Ethical framework for head and neck cancer care impacted by COVID-19.

The COVID-19 pandemic has upended head and neck cancer care delivery in ways unforeseen and unprecedented. The impact of these changes parallels other fields in oncology, but is disproportionate due to protective measures and limitations on potentially aerosolizing procedures and related interventions specific to the upper aerodigestive tract. The moral and professional dimensions of providing ethically appropriate and consistent care for our patients in the COVID-19 crisis are considered herein for head and neck oncology providers.

Creating Reflective Space for Reflective and "Unreflective" Medical Students: Exploring Seminal Moments in a Large-Group Writing Session.

PROBLEM: Reflection is a critical skill for all physicians, but some busy medical students describe themselves as "unreflective." The authors sought to provide all third-year medical students at the Medical College of Wisconsin (MCW) with opportunities to explore seminal clinical and personal moments through reflective writing during workshops on preparing a personal statement for the Electronic Residency Application Service. APPROACH: The authors developed and facilitated semiannual 1.5- to 2-hour sessions (January and June) for MCW third-year medical students (about 200 per class), pairing information on personal statements with reflective writing and group reflection activities. Students wrote reflectively but were not required to share their writing with peers or faculty. They discussed insights gleaned during the writing process in small groups and with the class. They completed pre- and postsession questions on an anonymous questionnaire. OUTCOMES: Eight all-class sessions were held between January 2015 and June 2018. Students completed 1,139 of 1,600 questionnaires (completion rate of approximately 71%). They misperceived their peers' views of reflective activities. Twice as many students agreed their peers felt writing, reflective, and narrative exercises were a waste of time as they themselves did (39% vs 19%). While 42% entered the session comfortable with creative writing, 57% were surprised by the amount, quality, and/or insight of their writing during the session and 77% agreed the session helped them think more clearly about clinical encounters. Students who believed reflective writing was a waste of time were more likely to believe their peers felt that also, and they were less likely to believe the session helped them reflect on clinical experiences. Most written comments were positive. NEXT STEPS: To expose students to narrative medicine techniques, the authors added a close-reading exercise and shortened the reflective writing activity in 2019, hoping this would better equip all students for their journeys.

Patients with Oncocytic Variant Papillary Thyroid Carcinoma Have a Similar Prognosis to Matched Classical Papillary Thyroid Carcinoma Controls.

BACKGROUND: Previous studies have suggested that oncocytic variant papillary thyroid carcinoma (PTC) may be more aggressive, with higher rates of recurrent disease. The aim of this study was to evaluate characteristics and outcomes of patients with oncocytic variant PTC compared to classical PTC. METHODS: Patients with oncocytic variant PTC were retrospectively identified from 519 patients who underwent thyroidectomy for PTC between January 2009 and August 2015. Data collected included patient demographics, laboratory and pathology findings, imaging studies, treatment, and follow-up. Patients were matched 1:1 by age, sex, and TNM stage with patients who underwent total thyroidectomy for classical PTC during the same time period. RESULTS: The cohort included 21 patients, of whom 18 (86%) were female, with a median age of 53 years (range 23-68 years). All patients underwent total thyroidectomy, and 17 (81%) had a central compartment neck dissection (8 [38%] prophylactic). The median tumor size was 2.0 cm (range 0.9-6.5 cm), and four (19%) patients had extrathyroidal extension. There was no significant difference in histopathologic characteristics, including extrathyroidal extension and lymphovascular invasion, between the two groups except for an increased incidence of thyroiditis in oncocytic variant PTC (90.5% vs. 57%; p = 0.01). In oncocytic variant PTC patients who underwent central compartment neck dissection, malignant lymph nodes were found in 12 (57%) patients compared to 13 (62%) classical (p = 0.75). Lateral neck dissection was performed in 5 (24%) oncocytic variant and classical PTC patients, with metastatic lymphadenopathy found in four (a median of four malignant lymph nodes; range 1-6) and five (a median of 2.5 malignant lymph nodes; range 1-9), respectively. Radioactive iodine was administered to 18 (86%) oncocytic variant PTC and 18 (86%) classical PTC patients. At a median follow-up of 51 months (interquartile range 38-61), one oncocytic variant PTC patient had recurrent disease and underwent reoperation at 24 months. In classical PTC patients with a median follow-up time of 77 months (range 56-87 months), two (9.5%) patients had detectable thyroglobulin levels indicating early recurrence, but neither has undergone reoperation. CONCLUSIONS: Oncocytic variant PTC was present in 5% of PTC patients. Most (95%) patients remain disease-free at four years, similar to classical PTC outcomes, suggesting that oncocytic variant may not represent a more aggressive variant.

