Management of Acute Complicated Mastoiditis: A Systematic Review and Meta-analysis.

BACKGROUND: The objective of our study was to evaluate the efficacy of treatment options for the most frequently reported complications of acute mastoiditis in the English literature. PubMed, EMBASE, and The Cochrane Library were searched from database inception through March 29, 2019. METHODS: Two independent reviewers (M.R.K., K.S.) evaluated search results for study inclusion. References cited in publications meeting inclusion criteria were reviewed. Twenty-three included studies were published from 1998 through 2018. Treatment efficacy was determined by comparing the change in number of complication subtypes in each treatment subgroup (medical, conservative, or surgical) from admission to discharge (range: 5-30 days) or postdischarge follow-up (range: 1-27.5 months) with a random effects model. RESULTS: Among 733 identified articles, 23 met inclusion criteria. Of the 883 included patients, 203 were managed medically (23%), 300 conservatively (34%) and 380 surgically (43%). Conservative patients had more extracranial complications (ECC, P = 0.04) and intratemporal complications (IT, P = 0.04) at follow-up compared with medical patients. Medical patients had more total number of complications (TNC, P = 0.03), ECC (P = 0.02), and IT (P = 0.01) at discharge compared with surgical patients. Conservative patients had more of all complications except intracranial/extracranial abscess and "other" at discharge and follow-up compared with surgical patients. CONCLUSIONS: There were larger reductions in TNC, ECC, and IT at discharge and follow-up among surgical patients compared with medical and conservative patients. There were greater reductions in TNC, ECC, IT, intracranial complications, subperiosteal abscess and lateral sinus thrombosis at discharge and follow-up among surgical patients compared with conservative patients.

Survival Differences Between Pediatric Head and Neck Versus Body Melanoma in the Surveillance, Epidemiology, and End Results Program.

OBJECTIVES/HYPOTHESIS: To review the demographics, treatment, and survival of pediatric melanoma of the head and neck and to determine if melanoma of the head and neck has worse survival than melanoma of other body sites. STUDY DESIGN: Retrospective database review. METHODS: Pediatric patients from 0 to 21 years in the Surveillance, Epidemiology, and End Results 18 registries database were included from 1975 to 2016 based on a diagnosis of melanoma of the skin using the primary site International Classification of Diseases for Oncology, Third Edition codes from C44.0-C44.9.skin of lip, C44.1-eyelid, C44.2-external ear, C44.3-skin other/unspecified parts of face, C44.4-skin of scalp and neck, C44.5-skin of trunk, C44.6-skin of upper limb and shoulder, C44.7-skin of lower limb and hip, C44.8-overlapping lesion of skin, and C44.9-skin, NOS (not otherwise specified). RESULTS: A total of 4,561 pediatric melanomas of the skin were identified. There were 854 (18.7%) cases of melanoma of the head and neck (MHN) and 3,707 (81.3%) cases of melanoma of the body (MOB). The hazard ratio for MHN versus MOB was 1.6 (95% confidence interval: 1.3-2.1) after accounting for sex, race, and age. Of MHN sites, the hazard ratio for melanoma of the scalp and neck was 2.2 (1.1-4.7). The 2- and 5-year Kaplan-Meier overall survival for MHN were 94.6% and 90.7%, respectively, compared with 96.6% and 94.7%, respectively, for MOB (P < .01). CONCLUSIONS: Survival outcomes of pediatric melanoma are notably related to anatomic site. Children with melanoma of the scalp and neck have the worst survival of all sites. Additionally, children who are older/white/male are at greater risk for worse survival outcomes. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E635-E641, 2021.

Pediatric laryngeal tumors and demographics, management, and survival in laryngeal squamous cell carcinoma.

