Multifocal and Recurrent Tonsillar Squamous Cell Carcinoma.

The following study describes a complex clinical course of recurrent and multifocal squamous cell carcinoma (SCC) of the tonsil, involving both initial and subsequent malignancies over several years. The patient, a 54-year-old male with a history of tobacco use, first presented with SCC of the left tonsil, treated with tonsillectomy and neck dissection. Despite clear margins post-surgery, the patient developed SCC in the right tonsil two years later, requiring further surgical intervention and a comprehensive treatment approach. The disease then progressed to the base of the tongue and right larynx, necessitating a total laryngectomy and subtotal glossectomy. The report emphasizes the critical role of advanced imaging and surgical techniques, including robotic-assisted surgery, in managing such complex cases. Additionally, the case highlights the challenges of treating advanced oropharyngeal SCC, the importance of multidisciplinary management, and the need for consistent follow-up to monitor treatment efficacy and manage complications. The case underscores the complexity of SCC in the head and neck region and the necessity for tailored therapeutic strategies to improve patient outcomes.

Primary Raynaud's Phenomenon of the Tongue.

Raynaud's phenomenon is a condition characterized by intermittent vasoconstriction of arteries in the fingers and skin, triggered by cold temperatures or emotional stress, aimed at conserving body heat. This condition is classified into primary and secondary forms, with secondary Raynaud's often linked to connective tissue diseases, medications, infections, and occupational exposures. A notable clinical case involves a 51-year-old male experiencing episodes of painful, white discoloration of the tongue, which were managed through a comprehensive diagnostic process, including rheumatological and cardiological evaluations, to rule out connective tissue diseases and cardiac dysfunction. We highlight the complex pathophysiology of Raynaud's, involving vascular, neurogenic, and immune mechanisms. Management strategies focus on lifestyle modifications and pharmacologic treatments, such as calcium channel blockers, to reduce attack frequency and severity. For refractory cases, advanced therapies, including phosphodiesterase inhibitors, intravenous prostaglandins, and surgical sympathectomy, may be considered. Effective diagnosis and individualized treatment are crucial for preventing complications and improving patient outcomes.

Pleomorphic Adenoma of the Nasal Cavity.

Pleomorphic adenoma (PA) most commonly manifests in the parotid gland, though it occasionally emerges in atypical locations. We present a case involving an 87-year-old female who exhibited chronic left-sided nasal symptoms, leading to the diagnosis of PA in the nasal cavity. This diagnosis was confirmed through rhinoscopy and subsequent pathological examination following the surgical excision of an 8x8 mm mass. The procedure, which included tumor-based cautery, alleviated her symptoms effectively. A follow-up strategy was established to monitor for any signs of recurrence. The patient has shown no signs of recurrence at subsequent three-month follow-up visits, highlighting the success of the intervention. This case underscores the importance of early recognition and intervention in atypical presentations of PA, which is crucial to prevent potential complications and ensure favorable outcomes.

Sialadenitis Secondary to Bilateral Hypertrophic Torus Mandibularis.

In this case report, we detail a rare instance of sialadenitis secondary to bilateral hypertrophic torus mandibularis (TM) in a 70-year-old Caucasian male who presented with neck swelling, dysphagia, and weight loss. Radiographic evaluations revealed enlarged TM obstructing Wharton's duct, further complicated by a sialolith. The patient's treatment regimen included antibiotics, oral steroids, and sialogogues, accompanied by surgical removal of the hypertrophic TM and sialoendoscopy, which resulted in significant symptomatic relief and the resolution of sialadenitis. This case emphasizes the importance of recognizing mechanical etiologies in patients presenting with sialadenitis, particularly when linked to pronounced anatomical abnormalities like TM.

Potential of Machine Learning for Predicting Sleep Disorders: A Comprehensive Analysis of Regression and Classification Models.

