Proposal for standardized ultrasound analysis of the salivary glands: Part 1 submandibular gland.

Objectives: The Salivary Gland Committee of the American Academy of Otolaryngology-Head and Neck Surgery seeks to standardize terminology and technique for ultrasonograpy used in the evaluation and treatment of salivary gland disorders. Methods: Development of expert opinion obtained through interaction with international practitioners representing multiple specialties. This committee work includes a comprehensive literature review with presentation of case examples to propose a standardized protocol for the language used in ultrasound salivary gland assessment. Results: A multiple segment proposal is initiated with this focus on the submandibular gland. We provide a concise rationale for recommended descriptive language highlighted by a more extensive supplement that includes an extensive literature review with additional case examples. Conclusion: Recommendations are provided to improve consistency both in performing and reporting submandibular gland ultrasound.

Sentinel lymph node biopsy for head and neck malignancies utilizing simultaneous radioisotope gamma probe and indocyanine green fluorescence navigation.

We depict an innovative surgical approach for sentinel lymph node biopsy (SLNB) in head and neck malignancies that utilizes both near-infrared (NIR) imaging with indocyanine green (ICG) dye and hand-held gamma probe intraoperatively to isolate and excise SLNs. Twenty-one patients presented to our institution with cutaneous melanoma, cutaneous squamous cell carcinoma (SCC), and oral cavity SCC tumors that met criteria for SLNB based on tumor depth and histology. The video offers a step-by-step approach for this technique along with descriptions of recommended equipment. Among 21 patients, two patients had positive SLNs on final pathology. One patient developed a local recurrence over an average of 16.2 months of follow-up (SD = 15.6). SLNB with ICG and radionucleotide co-localization may enhance the identification of sentinel nodes without compromising outcomes in the hands of surgeons well-versed in the technique.

Perioperative opioids and survival outcomes in resectable head and neck cancer: A systematic review.

BACKGROUND: Opioids are a mainstay in pain control for oncologic surgery. The objective of this systematic review is to evaluate the associations of perioperative opioid use with overall survival (OS) and disease-free survival (DFS) in patients with resectable head and neck cancer (HNC). METHODS: A systematic review of PubMed, SCOPUS, and CINAHL between 2000 and 2022 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies investigating perioperative opioid use for patients with HNC undergoing surgical resection and its association with OS and DFS were included. RESULTS: Three thousand three hundred seventy-eight studies met initial inclusion criteria, and three studies representing 562 patients (intraoperative opioids, n = 463; postoperative opioids, n = 99) met final exclusion criteria. One study identified that high intraoperative opioid requirement in oral cancer surgery was associated with decreased OS (HR = 1.77, 95% CI 0.995-3.149) but was not an independent predictor of decreased DFS. Another study found that increased intraoperative opioid requirements in treating laryngeal cancer was demonstrated to have a weak but statistically significant inverse relationship with DFS (HR = 1.001, p = 0.02) and OS (HR = 1.001, p = 0.02). The last study identified that patients with chronic opioid after resection of oral cavity cancer had decreased DFS (HR = 2.7, 95% CI 1.1-6.6) compared to those who were not chronically using opioids postoperatively. CONCLUSION: An association may exist between perioperative opioid use and OS and DFS in patients with resectable HNC. Additional investigation is required to further delineate this relationship and promote appropriate stewardship of opioid use with adjunctive nonopioid analgesic regimens.

Margins in Stage I and II Oral Cavity Squamous Cell Carcinoma: A Review From the American Head and Neck Society.

Importance: The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality. Observations: This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design. Conclusions and Relevance: Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.

Feasibility and Cost of Telehealth Head and Neck Cancer Survivorship Care: A Systematic Review.