OBJECTIVES: To evaluate the prevalence and features of pediatric laryngeal malignancies and to review the demographics, management, and survival of pediatric patients with laryngeal squamous cell carcinoma as compared to adult patients. METHODS: Patients aged 0 (younger than 1) to 18 with laryngeal malignancy identified in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2016 published April 2019. Diagnosis of malignant laryngeal tumor was made using the 3rd edition of the International Classification of Diseases for Oncology (ICDO-3) code: C32.0 Glottis, C32.1 Supraglottis, C32.2Subglottis, andC32.9 Larynx primary site. RESULTS: 23 cases of pediatric laryngeal malignancies were identified. 16 cases were squamous cell carcinomas and 7 were other histologic types. Pediatric laryngeal SCC tended to be diagnosed in adolescence (mean age 14.8 years, range younger than 1 to 18, 82.6% of cases were age 12 and above). Management of laryngeal SCC included no recorded treatment (18.8%), primary radiation (18.8%), primary surgery (12.5%), radiation and surgery (25%), radiation and chemotherapy combined (18.8%), and surgery with radiation and chemotherapy (12.5%). Surgeries were local excision, excision and lymphnode dissection, as well as total laryngectomy, and not otherwise specified. The 2-year and 5-year overall and disease-specific survivals were 78.6%. CONCLUSIONS: Pediatric laryngeal cancer is rare. Squamous cell carcinoma is the most commonly diagnosed malignant laryngeal histology affecting pediatric patients. Despite different risk factors, survival rates remain similar for pediatric patients with laryngeal squamous cell carcinoma as compared to adults. Physicians should include laryngeal cancer in the differential for pediatric patients with hoarseness, dysphagia, and progressive airway obstruction to avoid a late diagnosis.

Physician impact on the patient and family experience in a pediatric otolaryngology practice.

OBJECTIVE: On the Press Ganey (PG) survey, the item "likelihood of recommending practice" is a proxy for patient satisfaction because only the most satisfied patients will recommend a practice to friends and family. The objective of this study is to determine which other items on the PG survey best correlate with "likelihood of recommending practice" as a measure of patient satisfaction in pediatric otolaryngology. STUDY DESIGN: Retrospective analysis of a survey database. METHODS: The PG survey, consisting of 24 questions scaled from 1 to 5 representing (1) very poor, (2) poor, (3) fair, (4) good, and (5) very good, was sent to 28 different pediatric otolaryngology practices. Using the Pearson correlation coefficient, the statistical relationship of each PG survey question was analyzed in its association to the PG question "likelihood of recommending practice." Factors with a correlation coefficient greater than 0.65 were considered significant. RESULTS: Ten of 24 questions on the PG survey correlated with a top "likelihood of recommending practice" score. Eight of these 10 items were from the Care Provider category and were related to the physician-patient/family interaction. CONCLUSION: Patient satisfaction surveys are utilized as a quality metric of the patient and family experience. These scores serve as one of several measures that affect reimbursement. The results demonstrate that most of the factors correlated with "likelihood of recommending practice" are provider-based. In conclusion, the physician-patient interaction strongly influences the potential for a practice to earn top box scores on the PG item "likelihood of recommending practice" and thereby achieve the highest patient satisfaction. LEVEL OF EVIDENCE: NA. Laryngoscope, 129:2610-2613, 2019.

Juvenile nasopharyngeal angiofibroma in prepubertal males: A diagnostic dilemma.

OBJECTIVES/HYPOTHESIS: To highlight the presentation and management of juvenile nasopharyngeal angiofibroma (JNA) in prepubertal children. STUDY DESIGN: Single-institution 10-year retrospective review. METHODS: All identified cases of pathologically confirmed JNA in children <10 years of age were assessed from a gender, imaging and embolization findings, tumor stage, surgical approach, and clinical outcomes standpoint, and compared to a group of stage-matched older patients from the same time period. RESULTS: Of 45 patients over the 10-year study period, four male children between 8 to 9.8 years of age were identified. One patient had University of Pittsburgh Medical Center stage 1 disease, and the other three had stage 3 disease at presentation. A malignant process other than JNA was of concern preoperatively in two of the four children due to a combination of aggressive imaging characteristics and an absence of pterygopalatine fossa involvement. Such pterygopalatine fossa involvement was comparatively uniformly present in a group of stage-matched JNA patients aged 15 to 21 years. All four prepubescent children underwent surgical resection via transnasal endoscopic approach following ipsilateral sphenopalatine artery embolization without the need for blood transfusion. There were no recurrences in three of the four cases at a median follow-up duration of 2.3 years (range, 0.8-6.4 years). CONCLUSIONS: JNA may pose a diagnostic challenge in prepubertal males due to the atypical age at presentation and absence of classic imaging characteristics. Successful endoscopic transnasal resection is possible despite anatomic constrictions. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1777-1783, 2019.

