Oncologic outcomes of human papillomavirus-associated oropharynx carcinoma treated with surgery alone: A 12-institution study of 344 patients.

BACKGROUND: The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear. METHODS: The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses. RESULTS: The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59). CONCLUSIONS: With careful selection, surgery alone for AJCC 7th pT0-T2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.

Pre-clinical remote undergraduate medical education during the COVID-19 pandemic: a survey study.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has necessitated a sudden transition to remote learning in medical schools. We aimed to assess perceptions of remote learning among pre-clinical medical students and subsequently to identify pros and cons of remote learning, as well as uncover gaps to address in ongoing curricular development. METHODS: A survey was distributed to first- and second-year medical students at the University of California San Diego School of Medicine in March 2020. Frequencies of responses to structured multiple-choice questions were compared regarding impacts of remote learning on quality of instruction and ability to participate, value of various remote learning resources, living environment, and preparedness for subsequent stages of training. Responses to open-ended questions about strengths and weaknesses of the remote curriculum and overall reflections were coded for thematic content. RESULTS: Of 268 students enrolled, 104 responded (53.7% of first-year students and 23.9% of second-year students). Overall, students felt that remote learning had negatively affected the quality of instruction and their ability to participate. Most (64.1%) preferred the flexibility of learning material at their own pace. Only 25.5% of respondents still felt connected to the medical school or classmates, and feelings of anxiety and isolation were noted negatives of remote learning. Most second-year students (56.7%) felt their preparation for the United States Medical Licensing Examination Step 1 exam was negatively affected, and 43.3% felt unprepared to begin clerkships. In narrative responses, most students appreciated the increased flexibility of remote learning, but they also identified several deficits that still need to be addressed, including digital fatigue, decreased ability to participate, and lack of clinical skills, laboratory, and hands-on learning. CONCLUSIONS: Videocasted lectures uploaded in advance, electronic health record and telehealth training for students, and training for teaching faculty to increase technological fluency may be considered to optimize remote learning curricula.

Oncologic Safety of Close Margins in Patients With Low- to Intermediate-Grade Major Salivary Gland Carcinoma.

Importance: Postoperative radiation therapy for close surgical margins in low- to intermediate-grade salivary carcinomas lacks multi-institutional supportive evidence. Objective: To evaluate the oncologic outcomes for low- and intermediate-grade salivary carcinomas with close and positive margins. Design, Setting, and Participants: The American Head and Neck Society Salivary Gland Section conducted a retrospective cohort study from 2010 to 2019 at 41 centers. Margins were classified as R0 (negative), R1 (microscopically positive), or R2 (macroscopically positive). R0 margins were subclassified into clear (>1 mm) or close (≤1 mm). Data analysis was performed from June to October 2023. Main Outcomes and Measures: Main outcomes were risk factors for local recurrence. Results: A total of 865 patients (median [IQR] age at surgery, 56 [43-66] years; 553 female individuals [64%] and 312 male individuals [36%]) were included. Of these, 801 (93%) had parotid carcinoma and 64 (7%) had submandibular gland carcinoma, and 748 (86%) had low-grade tumors and 117 (14%) had intermediate-grade tumors, with the following surgical margins: R0 in 673 (78%), R1 in 168 (19%), and R2 in 24 (3%). Close margins were found in 395 of 499 patients with R0 margins (79%), for whom margin distances were measured. A total of 305 patients (35%) underwent postoperative radiation therapy. Of all 865 patients, 35 (4%) had local recurrence with a median (IQR) follow-up of 35.3 (13.9-59.1) months. In patients with close margins as the sole risk factor for recurrence, the local recurrence rates were similar between those who underwent postoperative radiation therapy (0 of 46) or observation (4 of 165 [2%]). Patients with clear margins (n = 104) had no recurrences. The local recurrence rate in patients with R1 or R2 margins was better in those irradiated (2 of 128 [2%]) compared to observed (13 of 64 [20%]) (hazard ratio [HR], 0.05; 95% CI, 0.01-0.24). Multivariable analysis for local recurrence found the following independent factors: age at diagnosis (HR for a 10-year increase in age, 1.33; 95% CI, 1.06-1.67), R1 vs R0 (HR, 5.21; 95% CI, 2.58-10.54), lymphovascular invasion (HR, 4.47; 95% CI, 1.43-13.99), and postoperative radiation therapy (HR, 0.10; 95% CI, 0.04-0.29). The 3-year local recurrence-free survivals for the study population were 96% vs 97% in the close margin group. Conclusions and Relevance: In this cohort study of patients with low- and intermediate-grade major salivary gland carcinoma, postoperative radiation therapy for positive margins was associated with decreased risk of local recurrence. In isolation from other risk factors for local recurrence, select patients with close surgical margins (≤1 mm) may safely be considered for observation.