Sleep disorder is a disease that can be categorized as both an emotional and physical problem. It imposes several difficulties and problems, such as distress during the day, sleep-wake disorders, anxiety, and several other problems. Hence, the main objective of this research was to utilize the strong capabilities of machine learning in the prediction of sleep disorders. In specific, this research aimed to meet three main objectives. These objectives were to identify the best regression model, the best classification model, and the best learning strategy that highly suited sleep disorder datasets. Considering two related datasets and several evaluation metrics that were related to the tasks of regression and classification, the results revealed the superiority of the MultilayerPerceptron, SMOreg, and KStar regression models compared with the other twenty three regression models. Furthermore, IBK, RandomForest, and RandomizableFilteredClassifier showed superior performance compared with other classification models that belonged to several learning strategies. Finally, the Function learning strategy showed the best predictive performance among the six considered strategies in both datasets and with respect to the most evaluation metrics.

Improved Cervical Lymph Node Characterization among Patients with Head and Neck Squamous Cell Carcinoma Using MR Texture Analysis Compared to Traditional FDG-PET/MR Features Alone.

Accurate differentiation of benign and malignant cervical lymph nodes is important for prognosis and treatment planning in patients with head and neck squamous cell carcinoma. We evaluated the diagnostic performance of magnetic resonance image (MRI) texture analysis and traditional 18F-deoxyglucose positron emission tomography (FDG-PET) features. This retrospective study included 21 patients with head and neck squamous cell carcinoma. We used texture analysis of MRI and FDG-PET features to evaluate 109 histologically confirmed cervical lymph nodes (41 metastatic, 68 benign). Predictive models were evaluated using area under the curve (AUC). Significant differences were observed between benign and malignant cervical lymph nodes for 36 of 41 texture features (p < 0.05). A combination of 22 MRI texture features discriminated benign and malignant nodal disease with AUC, sensitivity, and specificity of 0.952, 92.7%, and 86.7%, which was comparable to maximum short-axis diameter, lymph node morphology, and maximum standard uptake value (SUVmax). The addition of MRI texture features to traditional FDG-PET features differentiated these groups with the greatest AUC, sensitivity, and specificity (0.989, 97.5%, and 94.1%). The addition of the MRI texture feature to lymph node morphology improved nodal assessment specificity from 70.6% to 88.2% among FDG-PET indeterminate lymph nodes. Texture features are useful for differentiating benign and malignant cervical lymph nodes in patients with head and neck squamous cell carcinoma. Lymph node morphology and SUVmax remain accurate tools. Specificity is improved by the addition of MRI texture features among FDG-PET indeterminate lymph nodes. This approach is useful for differentiating benign and malignant cervical lymph nodes.

Grill-Cleaning Wire Brush Bristle Ingestion: Case Series and Review of the Literature.

OBJECTIVES: The authors report a small case series of an unusual ingested foreign body, wire brush bristles, whose small size can present a challenge for endoscopic removal. The authors describe transnasal endoscopic removal and provide a literature review. METHODS: From 2011 to 2017, 8 patients presented to an academic tertiary medical center with ingestion of wire brush bristles. The patients' medical records were reviewed and are described in this report, along with a literature review. RESULTS: In 4 patients, the bristles were in the lingual tonsils. In 1 patient, a bristle was within the pharyngoepiglottic fold and lingual tonsils. Three patients underwent office removal with a fiber-optic laryngoscope under local anesthesia. Two patients underwent direct laryngoscopy with bristle removal. In 1 patient the wire bristle transected the esophagus, requiring an open procedure. One patient presented with a complicated deep-space neck infection. CONCLUSIONS: Wire brush bristles easily become displaced and subsequently become lodged in the upper aerodigestive tract. Localization of a bristle can be difficult on examination and laryngoscopy. Radiography can be performed, but computed tomographic examination with contrast is superior for precise localization for preparation for an operative approach. Depending on the precise location of the bristle, endoscopic removal using a fiber-optic channeled scope may be a safe and effective solution. LEVEL OF EVIDENCE: Case Series, IV.

Gastrostomy in the era of minimally invasive head and neck cancer surgery.