Factors Associated With the Improved Survival of Head and Neck Neuroblastomas Compared to Other Body Sites.

OBJECTIVE: To examine pediatric neuroblastoma survival and management in the head and neck compared to other body sites. STUDY DESIGN: Retrospective analysis of a large population database. METHODS: Patients in the Surveillance, Epidemiology, and End Results (SEER) database with neuroblastoma, NOS; ganglioneuroblastoma; or olfactory neuroblastoma diagnosed from birth to 18 years between 1973 and 2014 were included. These patients were classified into 1 of 3 categories based on primary tumor site: head and neck, adrenal, and "other." RESULTS: Four thousand five hundred neuroblastoma cases were identified. One hundred seventy-five (3.9%) occurred in the head and neck, 1,934 (43.0%) occurred in the adrenal gland, and 2,391 (53.1%) occurred in "other" sites. The mean age at diagnosis was 4.21 years in the head and neck, 2.23 years in the adrenal gland, and 2.47 years in the "other" cohorts (P < .001). Two- and 5-year disease-specific survival rates were 89% and 84% in the head and neck versus 77% and 65% in the adrenal and 84% and 77% in the "other" cohorts (P < .001). The risk of disease-specific death (DSD) was higher in the adrenal cohort (adjusted hazard ratio [aHR] = 2.85; 95% CI, 1.54-5.27) compared to the head and neck cohort. Patients treated with surgery only had the lowest risk of DSD (aHR = 0.22; 95% CI, 0.13-0.35) compared to all other studied treatments. CONCLUSION: Our results demonstrate that primary neuroblastoma of the head and neck has a better prognosis than primary neuroblastoma of the adrenal gland.

A review of pediatric middle ear tumors and analysis of the demographics, management, and survival of pediatric rhabdomyosarcomas of the middle ear.

OBJECTIVE: To examine the types of pediatric middle ear tumors and review the demographics, management, and survival of pediatric patients with rhabdomyosarcoma (RMS) of the middle ear. METHODS: Pediatric patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of middle ear tumors using the ICD O-3 code: C30.1: Middle ear primary site. Patients were included from ages 0-18 years. RESULTS: Forty pediatric middle ear tumor cases were identified. Twenty patients were female (50%). Twenty-seven (67.5%) cases were rhabdomyosarcomas (RMS). Pediatric RMS patients tended to be diagnosed in early childhood (mean age 5.30 years, standard deviation 2.9, range 1.00-13.00, 59.3% of patients were ages 5 or below). Most pediatric RMS patients received chemotherapy and radiation therapy as part of the treatment regimen (88.8%). Finally, the 5-year overall and disease-specific survival rates were 59% and 63% respectively. CONCLUSIONS: Pediatric middle ear tumors are rare. Females and male pediatric patients are both at risk for middle ear tumors. RMS is the most common malignant middle ear tumor affecting pediatric patients. Despite the use of multimodality therapies, survival rates for pediatric patients with RMS of the middle ear are low. Physicians may consider including middle ear tumors on the differential diagnosis for pediatric patients with symptoms presenting similarly to non-resolving otitis media.

Has the management of pediatric mucoepidermoid carcinoma of the parotid gland changed?

OBJECTIVES/HYPOTHESIS: To examine the evolving changes in management of pediatric mucoepidermoid carcinoma of the parotid gland. STUDY DESIGN: Retrospective analysis of a large population database. METHODS: Pediatric patients in the Surveillance, Epidemiology, and End Results database were included from 1973 to 2014 based on a diagnosis of mucoepidermoid carcinoma of the parotid gland using the International Classification of Diseases for Oncology, Third Edition codes: C07.9: parotid gland and 8430/3: mucoepidermoid carcinoma. Patients were included from ages 0 to 18 years. Patients were categorized into 5- or 6-year cohorts based on their year of diagnosis. Two-year and 5-year survival was calculated using actuarial or life-table analysis. RESULTS: One hundred sixty-nine pediatric cases were identified. Eighty of the 169 cases (47.4%) were diagnosed from 2005 to 2014. The number of cases increased steadily across cohorts over time since 1995. Pediatric patients tended to be diagnosed in adolescence (mean age: 13.4 years, range: 3.0-18.0 years). Most patients received surgical management as a part of their case (95.3% of total cohort). The 5-year disease-specific survival was > 90% for each cohort. CONCLUSIONS: The age-adjusted incidence rate of pediatric mucoepidermoid carcinoma of the parotid gland remains low and is not greatly changing. This cancer is most likely diagnosed in adolescence affecting both male and female patients equally. Analysis of cases since 1973 revealed that most patients continue to receive surgical care. Survival for these pediatric patients continues to remain excellent. Healthcare providers should note these updates in pediatric mucoepidermoid carcinoma of the parotid gland as effective diagnosis and management continues to lead to good survival outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2408-2414, 2018.