Simulation-based workshop for emergency preparedness in otolaryngology.

Objectives: This study aimed to evaluate the outcomes of a hands-on simulation-based course with emphasis on procedural techniques, clinical reasoning, and communication skills developed to improve junior Otolaryngology - Head and Neck Surgery (OHNS) residents' preparedness in managing otolaryngologic emergencies. Methods: Junior OHNS residents and faculty from residency programs in California, Nevada, and Arizona participated in this workshop in 2020 and 2021. The stations featured airway management techniques, ultrasound-guided needle aspiration, nasoseptal hematoma evacuation, and facial fracture repair using various models and cadavers. Participants completed a pre-workshop survey, post-workshop survey, and 2-month follow-up survey that assessed resident anxiety and confidence in three OHNS emergency situations across knowledge, manual skills, and teamwork using a 5-point Likert scale. Results: Pre-workshop surveys reported the least anxiety and most confidence in teamwork, but the most anxiety and least confidence in technical skills and knowledge related to foreign body retrieval and airway management. Immediately post-workshop participants reported significant reductions in anxiety and increases in confidence, largest in the manual skills domain, in foreign body retrieval (anxiety: -0.99, confidence: +0.95, p < .01) and airway management stations (anxiety: -0.68, confidence: +1.07, p < .01). Data collected for the epistaxis station showed decreasing confidence and increasing anxiety following the workshop. Conclusion: Our findings demonstrate the effectiveness of a workshop in preparing junior residents in potentially lifesaving otolaryngologic techniques that residents will encounter. Optimizing use of simulation centered training can inform the future of residency education, improving confidence and decreasing anxiety in residents responsible for the safety of patients. Level of Evidence: III.

Steroid-eluting Stent Placement for Refractory Stenosis of Parotid Megaduct After Sialodochoplasty.

Salivary megaduct with stricture is characterized by recurrent pain, swelling, and infection, leading to reduced quality of life. Surgical management includes sialodochoplasty, however, recurrence is common and repeated surgery can lead to further scarring. In the sinuses, drug-eluting stents (DES) are used to reduce scarring after surgery, yet no such technology exists for salivary megaduct with stricture.We trialed DES for this condition with promising results which may pave the way for future development.

Student Perspectives on Remote Medical Education in Clinical Core Clerkships During the COVID-19 Pandemic.

PURPOSE: To assess student perceptions of remote learning curricula implemented by clinical clerkships at a single US medical school during the COVID-19 pandemic. METHOD: Students enrolled in core clinical clerkships at the UC San Diego School of Medicine from March to April 2020 were sent an anonymous online survey, assessing components of remote learning curricula via quantitative rating and free-response questions. RESULTS: Of 132 students enrolled, 96 (73%) completed the survey. Online question banks, remote progress reviews, and telehealth sessions were rated as the most valuable resources, while textbooks were rated least valuable. Most students felt that the number of resources was adequate (69/94, 74%), the quantity of required content was appropriate (77/93, 83%), and there was a good balance of rigidity versus flexibility in the schedule (81/94, 86%). Most students felt "prepared" or "somewhat prepared" for the shelf examination (61/91, 67%) and for the next year of medical training (73/94, 78%). In narrative reflections, students valued the flexibility afforded by remote curricula but desired some weekly structure. Students enjoyed expanded access to learning resources and participating in interactive remote sessions. Students expressed anxiety about the pandemic and uncertainty regarding medical education, but transparent communication from clerkship directors helped assuage these concerns. CONCLUSIONS: Student participation in direct patient care is fundamental to medical school core clerkships and was negatively impacted by the COVID-19 pandemic. Strategic incorporation of select remote learning components into clinical clerkships may permit a favorable student experience even when opportunities for on-site participation are limited.