Impact of Humanitarian Experiences on Otolaryngology Trainees: A Follow-up Study of Travel Grant Recipients.

In this study, we seek (1) to determine the impact of humanitarian experiences on otolaryngology trainee recipients of the American Academy of Otolaryngology-Head and Neck Surgery Foundation humanitarian travel grant (2001-2015); (2) to better understand trainee and trip characteristics, as well as motivations and attitudes toward future volunteerism; and (3) and to identify potential barriers to participation. An anonymous 30-question survey was distributed to 207 individuals, and 52 (25.1%) responded. Respondents viewed the trip as very worthwhile (score = 98 of 100), expressed improved cultural understanding (75.0%), and continued participation in humanitarian activities (75.0%). Competency-based evaluation results suggest a positive impact on systems-based practice and professionalism. Respondents commented on the trip's positive value and shared concerns regarding expense. Despite potential barriers, Foundation-supported humanitarian trips during training are perceived as worthwhile; they may enhance cultural understanding and interest in future humanitarian efforts; and they may positively affect competency-based metrics. Based on the potential benefits, continued support and formalization of these experiences should be considered.

Thyroid Surgery in a Resource-Limited Setting.

Objective The present study reviews a series of patients who underwent thyroid surgery in Eldoret, Kenya, to demonstrate the feasibility of conducting long-term (>1 year) outcomes research in a resource-limited setting, impact on the quality of life of the recipient population, and inform future humanitarian collaborations. Study Design Case series with chart review. Setting Tertiary public referral hospital in Eldoret, Kenya. Subjects and Methods Twenty-one patients were enrolled during the study period. A retrospective chart review was performed for all adult patients who underwent thyroid surgery during humanitarian trips (2010-2015). Patients were contacted by mobile telephone. Medical history and physical examination, including laryngoscopy, were performed, and the SF-36 was administered (a quality-of-life questionnaire). Laboratory measurements of thyroid function and neck ultrasound were obtained. Results The mean follow-up was 33.6 ± 20.2 months after surgery: 37.5% of subtotal thyroidectomy patients and 15.4% of lobectomy patients were hypothyroid postoperatively according to serologic studies. There were no cases of goiter recurrence or malignancy. All patients reported postoperative symptomatic improvement and collectively showed positive pre- and postoperative score differences on the SF-36. Conclusion Although limited by a small sample size and the retrospective nature, our study demonstrates the feasibility of long-term surgical and quality-of-life outcomes research in a resource-limited setting. The low complication rates suggest minimal adverse effects of performing surgery in this context. Despite a considerable rate of postoperative hypothyroidism, it is in accordance with prior studies and emphasizes the need for individualized, longitudinal, and multidisciplinary care. Quality-of-life score improvements suggest benefit to the recipient population.

Creating a Residency Application Personal Statement Writers Workshop: Fostering Narrative, Teamwork, and Insight at a Time of Stress.