Is sex an independent prognostic factor in esthesioneuroblastoma?

OBJECTIVE: To determine if sex independently affects presentation and disease-specific survival (DSS) in patients with esthesioneuroblastoma (ENB). STUDY DESIGN: A case-control study from the Surveillance Epidemiology and End Results (SEER) data base. METHODS: The assessment identified 611 patients in the SEER data base who were diagnosed with ENB from 1988 to 2010. Data on race, ethnicity, age at diagnosis, sex, histologic grade, radiation treatment status, and surgical treatment status of patients with ENB from 1988 to 2010 were extracted. By using tumor extension data, the modified Kadish stage of each case was determined. The modified Kadish system was able to successfully classify 547 of 611 tumors from 1988 to 2010. Histologic grade, modified Kadish stage and DSS of male patients was compared with the DSS of female patients. RESULTS: Demographic data showed that male patients presented with a significantly higher grade (p < 0.05) and a trend toward a higher stage (p = 0.08). With unmatched data, male patients had significantly worse DSS than female patients (p < 0.05). After case-matching, the difference between the DSS for male versus female patients was no longer significant. CONCLUSIONS: Male patients with ENB seemed to have significantly worse DSS at 10 years than female patients. This disparity seems to be due to higher grade and stage in male patients at presentation. After accounting for these two factors, the prognosis of male patients was not found to be significantly different from that of female patients.

Does buccal cancer have worse prognosis than other oral cavity cancers?

OBJECTIVES/HYPOTHESIS: To determine whether buccal squamous cell carcinoma has worse overall survival (OS) and disease-specific survival (DSS) than cancers in the rest of the oral cavity. STUDY DESIGN: Retrospective analysis of a large population database. METHODS: We began with a Kaplan-Meier analysis of OS and DSS for buccal versus nonbuccal tumors with unmatched data, followed by an analysis of cases matched for race, age at diagnosis, stage at diagnosis, and treatment modality. This was supported by a univariate Cox regression comparing buccal cancer to nonbuccal cancer, followed by a multivariate Cox regression that included all significant variables studied. RESULTS: With unmatched data, buccal cancer had significantly lesser OS and DSS values than cancers in the rest of the oral cavity (P < .001). After case matching, the differences between OS and DSS for buccal cancer versus nonbuccal oral cancer were no longer significant. Univariate Cox regression models with respect to OS and DSS showed a significant difference between buccal cancer and nonbuccal cancer. However, with multivariate analysis, buccal hazard ratios for OS and DSS were not significant. CONCLUSIONS: With the largest series of buccal carcinoma to date, our study concludes that the OS and DSS of buccal cancer are similar to those of cancers in other oral cavity sites once age at diagnosis, tumor stage, treatment, and race are taken into consideration. The previously perceived poor prognosis of buccal carcinoma may be due to variations in tumor presentation, such as later stage and older patient age. LEVEL OF EVIDENCE: 2b.

Are the elderly with oropharyngeal carcinoma undertreated?