Pre-Clinical Remote Undergraduate Medical Education During the COVID-19 Pandemic: A Survey Study .

Background : The COVID-19 pandemic has necessitated a sudden transition to remote learning in medical schools. We aimed to assess student perceptions of remote learning during the pre-clinical curricular training phase. Methods: A survey was distributed to first- and second-year medical students enrolled at the University of California San Diego School of Medicine in March 2020. Frequencies of responses to structured multiple-choice questions were compared regarding impacts of remote learning on quality of instruction and ability to participate, value of various remote learning resources, living environment, and preparedness for subsequent stages of training. Responses to open-ended questions about strengths and weaknesses of the remote curriculum and overall reflections were coded for thematic content. Results: Of 268 students enrolled, 104 responded (53.7% of first-year students and 23.9% of second-year students). Overall, students felt the quality of instruction and their ability to participate had been negatively affected. Most (64.1%) preferred the flexibility of learning material at their own pace. Only 25.5% of respondents still felt connected to the medical school or classmates. Most second-year students (56.7%) felt their preparation for the USMLE Step 1 exam was negatively affected and 43.3% felt unprepared to begin clerkships. In narrative responses, most appreciated the increased flexibility of remote learning but recognized that digital fatigue, decreased ability to participate, and lack of clinical skills and hands-on lab learning were notable deficits. Conclusions: Videocasted lectures uploaded in advance, electronic health record and telehealth training for students, and training for teaching faculty to increase technological fluency may be considered to optimize remote learning curricula.

Meta-analysis of risk of occult lymph node metastasis in the irradiated, clinically N0 neck.

BACKGROUND: Recurrent head and neck squamous cell carcinoma (HNSCC) after radiation is associated with poor survival, and management of the clinically negative (N0) neck during salvage surgery is controversial. METHODS: Studies were selected according to preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria were patients with HNSCC, prior radiation to the lateral neck nodal basin, undergoing salvage surgery for local recurrence, persistence or second primary, and N0 at time of salvage. Eleven studies with a total of 382 patients met inclusion criteria. RESULTS: The rate of occult metastasis was 15.4%. The pooled rate of occult nodal metastasis was 16.2% for oral cavity, 12.9% for oropharynx, 23.7% for hypopharynx, and 27.3% for supraglottic or transglottic tumors. There was a significantly higher relative risk of occult metastasis for locally advanced tumors. CONCLUSION: Elective neck dissection at time of salvage surgery should be considered based on subsite, T classification, and prior history of nodal metastasis.

Advanced head and neck surgery training during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has significantly impacted medical training. Here we assess its effect on head and neck surgical education. METHODS: Surveys were sent to current accredited program directors and trainees to assess the impact of COVID-19 on the fellow's experience and employment search. Current fellows' operative logs were compared with those of the 2018 to 2019 graduates. RESULTS: Despite reduction in operative volume, 82% of current American Head and Neck Society fellows have reached the number of major surgical operations to support certification. When surveyed, 86% of program directors deemed their fellow ready to enter practice. The majority of fellows felt prepared to practice ablative (96%), and microvascular surgery (73%), and 57% have secured employment to follow graduation. Five (10%) had a pending job position put on hold due to the pandemic. CONCLUSIONS: Despite the impact of the COVID-19 pandemic, current accredited trainees remain well-positioned to obtain proficiency and enter the work-force.

Facial Paralysis Following Core Needle Biopsy of a Deep Lobe Parotid Tumor: A Case Report.