PROBLEM: Every graduating medical student must write a personal statement for the Electronic Residency Application Service (ERAS), yet there are no widely available resources designed to aid the writing process, causing stress among applicants. APPROACH: The authors offered every Medical College of Wisconsin senior student in the Classes of 2014 and 2015 a voluntary self-contained two-hour Residency Application Personal Statement Writers Workshop. The session included the selection of writing prompts, speedwriting, and a peer-edit critique. Data were gathered before and after each workshop and at the time of ERAS submission. OUTCOMES: One hundred nine students elected to participate. Of the 96 participants completing a preworkshop questionnaire, only 28 (29%) were comfortable with creative and reflective writing. Fifty-four students completed a follow-up survey after submitting their ERAS application. Fifty-one (94%) found the session effective in getting their personal statement started, and 65 (70%) were surprised by the quality of their writing. Almost all could trace some of their final statement to the workshop. Forty-six (85%) found working with other students helpful, and 49 (91%) would recommend the session to future students; 47 (87%) agreed that the workshop was "fun." NEXT STEPS: The full workshop will be repeated yearly. Workshops will also be offered to residents preparing fellowship applications. A shorter version (without the peer-edit critique) was used successfully with the entire Class of 2016 to help them reflect on their initial clinical encounters. The authors will seek further opportunities to enhance reflection for students, residents, and faculty with these techniques.

Quality of life, shoulder range of motion, and spinal accessory nerve status in 5-year survivors of head and neck cancer.

OBJECTIVE: To determine the association of neck dissection and radiation treatment for head and neck cancer (HNC) with subsequent shoulder range of motion (ROM) and quality of life (QOL) in 5-year survivors. DESIGN: A cross-sectional convenience sample. SETTING: Otolaryngology clinics at tertiary care hospital and Veterans Affairs medical center. PATIENTS: Five-year, disease-free survivors of HNC. METHODS: Demographic and cancer treatment information was collected, including type of neck dissection (none, spinal accessory "nerve sparing," and "nerve sacrificing") and radiation. QOL questionnaires were administered, and shoulder ROM was measured. MAIN OUTCOME MEASUREMENTS: University of Washington Quality of Life (UWQOL), Functional Assessment of Cancer Therapy (FACT) Head and Neck, and Performance Status Scale for Head and Neck. Shoulder ROM measurements included abduction, adduction, flexion, extension, internal and external rotation. RESULTS: One hundred and five survivors completed QOL surveys; 85 survivors underwent additional shoulder ROM evaluations. The nerve sacrifice group exhibited significantly poorer scores for UWQOL measures of disfigurement, level of activity, recreation and/or entertainment, speech and shoulder disability, and willingness to eat in public, FACT functional well-being, and FACT Head and Neck (P < .05). Shoulder ROM for flexion and abduction was poorest in the nerve sacrifice group (P < .05). Radiation was associated with significantly worse UWQOL swallowing (P < .05), but no other differences were found for QOL or ROM measurements. Decreased QOL scores were associated with decreased shoulder flexion and abduction (P < .05). Survivors with decreased shoulder abduction had significantly (P < .05) worse scores in disfigurement, recreation and/or entertainment, employment, shoulder disability, and FACT emotional well-being. CONCLUSIONS: Sparing the spinal accessory nerve during neck dissection is associated with significantly less long-term shoulder disability in 5-year survivors of HNC. QOL measures demonstrated the highest level of function in the no dissection group, an intermediate level of functioning with nerve sparing, and poorest function when the nerve is sacrificed. Decreased shoulder flexion and abduction is associated with reduced QOL in long-term survivors of HNC.

Survivorship care plans for patients with head and neck cancer.

OBJECTIVE: To determine the perceived value of survivorship care plans (SCPs) (cancer treatment summaries and follow-up recommendations). DESIGN: Survey of patients and their physicians between 3 and 4 years after receipt of the SCP. SETTING: Ambulatory, tertiary care medical center. PATIENTS: A convenience sample of head and neck cancer survivors living 3 years after each had been mailed a personal SCP shortly after completion of cancer treatment. Twenty survivors were contacted, and all agreed to participate. INTERVENTIONS: Institutional review board-approved, scripted telephone survey to determine whether patients and their primary care physicians still had their SCPs and found them useful. MAIN OUTCOME MEASURES: Survey responses. RESULTS: Only 2 of 20 survivors and 11 of 21 physicians or dentists were able to locate or remember having received the SCPs 3 years later. Eighteen of 20 survivors were unsure of the value of SCPs. CONCLUSIONS: Despite a widely held belief that patients benefit from receiving SCPs, our initial attempt found little awareness of these documents by either the head and neck cancer survivors or their primary care physicians.

A case of a dermoid cyst compressing the airway.