OBJECTIVE: Evaluate the feasibility and cost-effectiveness of telehealth head and neck cancer (HNC) survivorship care. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, CINAHL. REVIEW METHODS: A systematic search for peer-reviewed feasibility studies on telehealth models for HNC survivorship care published between 2005 and 2021 was conducted using the terms "head and neck cancer" and "telehealth" and their synonyms. Inclusion criteria were studies on telehealth survivorship program interventions for HNC patients with quantitative feasibility outcome measures (eg, enrollment, retention, attrition/dropout rate, adherence/task completion rate, patient satisfaction, cost). RESULTS: Thirty-eight studies out of 1557 identified met inclusion criteria and were included for analysis. Feasibility outcomes evaluated were enrollment and attrition rates, adherence/task completion rates, patient satisfaction, and user feedback surveys in different survivorship domains. Patient enrollment ranged from 20.8% to 85.7%, while attrition ranged from 7% to 47.7%. Overall, adherence was 30.2% higher in the intervention group than in the control group (46.8% vs 16.6%). Studies with cost analysis found telehealth models of care to be statistically significantly less expensive and more cost-efficient than the standard model of care, with a $642.30 saving per patient (n = 3). Telehealth models also substantially reduced work time saving per visit (on average, 7 days per visit). CONCLUSION: While telehealth survivorship programs are feasible and cost-effective and are associated with improved patient outcomes, they might not be ideal for every patient. Further investigations are needed to understand the role of telehealth in survivorship care, given the variability in study design, reporting, measures, and methodological quality.

Minimally invasive retroauricular approach parotidectomy: A pictorial essay.

The surgical approach to a parotid neoplasm has traditionally been taught through a modified-Blair incision. This approach results in a visible scar in the preauricular, retromandibular, and upper neck skin. Various modifications have been undertaken which aim to improve cosmesis either by decreasing overall incision length and/or relocation of the incision to the hairline via what is commonly described as a "facelift approach". We describe a novel minimally invasive parotidectomy approach which utilizes a single retroauricular incision. This approach eliminates both the preauricular scar as well as the extended incision in the hairline and additional skin flap elevation which accompanies it. Sixteen patients underwent parotidectomy using this minimally invasive incision and the excellent clinical outcomes are reviewed. The minimally invasive retroauricular approach to parotidectomy provides excellent exposure with no visible incision/scar in appropriately selected patients.

Examination of care processes and treatment optimization for head and neck cancer patients in a community setting "hub and hub" model.

Objective: To examine referral pattern, the timing of diagnostic/staging processes, and treatment initiation for new head and neck cancer patients in a community setting. Methods: Patients with a newly diagnosed previously untreated diagnosis of head neck cancer managed at Asplundh Cancer Pavilion/Abington Memorial Hospital from October 2018 to March 2020. Source of referral and preceding workup were examined as well as intervals between initial head and neck consult and various timepoints of treatment initiation. Results: One hundred and five patients were included in the study. The primary referral sources were external general otolaryngology (56.3%). Oral surgery and dermatology obtained tissue biopsy approximately 80% of the time before referral. The average time from the ordering of initial staging positron emission tomography/computed tomography to finalized results was 14 days (range: 10-25 days). Patients referred from dermatology and oral surgery were more likely to require single modality care, namely definitive surgical management. Time to treatment initiation average was 37 days (range: 29-41 days). Patients with longer treatment times noted significantly higher times to both radiation and medical oncology consults (48.42 vs. 18.13 days; P < 0.001). Conclusions: No notable differences in treatment initiation times were identified based on referral source or extent of workup performed before head/neck surgery consult. It appears the largest opportunities for improvement in terms of reducing overall treatment length exist in the optimization of radiation initiation time.

Evaluating the impact of smoking on disease-specific survival outcomes in patients with human papillomavirus-associated oropharyngeal cancer treated with transoral robotic surgery.