OBJECTIVES:: To report a case of total facial paralysis as the result of a core needle biopsy. METHODS:: Case report and literature review. RESULTS:: A 70-year-old man was diagnosed with a deep lobe parotid tumor on computed tomography. During a core needle biopsy, he developed complete facial paralysis. The cause was discovered to be a direct stab injury to the main trunk of the facial nerve. CONCLUSIONS:: When biopsying parotid lesions adjacent to the main trunk of the facial nerve, the use of smaller-gauge needles and additional patient counseling should be considered.

Implementation of submandibular gland transfer: A multi-institutional study of feasibility and time to treatment.

BACKGROUND: Submandibular gland transfer (SMGT) mitigates radiation-induced xerostomia but has yet to be widely adopted. We evaluate the feasibility of incorporating SMGT at multiple academic institutions and report the incidence of treatment delay. METHODS: Forty-nine patients were identified who underwent SMGT. Time points pertaining to diagnosis and key treatment events including SMGT, surgery, chemotherapy, and radiation were extracted. Treatment delay was defined as either >60 days from diagnosis to definitive therapy or >6 weeks between surgery and adjuvant therapy. RESULTS: Median time from diagnosis to primary treatment was 42 days (IQR, 32-54). Median time from surgery to adjuvant therapy was 33 days (IQR, 28-47). Delay in starting treatment was observed in 7/49 patients (14%). Six patients incurred a delay in postoperative radiation therapy (6/19; 32%). CONCLUSIONS: With appropriate care coordination, SMGT can be implemented into a clinical pathway with a goal of decreasing radiation-induced xerostomia without increasing treatment delays.

Behavioral sensitivity to interaural time differences in the rabbit.

An important cue for sound localization and separation of signals from noise is the interaural time difference (ITD). Humans are able to localize sounds within 1-2 degrees and can detect very small changes in the ITD (10-20micros). In contrast, many animals localize sounds with less precision than humans. Rabbits, for example, have sound localization thresholds of approximately 22 degrees . There is only limited information about behavioral ITD discrimination in animals with poor sound localization acuity that are typically used for the neural recordings. For this study, we measured behavioral discrimination of ITDs in the rabbit for a range of reference ITDs from 0 to +/-300micros. The behavioral task was conditioned avoidance and the stimulus was band-limited noise (500-1500Hz). Across animals, the average discrimination threshold was 50-60micros for reference ITDs of 0 to +/-200micros. There was no trend in the thresholds across this range of reference ITDs. For a reference ITD of +/-300micros, which is near the limit of the physiological window defined by the head width in this species, the discrimination threshold increased to approximately 100micros. The ITD discrimination in rabbits less acute than in cats, which have a similar head size. This result supports the suggestion that ITD discrimination, like sound localization [see Heffner, 1997. Acta Otolaryngol. 532 (Suppl.), 46-53] is determined by factors other than head size.

Needle Biopsy of Routine Thyroid Nodules Should Be Performed Using a Capillary Action Technique with 24- to 27-Gauge Needles: A Systematic Review and Meta-Analysis.

BACKGROUND: Fine-needle biopsy is the international standard for diagnostic evaluation of thyroid nodules. There is a lack of consensus regarding the optimal needle biopsy technique. The implementation of capillary action versus aspiration and the optimal needle gauge remain topics of debate. METHODS: A systematic review of the Medline, Embase, and Cochrane databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles evaluating the effects of capillary action versus aspiration and needle gauge on success rates of fine-needle biopsy of the thyroid were assessed for inclusion. The primary outcome of interest was the rate of non-diagnostic cytopathology. RESULTS: Twenty-four articles with a collective 4428 nodules were ultimately included in the review. Twenty articles evaluated capillary action versus aspiration, and six evaluated needle gauge. All but two studies were prospective, most of which were blinded trials with or without randomization. Using a random-effects model, capillary action was associated with a statistically significant reduction in the relative risk of non-diagnostic cytopathology (relative risk = 0.57 [confidence interval 0.34-0.92]; p = 0.02). There was a nonsignificant trend in favor of smaller needle gauges. CONCLUSION: Given the statistically significant deceased rate of non-diagnostic cytopathology with capillary action and the potential for increased pain and complications with larger needles without a proven benefit, needle biopsy of routine thyroid nodules should be performed without aspiration and with smaller needle gauges (24-27G).