OBJECTIVE: Minimally invasive transoral robotic surgery (TORS) is less likely to necessitate gastrostomy tube (GT) following resection of head and neck lesions versus conventional open procedures. However, the incidence of and indications for GT after TORS have not been reported in detail. This study defines the incidence of intra- and postoperative gastrostomy following robotic resection of advanced head and neck disease. It seeks to clarify the relevance of GT after TORS. STUDY DESIGN: Adult patients undergoing TORS and neck dissection from 2008 to 2014 were identified in the New York Statewide Planning and Research Cooperative System all-payer administrative database. METHODS: Demographic data and timing of GT in relation to surgery were recorded. Emergency department (ED) visits and inpatient readmissions were compared with multivariable logistic analysis. RESULTS: Of the 441 included patients, immediate, delayed, and total GT incidence within the first postoperative year was 9.5%, 11.6%, and 21.1%, respectively. Gastrostomy tube complications resulted in 4.5% of 30-day ED visits, 3.3% of 30-day readmissions, and 3.5% of 90-day readmissions. Thirty-nine percent of 90-day readmissions were linked to poor postoperative oral intake. Delayed GT status was associated with an increase in 30-day ED visits, and 30- or 90-day readmissions attributable to poor oral intake (P = 0.10, P < 0.0001, 0.002, respectively). CONCLUSION: Even in the era of minimally invasive TORS, impaired oral intake is a significant postoperative burden to head and neck cancer patients with advanced disease. Attention to patient risk factors combined with a complicated hospital course may identify patients benefiting from early GT. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:847-851, 2018.

Compared Outcomes of Concurrent versus Staged Transoral Robotic Surgery with Neck Dissection.

Objective Outcomes of concurrent versus staged neck dissection with transoral robotic surgery have not been studied. This study compares outcomes of concurrent versus staged transoral robotic surgery and neck dissection. Design Retrospective administrative database analysis. Setting Article 28 licensed inpatient and outpatient care facilities in New York State. Subjects/Methods Adults undergoing transoral robotic surgery with staged or concurrent neck dissection from 2008 to 2014 were identified in the New York Statewide Planning and Research Collaborative System database. We compared complications, readmissions, subsequent procedures, and length of stay for concurrent versus staged procedures with multivariable logistic regression and multiple linear regression models. Results Of the 425 patients undergoing transoral robotic surgery and neck dissection, 333 had concurrent procedures, and 92 had staged. Risk-adjusted length of stay for concurrent procedures was 42.3% less than that of staged procedures ( P < .0001). Neck dissection timing was not associated with postoperative complications ( P = .41), readmissions ( P = .67), or additional procedures, including reconstruction, tracheostomy, or gastrostomy ( P = .17, .84, .82, respectively). Bleeding (7.8%) was the most common complication, and the majority (78.8%) required reoperation. Bleeding or surgical error was not associated with either concurrent or staged surgery (concurrent vs staged: adjusted odds ratio, 0.68; 95% CI, 0.35-1.37; P = .26). Conclusions Concurrent and staged procedures are equivalent with respect to adverse events, but length of stay is shorter for concurrent procedures. Cost and clinical benefits associated with length of stay are unknown, and it is reasonable to allow operator preference and patient factors to determine surgical logistics.

Hemostasis in endoscopic endonasal skull base surgery using the Aquamantys bipolar sealer: Technical note.

BACKGROUND: A major challenge during endoscopic transsphenoidal surgery is adequate intraoperative hemostasis. The Aquamantys® is a relatively new bipolar sealing device which uses radiofrequency energy and saline. This promotes hemostasis while decreasing charring and thermal spread. In this paper, we describe our experience with the Aquamantys® Mini EVS 3.4 Epidural Vein Sealer Bipolar Electrocautery System (Medtronic Advanced Energy, Portsmouth, NH, USA) during endoscopic surgery for tumors of the skull base with particular attention to ergonomic benefits and technical nuances. METHODS: We conducted a retrospective review of all patients undergoing endoscopic surgery for skull base tumors from September 2012 to June 2016 at our institution. All procedures used the Aquamantys® system. 45 cases were identified. RESULTS: Successful hemostasis was achieved in all cases with an average estimated blood loss (EBL) of 46mL (Range 10-250). There were no intraoperative complications. The single-shaft design allowed for excellent manipulation compared to pistol-grip bipolar forceps. The thermal energy provided excellent radial coverage without extensive penetration into viable pituitary tissue. CONCLUSION: To our knowledge, this is the largest series documenting the use of the Aquamantys® system in skull base surgery. The device is easily mobile and highly effective within the endonasal corridor and should be a tool in the repertoire of the endoneurosurgeon. Randomized control trials would be useful in comparing EBL between the Aquamantys® and standard bipolar electrocautery.