BACKGROUND: When treated nonsurgically with definitive chemoradiation, smokers with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) have a worse prognosis compared with their nonsmoking counterparts. To the authors' knowledge, the prognostic significance of smoking in surgically treated patients is unknown. METHODS: The current study is a retrospective case series of patients with HPV-positive OPSCC who underwent upfront transoral robotic surgery at a single institution from 2010 through 2017. Exclusion criteria were nonoropharyngeal primary tumors, histology other than SCC, HPV-negative tumors, previous history of head and neck cancer, and/or previous head and neck radiotherapy. Recurrence-free survival (RFS), overall survival, and disease-specific survival were compared using the Kaplan-Meier method and the log-rank test. Smoking history was categorized as never smokers (<1 pack-year), current smokers (smoking at the time of the cancer diagnosis), and former smokers. RESULTS: A total of 258 patients met the study criteria. The average age was 60 years, and approximately 87% of patients were male. A total of 148 patients (57.4%) were smokers whereas 110 (42.6%) reported never smoking. There were 44 active smokers (17.1%) and 104 former smokers (40.3%). The median follow-up was 3.23 years. There were 17 patients of disease recurrence. Smoking pack-year history was not found to be significant for RFS (hazard ratio, 1.01; 95% CI, 0.99-1.03 [P = .45]). There was no significant difference in RFS noted between never and ever smokers (92% vs 89.8%; P = .85) nor was there a difference observed between never, former, and current smokers (92% vs 91.5% vs 86.1%, respectively; P = .69). CONCLUSIONS: A smoking history is common in patients with HPV-positive OPSCC. In the current study, HPV-positive smokers were found to have excellent survival and locoregional control, similar to their nonsmoking counterparts. The results of the current study do not support the exclusion of smokers with early-stage, HPV-positive OPSCC from transoral robotic surgery-based deintensification trials.

Surgical management of the recurrent laryngeal nerve in thyroidectomy: American Head and Neck Society Consensus Statement.

"I have noticed in operations of this kind, which I have seen performed by others upon the living, and in a number of excisions, which I have myself performed on the dead body, that most of the difficulty in the separation of the tumor has occurred in the region of these ligaments…. This difficulty, I believe, to be a very frequent source of that accident, which so commonly occurs in removal of goiter, I mean division of the recurrent laryngeal nerve." Sir James Berry (1887).

Fusion proteins in head and neck neoplasms: Clinical implications, genetics, and future directions for targeting.

Fusion proteins resulting from chromosomal rearrangements are known to drive the pathogenesis of a variety of hematological and solid neoplasms such as chronic myeloid leukemia and non-small-cell lung cancer. Efforts to elucidate the role they play in these malignancies have led to important diagnostic and therapeutic triumphs, including the famous development of the tyrosine kinase inhibitor dasatinib targeting the BCR-ABL fusion. Until recently, there has been a paucity of research investigating fusion proteins harbored by head and neck neoplasms. The discovery and characterization of novel fusion proteins in neoplasms originating from the thyroid, nasopharynx, salivary glands, and midline head and neck structures offer substantial contributions to our understanding of the pathogenesis and biological behavior of these neoplasms, while raising new therapeutic and diagnostic opportunities. Further characterization of these fusion proteins promises to facilitate advances on par with those already achieved with regard to hematologic malignancies in the precise, molecularly guided diagnosis and treatment of head and neck neoplasms. The following is a subsite specific review of the clinical implications of fusion proteins in head and neck neoplasms and the future potential for diagnostic targeting.

Considerations in surgical versus non-surgical management of HPV positive oropharyngeal cancer.

Given the marked difference in clinical presentation and treatment response based on human papilloma virus (HPV) status, HPV-associated oropharyngeal squamous cell carcinoma is now viewed as a distinct biologic and clinical entity. HPV-associated oropharyngeal squamous cell carcinoma has increased by nearly 7.5 % per year, from approximately 16 % in the early 1980's to nearly 70 % today, and is believed will continue to increase dramatically in the coming years. Currently, a myriad of treatment options exist for these patients as many active clinical trials are underway which aim to identify the most appropriate interventions for this unique group of patients. This review aims to provide considerations between surgical and non-surgical management for HPV-associated oropharyngeal squamous cell carcinoma.

Surgical Techniques for Zenker's Diverticulum: A Comparative Analysis.