OBJECTIVES/HYPOTHESIS: To determine if elderly patients with oropharyngeal squamous cell carcinoma (OPSCC) are receiving less treatment and to evaluate the benefit of aggressive therapy in this population. STUDY DESIGN: Retrospective analysis of a large population database. METHODS: Patients in the Surveillance, Epidemiology, and End Results database with OPSCC diagnosed from 2004 to 2009 were included. The patients were categorized into age groups 45 to 54, 55 to 64, 65 to 74, 75 to 84, and 85 years and older, then further categorized by treatment status. Kaplan-Meier analysis of disease-specific survival (DSS) for late-stage (III and IV) OPSCC was performed for all age and treatment categories, followed by a multivariate cox regression of treatment status, tumor site, race, stage, and sex per age group. RESULTS: A total of 14,909 patients with OPSCC were identified. In our demographic data, we observed a significant increase in the number of patients who did not receive treatment (surgery, radiation, or combined therapy) after age 55. Kaplan-Meier analysis showed that age groups 65 to 74 and 75 to 84 had substantial benefits in DSS with surgery, radiation, or combined therapy. Multivariable analysis did not demonstrate any statistically significant difference in the hazard ratios for combined treatment among age groups 45 to 54, 55 to 64, 65 to 74, and 75 to 84. CONCLUSIONS: Proportionally fewer elderly patients with OPSCC are being treated than younger individuals. These patients can have significant benefits from aggressive treatments despite their older age as shown by our survival analysis. We recommend the use of objective measures to assess patient fitness to reduce the potential for undertreatment in the elderly population.

Is sex an independent prognostic factor in cutaneous head and neck melanoma?

OBJECTIVES/HYPOTHESIS: To determine if sex independently affects disease-specific survival (DSS) in patients with cutaneous head and neck melanoma. STUDY DESIGN: Retrospective analysis of a large population database. METHODS: Our study included patients in the Surveillance, Epidemiology, and End Results database with cutaneous head and neck melanoma diagnosed from 2004 to 2009. Any cases with a history of previous malignancy or with multiple primaries were excluded. We obtained data on stage, race, age at diagnosis, radiological treatment status, and surgical treatment status. Our analysis consisted of a Kaplan-Meier analysis of DSS by sex [correction made here after initial online publication] that was supported by a multivariate Cox regression of all significant variables studied. RESULTS: There were 13,507 patients identified with cutaneous head and neck melanoma who were diagnosed between 2004 and 2009. We observed that female patients had a better prognosis than their male counterparts, with 5-year DSS of 90.40% (95% confidence interval [CI], 89.03%-91.72%) and 87.10% (95% CI, 86.12%-88.08%), respectively. Multivariable analysis demonstrated a statistically significant decrease in disease-specific hazard ratio due to female sex independent of stage, treatment, age, or race. CONCLUSIONS: Our study concludes that female sex is an independent prognostic factor for cutaneous head and neck melanoma. We demonstrated better 5-year DSS in female compared to male patients. Better prognosis could be due to multiple factors including differing hair, levels of sun exposure, and advanced male age. LEVEL OF EVIDENCE: 2b.

Linking of bone morphogenetic protein-2 to resorbable fracture plates for enhancing bone healing.

OBJECTIVE: To test whether bone morphogenetic protein (BMP)-2 may be covalently linked to resorbable fracture repair plates using an ester-hydrolysis reaction and determining whether the linked compound can facilitate bone growth. STUDY DESIGN: Laboratory in vitro experiments. METHOD: Resorbable fracture repair plates were partially hydrolyzed using varying concentrations of acid or base. This intermediate was then reacted with EDAC (1-ethyl-3[-3-dimethylamino propyl carbodiimide) to form an EDAC intermediate, which was then reacted with either horseradish peroxidase (HRP), interleukin (IL)-2, or BMP-2. Compound binding to the plate was confirmed by immunofluorescent staining. Confirmation of protein function was determined by the following assays: HRP's ability to cleave peroxide, IL-2's ability to stimulate lymphocytes, and BMP-2's ability to stimulate C3H10T1/2 cells to generate alkaline phosphatase. RESULTS: Three compounds (HRP, IL-2, and BMP-2) were successfully linked to plates as confirmed by immunofluorescence staining or functional testing. Compounds demonstrated better covalent linking to plates under basic conditions. HRP, IL-2, and BMP-2 retained function after binding as measured by cleaved peroxide levels, lymphocytes proliferation, and alkaline phosphatase production. CONCLUSIONS: Covalent linking of compounds such as HRP, IL-2, and BMP-2 to resorbable plates is possible and represents a novel protein delivery technique. BMP-2 covalently linked to resorbable plates may be used to facilitate bone healing. Covalent linking of compounds to plates represents a novel method for delivering concentrated levels of growth factors to a specific site and potentially extending their half-life. Further investigation into this application for bone healing may lead to quicker healing.