Trends and the utilization of transoral robotic surgery with neck dissection in New York State.

OBJECTIVES: The timing of neck dissection (ND) in relation to transoral robotic surgery (TORS) is controversial. This study identifies local practice patterns and economic and social access disparities during adoption of TORS. STUDY DESIGN: We analyzed utilization patterns of TORS and ND using the New York Statewide Planning and Research Cooperative System all-payer administrative database. Statewide head and neck cancer incidence from the Centers for Disease Control and Prevention (Bethesda, MD) was used to control for overall cancer incidence. METHODS: Patient demographic, insurer, and institutional information of patients aged ≥ 18 (n = 225) years from 2008 to 2012 were evaluated. Temporal trends were analyzed with Poisson regression models for counts. RESULTS: Transoral robotic surgery was used in 386 procedures, and 58.3% involved ND (n = 225). Concurrent ND was most frequent (n = 173), followed by staged TORS then ND (n = 44) and staged ND preceding TORS (n = 8). Caucasians were more likely than Blacks/Hispanics to undergo TORS (P = 0.03). Medicare (26.2%) and Medicaid (2.7%) payers comprised a minority of patients compared to those commercially insured (70.2%). Only 20% of patients received care outside a major urban center, and these patients were more likely to undergo staged procedures, P = 0.02. Staged procedures resulted in higher mean hospital charges (P = 0.02). CONCLUSION: Concurrent TORS + ND, the most common practice in New York, is more cost-effective. Patients without commercial insurance, patients in racial minorities, or patients residing outside major urban centers may be targeted to improve care access disparities with respect to minimally invasive TORS technology. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:1571-1576, 2017.

MT1-MMP Activation of TGF-ß Signaling Enables Intercellular Activation of an Epithelial-mesenchymal Transition Program in Cancer.

Membrane type 1-matrix metalloproteinase (MT1-MMP, MMP-14) is associated with cancer invasion and metastasis leading to poor patient prognosis. MT1-MMP mediates cancer cell invasion via degradation of basement membrane and extracellular matrix, and induction of cell migration. However, MT1-MMP expression in the cancer stroma can drive invasion of carcinoma cells in vivo, suggesting MT1-MMP may also promote cancer invasiveness via paracrinemediated mechanisms. A major step in cancer cell metastasis is thought to be an epithelial-mesenchymal transition (EMT), in which carcinoma cells evolve from a stationary epithelial phenotype to a more motile mesenchymal phenotype. We demonstrate here that EMT is triggered by MT1-MMP-mediated activation of TGF-. signaling, involving induction of CUTL1 and subsequently, of Wnt5a. Mesenchymal-like cancer cells expressing endogenous MT1-MMP reverted to an epithelial phenotype when MT1-MMP, SMAD4, CUTL1, or Wnt5a expression or TGF-. activity was inhibited. Wnt5a knockdown in MT1- MMP expressing LNCaP cells caused decreased cell migration and cell growth in soft agar. While MT1-MMP expression did not affect total TGF-. level, MT1-MMP catalytic activity increased the availability of active TGF-., enabling MT1-MMP-expressing cells to activate the EMT in nearby cells. MT1-MMP-expressing cells induced co-cultured non-MT1-MMP-expressing cells to undergo EMT by a TGF-.-dependent process. These results highlight a pathway by which tumor invasiveness may be expanded via MT1-MMP-mediated activation of TGF-. signaling, enabling autocrine and paracrine-mediated induction of EMT.

Robot-assisted sialolithotomy with sialendoscopy for the management of large submandibular gland stones.