INTRODUCTION: In this report we discuss the etiology, common locations, diagnostic approach, and treatment of a dermoid cyst. CASE PRESENTATION: A 22-year-old man arrived at the emergency department complaining of submental fullness, an increase in snoring, choking, gagging, and difficulty breathing. The patient was taken to the operating room for a complete resection of a large dermoid cyst that was compressing his airway. DISCUSSION: Dermoid cysts are uncommon head and neck tumors mainly presenting in patients aged 15 to 35. The origin of dermoid cysts is thought to be congenital in most cases, but they can also develop from acquired factors such as trauma or surgical implantation that forces epithelial cells into deep tissues. CONCLUSION: Although benign and often asymptomatic, dermoid cysts may cause other associated symptoms due to compression of structures in the head and neck.

Comparison of physical examination and fluorodeoxyglucose positron emission tomography/computed tomography 4-6 months after radiotherapy to assess residual head-and-neck cancer.

PURPOSE: To retrospectively compare fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) and physical examination 4-6 months after radiotherapy for assessing residual head-and-neck cancer (HNC). METHODS AND MATERIALS: From July 2002 through March 2006, 52 HNC patients underwent definitive radiotherapy or chemoradiotherapy. Categoric assessments of residual tumor by PET/CT and physical examination 4-6 months after therapy were correlated and compared with clinical outcomes. Pretreatment data, including tumor stage and primary site standardized uptake value, were also gathered retrospectively and correlated with clinical outcomes. Median follow-up time was 58 months. RESULTS: Twenty-one patients had either locoregionally "positive" (17 of 21) or "equivocal" (4 of 21) PET/CT scans, whereas 31 patients had locoregionally negative scans. Four patients failed treatment and had biopsy-confirmed residual or recurrent local disease. All patients, including patients with locally suspicious scans or examinations who refused biopsies, were followed clinically for a minimum of 29 months after therapy, with no other cases of treatment failure detected during this time. No patient had residual nodal disease after therapy. Sensitivities of PET/CT vs. physical examination for early detection of treatment failure were 100% vs. 50%, whereas the specificities of the two modalities were 64.6% vs. 89.6%, respectively. Higher initial T stage and American Joint Commission on Cancer stage correlated with increased incidence of positive/equivocal PET/CT results and treatment failure. Maximal standardized uptake value was not predictive of any clinical outcome. CONCLUSIONS: A negative result on PET/CT obtained 4-6 months after radiotherapy is highly sensitive and correlates with successful locoregional control. Patients with negative scans may reasonably be spared invasive diagnostic procedures, such as biopsy and neck dissection, unless recurrent disease is suspected on clinical grounds. Close follow-up is prudent for HNC patients with abnormal findings on posttherapy PET/CT scan.

Analysis of pepsin in tracheoesophageal puncture sites.

OBJECTIVES: Tracheoesophageal puncture (TEP) and prosthesis insertion is a well-established method of voice rehabilitation after laryngectomy. Maintenance of the prosthesis and tract can be challenging, and reflux to the TEP site has been proposed as a cause. The sites of TEP were evaluated for the presence of pepsin in tissue biopsy specimens and tract secretions to explore this association. METHODS: Patients with TEP were interviewed for a history of symptoms related to reflux, medication use history, TEP voice quality, and incidence of TEP complications. Tissue biopsy specimens and tract secretions were obtained from TEP sites and analyzed for the presence of pepsin via sodium dodecyl sulfate-polyacrylamide gel electrophoresis Western blot analysis. RESULTS: Twelve of 17 patients (47%) had some history of preoperative or postoperative symptoms of gastroesophageal reflux disease or laryngopharyngeal reflux. Pepsin was present within the TEP site in a total of 10 of 17 patients (58%; 7 of 17 tissue biopsy specimens and 6 of 7 secretion samples). There were no statistically significant associations between the presence of pepsin and sex, reflux history, use of acid suppressive medicine, or time since laryngectomy. CONCLUSIONS: Reflux with subsequent pepsin deposition into the TEP tract occurs in a majority of laryngectomy patients. Further studies on the effect of reflux on the health and function of the TEP tract are warranted.