Esophageal dilation in head and neck cancer patients: A systematic review and meta-analysis.

OBJECTIVE: To characterize the safety profile and effectiveness of esophageal dilation in head and neck cancer patients. METHODS: A systematic review was undertaken for articles reporting outcomes of esophageal dilation in head and neck cancer patients. The Medline, Scopus, Web of Science, and Cochrane databases were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Complications related to esophageal dilation in head and neck cancer patients was the primary outcome of interest. Success rates, demographic data, cancer staging, and treatment data were assessed secondarily. Statistical analyses included both qualitative and quantitative assessments. A limited meta-analysis and pooling of the data was performed using a random effects model. RESULTS: Of the collective 8,243 initial candidate articles, 15 retrospective studies containing data for a collective 449 patients were ultimately included in the analysis. There was significant heterogeneity in the outcomes data. With an overall complication rate of 10.6% (95% confidence interval [CI]: 4.1%,17%) and a pooled success rate of 72.9% (95% CI: 65.7%,80.1%) per patient, the articles generally supported the use of dilation. CONCLUSION: Head and neck cancer patients experience a higher rate of complications following dilation compared to patients with other causes of benign stricture. Esophageal dilation is effective in improving dysphagia, but these benefits are often transient and thus necessitate repeat interventions. Laryngoscope, 128:111-117, 2018.

Opioid prescribing practices in patients undergoing surgery for oral cavity cancer.

OBJECTIVES: Opioids have been overprescribed after general and orthopedic surgeries, but prescribing patterns have not been reported for head and neck surgery. The objectives of this retrospective review are to describe postoperative opioid prescriptions after oral cancer surgery and determine which patients receive higher amounts. METHODS: A single institution retrospective review was performed for 81 adults with oral cavity tumors undergoing surgery. Opioid prescriptions upon discharge were reported in daily oral morphine equivalents (OME). High opioids were defined as > 90 mg daily and > 200 mg total, commensurate with U.S. Center for Disease Control and Prevention and state guidelines. Multivariable logistic regression was performed to investigate factors associated with high opioids. RESULTS: The median number of doses dispensed was 30 (interquartile range [IQR] 30-45; range 3-120). The median daily dose was 30 mg (IQR 20-45 mg; range 15-240 mg). Five patients (6%) received higher than the recommended daily dose. The median total dispensed amount was 225 mg (IQR 150-250 mg; range 15-1200 mg). Fifty-one (63%) received greater than the recommended total dose. On multivariable logistic regression, advanced tumor stage (odds ratio [OR] 11.5; 95% confidence interval [CI] 1.2-109.4; P = 0.034) and inpatient pain scores (OR 1.3 per 1-unit increase; 95% CI 1.0-1.7; P = 0.039) were associated with receiving high total opioids after surgery. CONCLUSION: The majority of patients received greater than the recommended 200 mg total OME. Advanced stage and higher inpatient pain scores were associated with receiving more opioids for discharge. Consensus-driven analgesic plans are needed to reduce excess opioids after discharge following head and neck surgery. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2361-2366, 2018.

Isolated sphenoid sinus opacifications: a systematic review and meta-analysis.