OBJECTIVE: To compare the different modalities for treatment of Zenker's diverticulum and the associated clinical outcomes. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Between 1995 and 2011, 164 patients underwent surgery for Zenker's diverticulum (stapler, n = 69; laser, n = 68; open, n = 27). Patient sociodemographics, medical comorbidities, pre- and postoperative subjective dysphagia and regurgitation score, complications, length of stay, time to oral intake, and recurrence were reviewed for each surgical modality. RESULTS: No statistically significant difference in diverticulum prevalence was associated with age, gender, or treatment group. Mean length of hospital stay was not significantly different between the 3 groups (P = .14). A significant difference in time to oral intake was observed in the laser group compared with the other 2 groups (P = .012). No significant difference in recurrence (P = .21) or complication (P = .12) rates was identified between the 3 groups. Although all 3 groups demonstrated a significant decrease between preoperative and postoperative dysphagia and regurgitation scores, the degree of improvement was not significant when the 3 groups were compared. CONCLUSION: There is no single "best" approach to Zenker's diverticulum. The open, laser, and stapler methods are equally effective and have similar complication rates.

The snare technique: a novel atraumatic method for the removal of difficult nasal foreign bodies.

BACKGROUND: Nasal foreign bodies (NFBs) are a common occurrence, particularly in children between 2 and 4 years old. Many techniques have been developed to remove NFBs, though intranasal batteries, in particular, possess characteristics such as round shape, smooth surface, and limited visibility that make attempts at removal significantly more difficult. In the context of intranasal batteries, a considerable local soft tissue reaction and potential necrosis may exist to further complicate removal. OBJECTIVE: To present a technique for removal of difficult intranasal foreign bodies that may be utilized by health care practitioners, particularly in the Emergency Department setting. CASE REPORT: We present a case of a 4-year-old child presenting with intranasal battery with mucosal necrosis. After conventional techniques failed, we utilized a novel wire snare technique to dissect the NFB free from the nasal mucosa safely and in an atraumatic fashion. CONCLUSION: This technique is noted to be a rapid, atraumatic, and effective means for the removal of difficult NFBs.

Middle ear carcinoid with distant osseous metastasis.

Middle ear carcinoid is a rare entity with an indolent clinical course. Numerous reports have described local recurrence and metastasis to the cervical lymph nodes, although only one report of distant visceral metastasis exists in the literature. We describe the potential for osseous metastasis. A 52-year-old male with previous middle ear carcinoid (resected 10 years prior) presented with a neck mass. Subsequent workup revealed a suspicious lytic lesion of the iliac crest. Selective neck dissection and core biopsy of the iliac lesion were performed, which revealed concurrent histologically identical metastasis to both the cervical lymph nodes and iliac crest, morphologically indistinguishable from the previous middle ear carcinoid. This case presents the novel description of distant osseous metastasis of middle ear carcinoid.

Cross-sectional vestibular nerve analysis in vestibular neuritis.

OBJECTIVES: We examined the association between the size and cross-sectional area of the superior vestibular nerve as measured on constructive interference in steady-state (CISS) parasagittal magnetic resonance imaging (MRI) and the vestibular nerve function as measured by electronystagmography. METHODS: The retrospective observational cohort study took place at an academic tertiary referral center. Twenty-six patients who met established clinical and electronystagmographic criteria for vestibular neuritis and who underwent parasagittal CISS MRI were identified. Two blinded investigators measured vestibular nerve height and width bilaterally at the level of the fundus of the internal auditory canal and calculated the cross-sectional nerve areas. The inter-rater reliability and agreement were analyzed. Symptom duration, age, and gender were also examined. RESULTS: A statistically significant decrease was observed in both vestibular nerve cross-sectional area and height as compared to the contralateral vestibular nerve. A non-statistically significant trend was observed for a relative decreased cross-sectional nerve area with increased age, as well as a decrease in nerve area with an increase in symptom duration. CONCLUSIONS: Decreases in both vestibular nerve cross-sectional area and height are observed in patients with unilateral vestibular neuritis as measured on parasagittal CISS MRI.

