use), low expression of ERCC1, XPB/ERCC3, XPG/ERCC5, and CSB/ERCC6 was associated with a statistically significant increased risk for SCCHN (adjusted odds ratios [95% confidence intervals] 6.42 [2.63-15.69], 2.86 [1.39-5.90], 3.69 [1.73-7.90], and 2.46 [1.19-5.09], respectively). CONCLUSIONS: Reduced expression of ERCC1, XPB/ERCC3, XPG/ERCC5, and CSB/ERCC6 is associated with a more than two-fold increased risk of SCCHN.

A prospective study of intraoperative lymphatic mapping for head and neck cutaneous melanoma.

BACKGROUND: Intraoperative lymphatic mapping and sentinel lymph node biopsy have been used successfully to stage regional lymphatics for trunk and extremity melanomas. However, the accuracy and applicability of these techniques in the head and neck have not been determined conclusively. OBJECTIVE: To report the results of a prospective trial of intraoperative lymphatic mapping and sentinel lymph node identification in patients with head and neck cutaneous melanoma. METHODS: Using technetium Tc 99m--labeled sulfur colloid and isosulfan blue, intraoperative lymphatic mapping and sentinel lymph node identification were performed in 43 patients with melanomas of intermediate thickness. After the sentinel lymph nodes were identified in situ, an elective dissection of levels I through V or II through V was performed, based on the location of the primary tumor. The parotid, postauricular, and suboccipital lymphatics were dissected as clinically indicated. The sentinel lymph nodes were isolated ex vivo and evaluated pathologically by serial sectioning, and the accuracy of the lymphatic mapping was determined. RESULTS: Intraoperative lymphatic mapping identified 155 sentinel lymph nodes in 94 nodal basins, with a mean of 3.6 sentinel nodes and 2.2 basins per patient. Sentinel nodes were located in the parotid gland in 19 patients (44%), necessitating superficial parotidectomies, and they were distributed throughout nonadjacent nodal basins in 18 patients (42%). Nine patients (21%) had metastatic disease in 1 or more sentinel nodes, 3 of whom had metastatic disease in a nonsentinel node. No patient who had negative sentinel nodes had a positive nonsentinel node (false-negative incidence, 0). CONCLUSIONS: Although intraoperative lymphatic mapping accurately identifies sentinel lymph nodes for head and neck cutaneous melanomas, the multiplicity of these nodes, their widespread distribution, and their frequent location within the parotid gland may preclude sentinel lymph node biopsy in many patients. Therefore, we advocate selective lymphadenectomy of sentinel nodal basins, allowing histological staging of the regional lymphatics with limited morbidity. However, further study is necessary to define the true role of sentinel lymph node identification for head and neck cutaneous melanoma.