BACKGROUND: Isolated sphenoid sinus opacifications (ISSOs) represent a relatively uncommon disease with the potential for serious complications. To better understand this disease, we performed a systematic review to further characterize the underlying pathologies, associated symptoms, and treatment outcomes of patients with ISSOs. METHODS: A systematic review of ISSO case series was performed utilizing the Medline, Embase, Web of Science, and Cochrane databases in accordance with guidelines established by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Data of interest included disease pathology, associated symptoms, and treatment outcomes. RESULTS: Of the initial 1051 hits from the 4 databases, 17 articles, with a combined 1133 ISSO patients, were ultimately included in the review. On a weighted analysis, the underlying pathologies were classified as chronic rhinosinusitis without nasal polyps (CRSsNP) (28.3%), mucoceles (20.3%), fungal sinusitis (12.5%), malignant neoplasms (7.7%), intracranial lesions (7.0%), benign neoplasms (5.7%), chronic rhinosinusitis with nasal polyps (CRSwNP) (3.4%), and other lesions (4.7%). Cranial neuropathies were present in 16.3% (95% confidence interval [CI], 10.1-22.5%) of ISSO patients. A favorable surgical complication rate of 1.5% (95% CI, -0.1% to 3.2%) was found in patients undergoing surgery for an ISSO. CONCLUSION: ISSOs are caused by diverse pathologies. Given the considerable rates of neoplastic disease and cranial neuropathies, patients affected by an ISSO should be monitored closely and treated aggressively. Prompt surgical intervention, with either diagnostic or therapeutic intent, is often indicated.

Detection of interaural correlation by neurons in the superior olivary complex, inferior colliculus and auditory cortex of the unanesthetized rabbit.

A critical binaural cue important for sound localization and detection of signals in noise is the interaural time difference (ITD), or difference in the time of arrival of sounds at each ear. The ITD can be determined by cross-correlating the sounds at the two ears and finding the ITD where the correlation is maximal. The amount of interaural correlation is affected by properties of spaces and can therefore be used to assess spatial attributes. To examine the neural basis for sensitivity to the overall level of the interaural correlation, we identified subcollicular neurons and neurons in the inferior colliculus (IC) and auditory cortex of unanesthetized rabbits that were sensitive to ITDs and examined their responses as the interaural correlation was varied. Neurons at each brain level could show linear or non-linear responses to changes in interaural correlation. The direction of the non-linearities in most neurons was to increase the slope of the response change for correlations near 1.0. The proportion of neurons with non-linear responses was similar in subcollicular and IC neurons but increased in the auditory cortex. Non-linear response functions to interaural correlation were not related to the type of response as determined by the tuning to ITDs across frequencies. The responses to interaural correlation were also not related to the frequency tuning of the neuron, unlike the responses to ITD, which broadens for neurons tuned to lower frequencies. The neural discriminibility of the ITD using frozen noise in the best neurons was similar to the behavioral acuity in humans at a reference correlation of 1.0. However, for other reference ITDs the neural discriminibility was more linear and generally better than the human discriminibility of the interaural correlation, suggesting that stimulus rather than neural variability is the basis for the decline in human performance at lower levels of interaural correlation.

A Rare Case of Exclusively Oncocytic Mucoepidermoid Carcinoma with MAML2 Translocation.

Mucoepidermoid carcinoma is the most common malignant tumor of the salivary gland. The oncocytic variant of mucoepidermoid carcinoma (OMEC) is rare and a small subset shows exclusive oncocytic morphology. Here we report an OMEC case of the parotid gland in a 74-year-old woman with exclusive oncocytes and rare mucocytes. The oncocytes showed diffuse nuclear positivity with p63 immunostaining. The MAML2 translocation was present, supporting the diagnosis of OMEC. Distinguishing OMEC with exclusive oncocytes from oncocytoma and oncocytic carcinoma can be very challenging for pathologists and is critical for proper clinical management. Our experience suggests that appropriate ancillary studies, especially the MAML2 translocation, may provide the essential evidence in difficult cases. Our literature review shows that the presence of mucocytes in an oncocytic neoplasm might be an important morphologic clue of OMEC.

Concordant Oral and Vaginal Human Papillomavirus Infection in the United States.