Pharmacokinetics after endovascular lung perfusion with Cisplatin.

PURPOSE: Endovascular lung perfusion (ELP) is a technique designed to deliver high doses of cisplatin via the pulmonary artery for the treatment of lung tumors. The purpose of the current study was to evaluate variables that affect adduct formation. MATERIALS AND METHODS: Thirteen swine underwent ELP. The first group (n = 6) underwent infusion of 150 mg cisplatin diluted to 0.5 mg/mL via a balloon occlusion catheter in the left pulmonary artery. Uptake was compared with that seen with systemic infusion. A second group (n = 7) underwent bilateral sequential infusion of the left pulmonary artery, followed by the right. Cisplatin (150 mg) was infused at one of three concentrations: 1 mg/mL (n = 5 lungs), 0.67 mg/mL (n = 5 lungs), or 0.5 mg/mL (n = 4 lungs). The Pearson coefficient was used to correlate uptake with infusion time, infusate concentration, animal weight, and initial mean pulmonary artery pressure. RESULTS: In the first group, cisplatin uptake in the control lung was less than 8% of that in the study lung. Infusion times for both groups ranged from 3 minutes to 56 minutes. Increases in infusion time correlated with increased adduct levels (r = 0.831; P < .0001). Mean uptake at concentrations of 0.5, 0.67, and 1 mg/mL were 25.79, 12.43, and 13.12 fmol/mug, respectively. There was no significant correlation between pulmonary adduct levels and infusate concentration (r = 0.106; P = .72). Animal weight and initial mean pulmonary artery pressure were not correlated with adduct formation. CONCLUSIONS: ELP with longer infusions of cisplatin may lead to greater adduct formation in pulmonary tissues. Changes in concentration of the infusate do not affect uptake of cisplatin. Hemodynamic parameters do not affect cisplatin uptake.

Long-term osseous morphologic outcome of surgically treated unilateral coronal craniosynostosis.

BACKGROUND: Unilateral coronal craniosynostosis has characteristic osseous dysmorphology that persists into adulthood if untreated. Knowledge of the long-term in vivo osseous morphologic outcome of surgically treated unilateral coronal craniosynostosis patients is limited. The purpose of this study was to define the osseous morphology of adolescent patients who underwent surgery for unilateral coronal craniosynostosis in infancy, compared with both their 1-year postoperative morphology and the morphology of other individuals with untreated unilateral coronal craniosynostosis. METHODS: Three populations of unilateral coronal craniosynostosis were studied: group 1, patients with surgical treatment of unilateral coronal craniosynostosis in infancy who had reached dentoskeletal maturity, ranging in age from 13.5 to 32.7 years (n= 9); group 2, individuals with untreated unilateral coronal craniosynostosis, ranging in age from 1.1 to 21 years (n= 11); and group 3, a subset of group 1 patients 1 year after surgical correction of unilateral coronal craniosynostosis, ranging in age from 1.2 to 2.6 years (n= 6). Data from high-resolution, thin-slice computed tomographic scans of the head were analyzed. Thirty-five reproducible osseous landmarks were recorded as three-dimensional coordinates using ETDIPS imaging software. Nonmidline landmarks were designated as either ipsilateral or contralateral to the synostosis. One researcher performed all landmarking with high intrarater reliability (average error, <2 mm). Data from the three groups were analyzed for asymmetry using Euclidean distance matrix analysis techniques. RESULTS: Euclidean distance matrix analysis asymmetry analysis demonstrated more statistically significant ipsilateral-contralateral asymmetric pairs in group 1 (68 of 135) than in group 3 (25 of 135), but fewer statistically significant ipsilateral-contralateral asymmetric pairs than in group 2 (93 of 135). CONCLUSIONS: Surgical treatment of unilateral coronal craniosynostosis in infancy results in a less asymmetric craniofacial skeleton in adolescence than nontreatment. However, patients who have been followed to dentoskeletal maturity have a greater degree of asymmetry than those evaluated at 1 year postoperatively. These results support the conclusion that with time there is a partial reversion to the untreated phenotype.