OBJECTIVES/HYPOTHESIS: The objectives of this study were to describe robot-assisted sialolithotomy with sialendoscopy (RASS) for the management of large palpable hilar submandibular gland (SMG) stones and analyze procedural success and lingual nerve damage following RASS in comparison to the combined transoral sialendoscopic approach. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was performed on patients with large palpable hilar SMG stones managed with RASS following institutional review board approval. Large stones were defined as ≥5 mm, the upper limit that can be removed via sialendoscopy. Twenty-two patients between January 2012 and June 2014, with mean stone size of 12.3 mm, were identified. Data collected included symptoms of recurrence, postoperative lingual nerve function, and patient satisfaction at a mean follow-up of 14 months. Procedural success was defined as absence of symptom recurrence in conjunction with gland preservation. These measures were compared with the combined approach (CA) outcomes reported in the English literature. RESULTS: Procedural success was 100% (22/22) for our cohort. No patients reported symptoms of lingual nerve damage at follow-up, whereas four patients reported transient lingual nerve paresthesia (mean duration, 2.5 weeks). Mean patient satisfaction was 9.9 out of 10. Literature review identified 135 patients in the CA cohort. Procedural success rate for these patients was 75%, and lingual nerve damage was reported in 2% of patients. CONCLUSIONS: Our study demonstrates the safety and efficacy of RASS in the management of large SMG sialoliths. We attribute this preliminary success of RASS to the enhanced visualization, magnification, and technical advantages of the procedure. LEVEL OF EVIDENCE: 4.

CXCR4-mediated adhesion and MMP-9 secretion in head and neck squamous cell carcinoma.

The chemokine CXCL12 (SDF-1) and its receptor, CXCR4, have been implicated in organ-specific metastases of several malignancies. Head and neck squamous cell carcinoma (HNSCC) predominantly metastasizes to lymph nodes, and recent evidence has shown that CXCL12 stimulates HNSCC migration. We explored the potential role of CXCR4 in mediating other metastatic processes in HNSCC cells. CXCR4 mRNA and cell-surface expression was assessed in HNSCC cell lines. CXCR4 mRNA expression was detected in five HNSCC cell lines. Cell-surface CXCR4 was also detected in each of the HNSCC cell lines and in resected HNSCC tissues. CXCL12 induced rapid intracellular calcium mobilization in a metastatic HNSCC cell line (HN), as well as rapid phosphorylation of ERK-1/2. HNSCC cell adhesion to fibronectin and collagen was increased by CXCL12 treatment, while the addition of an inhibitor of ERK-1/2 signaling, PD98059, reduced the effects of CXCL12. CXCL12 also increased the active matrix metalloproteinase (MMP)-9 secreted. Thus, HNSCC cells express functional CXCR4 receptors that induce rapid intracellular signaling upon binding to CXCL12. Such binding leads to increased HNSCC cell adhesion and MMP secretion, suggesting that CXCR4 may be a novel regulator of HNSCC metastatic processes.

The effects of the plasminogen pathway on scar tissue formation.

OBJECTIVES/HYPOTHESIS: The authors sought to determine the role of the plasminogen pathway in wound healing. They hypothesized that decreased fibrin degradation may lead to increased collagen deposition. Presuming that the degree of histopathological abnormality correlates with the aesthetic appearance of the scar, we conducted a study that attempted to determine the histopathological appearance of scar tissue in mice with and without impaired function of the plasminogen pathway. STUDY DESIGN: Mice with and without deficiencies in the plasminogen pathway underwent surgery. The role of the plasminogen pathway in wound healing was studied by analysis of scar tissue formation using the methods described. METHODS: A 2-cm incision was made on the dorsum of mice with and without specified genetic deficiencies in the plasminogen pathway. After the animals were killed, the tissue was harvested, fixed, and prepared using hematoxylin and eosin as well as trichrome stains. Histopathological analysis and scoring were performed by two separate investigators in a blinded manner. Student's t test was used to determine statistical significance between groups. RESULTS: A statistically significant difference in collagen orientation was noted between mice with impaired plasminogen pathway function and the wild-type (control) group (P =.0163). A statistical trend toward improved wound healing for plasminogen-deficient mice was found for overall histomorphological score (P =.0706). CONCLUSION: The role of the plasminogen pathway in wound healing is one that should be noted and may lead to the development of new therapies that reduce scar tissue formation. Hence, the role of other thrombolytic and anti-thrombolytic agents in wound healing should be further investigated to precisely identify agents that play the most significant role in scar tissue formation.