IMPORTANCE: Human papillomavirus (HPV) is a common infection in adults, with tropism for sites in the head and neck and the genital tracts. To date, few studies have addressed concurrent infection in these sites. OBJECTIVE: To understand the prevalence, characteristics, and concordance of HPV infections in the oral and vaginal regions. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective analysis of cross-sectional survey data from the National Health and Nutrition Examination Survey, 2009-2012. The database was reviewed for all women aged 18 to 69 years with available oral and vaginal HPV DNA screening data. The study was performed from August 1, 2014, to November 1, 2014. Data analysis was performed from November 1, 2014, to June 30, 2015. MAIN OUTCOMES AND MEASURES: Logistic regression models were constructed to identify factors associated with infection. Covariates for multivariate analysis included age, income to poverty ratio, number of prior sexual partners, number of prior oral sex partners, and having recent oral sex partners. Dual infection was defined as having an infection of any serotype in both the oral and vaginal HPV regions. Concordant infection was defined as an infection of matching serotype in both locations. RESULTS: A total of 3463 women were identified (mean [SD] age, 37.5 [12.1] years). Racial distribution was 1341 white (38.7%), 786 black (22.7%), 554 Mexican American (16.0%), 378 other Hispanic (10.9%), and 404 self-identified as other (11.7%). Vaginal HPV infection was present in 1586 (45.2%) and oral HPV infection in 141 (4.1%). Dual infection was identified in 107 (3.0%) of all patients, and concordant infection was observed in 41 (1.1%). The prevalence of dual infection was 75.9% in those with oral infection and 6.8% in those with vaginal infection. On multivariate analysis, age (30-50 years) and higher income to poverty ratios had negative associations with dual and concordant infections. A new sexual partner within the last year was positively associated with dual infection (odds ratio, 2.28; 95% CI, 1.03-5.02; P = .04). More than 2 oral sex partners in the past year was positively associated with concordant infection (odds ratio, 3.43; 95% CI, 1.06-11.06; P = .04). CONCLUSIONS AND RELEVANCE: This analysis reveals the importance of several demographic factors (age and socioeconomic status) and behavioral factors (oral sex practices) in the development of dual and concordant HPV infection in women. Notably, other sexual behaviors, other sexually transmitted infections, sexual orientation, and number of lifetime sexual partners did not demonstrate any significant associations. Women with multiple oral sex partners and oral HPV infection have a high likelihood of having concurrent vaginal HPV infection.

Predictors of high-risk and low-risk oral HPV infection in the United States.

OBJECTIVES/HYPOTHESIS: Determine predictors of high-risk and low-risk oral HPV infection in the United States. STUDY DESIGN: Retrospective analyses of National Health and Nutrition Examination Survey cross-sectional data of U.S. population from 2009 to 2012. METHODS: Database queried for subjects aged 18 to 69 with oral rinse human papillomavirus (HPV) DNA data. Logistic regression identified factors associated with high-risk and low-risk infection. Covariates included age, gender, ethnicity, income-to-poverty (IP) ratio, sexual orientation, human immunodeficiency virus infection, other sexually transmitted infections, lifetime sexual partners, and lifetime oral sex partners. RESULTS: In total, 9,256 subjects were identified with mean age of 42.1 years. Oral HPV infection was present in 8.1% (N = 747); 55.7% were high-risk and 55.3% were low-risk types, including 11% with both. Oral infection had a negative association with female gender (odds ratio [OR] 0.3, P < 0.001), IP ratio ≥ 3 (OR 0.7, P = 0.02), and one lifetime oral sex partner (OR 0.7, P = 0.03). Increasing oral sex behavior (6-21+ lifetime partners) was positively associated with oral HPV (OR 1.4-3.0, P = 0.03). Low-risk infection had negative associations with female gender (OR 0.4, P < 0.001) and non-Hispanic white ethnicity (OR 0.6, P = 0.02), IP ratio ≥ 3 (OR 0.6, P = 0.01), and positive association with > 20 sexual partners (all sex OR 1.7, P = 0.04; oral sex OR 1.9, P = 0.02). Predictors of high-risk HPV infection included male gender and increasing oral sex partners. CONCLUSION: Increasing oral sex partners is positively associated with oral HPV infection; female sex and higher socioeconomic class are negatively associated. The risk-factor profiles for high-risk and low-risk HPV types are distinct, with similar trends related to sexual behaviors. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1365-1372, 2016.