Hepatic arterial chemoembolization for hepatocellular carcinoma: comparison of survival rates with different embolic agents.

PURPOSE: The optimal embolic agent for transhepatic arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) has not been identified. This study reports outcomes of TACE for HCC with Gelfoam powder and polyvinyl alcohol (PVA). MATERIALS AND METHODS: Eighty-one patients underwent 152 TACE sessions with Gelfoam powder (n = 41) or polyvinyl alcohol (PVA) and Ethiodol (n = 40) as the embolic agent. Chemotherapeutic drugs were the same for all patients (50 mg cisplatin, 20 mg doxorubicin, 10 mg mitomycin-c). The groups were compared based on number of TACE sessions, maximum tumor size, bilirubin level, aspartate and alanine aminotransferase levels, Child-Pugh score, Model for End-stage Liver Disease score, and hepatitis B or C virus positivity. The number of cases of each Child class in each group was also evaluated. Survival starting from the first TACE session was calculated according to Kaplan-Meier analysis. Forty-eight patients died during the study period, 19 received transplants, and 14 were alive at the end of the study period. RESULTS: The groups were statistically similar in all categories regarding liver function, Child-Pugh score, tumor size, hepatitis status, and percentage of patients with Child class A, B, and C disease. The number of TACE sessions was significantly greater for the Gelfoam powder group (mean, 2.2) versus the PVA group (mean, 1.6; P = .01). Overall survival was similar between groups whether patients who received transplants were included in the analysis (mean, 659 days +/- 83 with Gelfoam powder vs 565 days +/- 71 with PVA; P = .42) or were excluded (mean, 519 days +/- 80 with Gelfoam powder vs 511 days +/- 75 with PVA; P = .93). CONCLUSION: In similar patient groups, survival after treatment of HCC with TACE with Gelfoam powder or PVA and Ethiodol was similar.

Comparison of MELD and Child-Pugh scores to predict survival after chemoembolization for hepatocellular carcinoma.

PURPOSE: To compare the value of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores to predict patient survival rates after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Eighty-seven patients underwent 169 TACE sessions. Child-Pugh and MELD values were calculated before initial treatment. Survival length was tracked from the date of the first TACE procedure. Transplant recipients were censored from the study at the time of surgery. Child-Pugh and MELD scores as well as bilirubin and albumin levels and International Normalized Ratio were placed in high and low categories defined by their respective medians. Patient survival was compared at 3 months, 6 months, 12 months, and 24 months, and patterns were tested with chi2 or Fisher exact tests. Survival over the entire period was examined with Kaplan-Meier analysis and differences were tested with log-rank tests. RESULTS: Mean and median survival times for all patients were 24 and 17 months, respectively. Sixteen patients were censored for transplantation at a mean of 12.9 months. MELD and Child-Pugh scores correlated well with each other (r = 0.68). Child-Pugh score (r = -0.35, P = .04) correlated more strongly with 12-month survival than did MELD score (r = -0.26, P = .12). After high/low score category division, a significantly greater survival difference was predicted by Child-Pugh score (27.2 months vs 10.3 months; P = .03) versus MELD score (27.5 months vs 15.8 months; P = .19). An albumin level greater than 3.4 g/dL was also associated with significantly improved survival (29.3 months vs 10.1 months; P = .0032). Survival differences between high-risk and low-risk groups at the 3-, 6-, 12-, and 24-month intervals were significant for low Child-Pugh scores and for albumin levels greater than 3.4 g/dL. Statistical significance was not approached at any of the time lengths with MELD scores. CONCLUSIONS: Child-Pugh score correlates better than MELD score to overall patient survival and is a better predictor than MELD score of survival at specific time points. Of the components of the Child-Pugh and MELD systems, albumin level is the most useful predictor of survival.