Individual head and neck screening: Initiating a dialogue about best approach.

PURPOSE: We aim to investigate the true benefits of free individual HNC screening in a high-risk urban population as well as the associated risks. MATERIALS AND METHODS: This is a retrospective descriptive study. Free HNC screening was performed from 2014 to 2019. Participants were issued a questionnaire at the time of screening. After exemption by the Institutional Review Board, completed screening questionnaires were entered into a database and descriptive statistics were generated. The primary outcome measure for this study was the detection rate for HNC. We hypothesized that screening would be low yield based on previous studies (Gogarty et al., 2016). RESULTS: This was a volunteer sample with a total of 410 participants, and the highest yield screening year was 2019 (n = 187). For all years, the cancer detection rate was 0%. In 2019, 134 (77.9%) of participants did not recognize the early symptoms of HNC, and 120 (73.2%) reported the screening program increased their awareness of the disease. 13 (7.6%) reported HPV vaccination while 126 (71.2%) were unaware that HPV has been linked with head and neck cancer. CONCLUSIONS: HNC screening is an excellent opportunity for education regarding HNC risk factors. However, it is not a cost-effective use of physician time, does not increase detection rates even in high-risk segments of the general population, and is not completely without risk in the context of COVID-19. Perhaps the focus of HNC screening should shift from individualized screening to education and health promotion.

A combined thoracoscopic and laparoscopic approach for high epiphrenic diverticula and the importance of complete myotomy.

BACKGROUND: The traditional approach to epiphrenic diverticula is thoracotomy and diverticulectomy, together with myotomy ± partial fundoplication to address underlying dysmotility. A laparoscopic approach has been advocated but access to more proximal diverticula is problematic. We propose the selective addition of a thoracoscopic approach to overcome these challenges and reviewed our results. METHODS: A retrospective review from 2004 to 2015 identified 17 patients with an epiphrenic diverticulum who underwent surgery. Patients were grouped according to height of the diverticular neck (HDN) above the GEJ: group A < 5 cm, group B > 5 cm. Preoperative evaluation and type of surgery performed were recorded. Postoperative complications, mortality, and clinical outcomes using quality of life metrics and objective testing were assessed. RESULTS: The mean size of the diverticulum was 3.3 cm (2-6 cm) with a mean height above the GEJ of 5.5 cm (0-12 cm). A motility disorder was identified in 15/17. Group A, 9 patients, underwent laparoscopic diverticulectomy, myotomy, and partial fundoplication. For group B, 8 patients, the intended procedure was thoracoscopic diverticulectomy followed by laparoscopic myotomy and partial fundoplication, but this was only completed in 5. In 3 the myotomy was aborted or incomplete with subsequent staple line leaks resulting in 1 death. At a mean follow-up of 21 months, improvement of median QOLRAD scores from 3.42 to 6.2 (p = 0.18); GERD-HRQL from 23 to 1 (p = 0.05), swallowing score from 17.5 to 30 (p = 0.22), and Eckardt scores from 5 to 0 (p < 0.05) were observed. CONCLUSIONS: A minimally invasive strategy for epiphrenic diverticula based HDN above the GEJ and selective thoracoscopy for higher diverticula is feasible and appropriate, and resulted in improved quality of life. Incomplete myotomy was associated with a substantially higher complication rate. Laparoscopic myotomy should precede diverticulectomy for all cases, especially for high diverticula.

E-cigarette use and tobacco harm reduction: Pilot survey study evaluating perspectives of head and neck surgeons.

BACKGROUND: Electronic cigarettes (EC) are popular devices that aerosolize a nicotine and have been controversially considered tool for smoking cessation and tobacco harm reduction (THR). The purpose of this pilot study was to identify head and neck cancer (HNC) surgeons' attitudes/perspectives of EC and smoking cessation counseling. METHODS: Cross-sectional survey administered to American Head and Neck Society (AHNS) members. RESULTS: Response rate was 136 members (15.1%) with the majority 102 (75.00%) having unfavorable attitude toward EC for smoking cessation. Fifty-eight respondents (42.7%) were familiar with THR. Those familiar with THR 37 (63.79%) routinely inquire about EC use. Compared between THR familiarity, 22 (37.93%) believed the benefits of EC for smoking cessation outweighed the potential risks. CONCLUSIONS: HNC specialists have an unfavorable attitude toward EC. Those familiar with THR were more likely to inquire about EC use. They were also less likely to have a definitive opinion on the benefits of quitting combustible cigarettes.

A Tale of Two Centers: Visual Exploration of Health Disparities in Cancer Care.

The annual incidence of head and neck cancers (HNC) worldwide is more than 550,000 cases, with around 300,000 deaths each year. However, the incidence rates and disease-characteristics of HNC differ between treatment centers and different populations, due to undetermined reasons, which may or not include socioeconomic factors. The multi-faceted and multi-variate nature of the data in the context of the emerging field of health disparities research makes automated analysis impractical. Hence, we present a visual analysis approach to explore the health disparities in the data of HNC patients from two different cohorts at two cancer care centers. Our approach integrates data from multiple sources, including census data and city data, with custom visual encodings and with a nearest neighbor approach. Our design, created in collaboration with oncology experts, makes it possible to analyze the patients' demographic, disease characteristics, treatments and outcomes, and to make significant comparisons of these two cohorts and of individual patients. We evaluate this approach through two case studies performed with domain experts. The results demonstrate that this visual analysis approach successfully accomplishes the goal of comparing two cohorts in terms of different significant factors, and can provide insights into the main source of health disparities between the two centers.

Examining the relationship of immunotherapy and wound complications following flap reconstruction in patients with head and neck cancer.

BACKGROUND: Immunotherapy agents are used to treat advanced head and neck lesions. We aim to elucidate relationship between immunotherapy and surgical wound complications. METHODS: Retrospective multi-institutional case series evaluating patients undergoing ablative and flap reconstructive surgery and immunotherapy treatment. MAIN OUTCOME: wound complications. RESULTS: Eight-two (62%) patients received preoperative therapy, 89 (67%) postoperative, and 33 (25%) in both settings. Forty-one (31%) patients had recipient site complications, 12 (9%) had donor site. Nineteen (14%) had major recipient site complications, 22 (17%) had minor. There was no statistically significant difference in complications based on patient or tumor-specific variables. Preoperative therapy alone demonstrated increased major complications (odds ratio [OR] 3.7, p = 0.04), and trend to more donor site complications (OR 7.4, p = 0.06), however treatment in both preoperative and postoperative therapy was not. CONCLUSIONS: Preoperative immunotherapy may be associated with increased wound complications. Controlled studies are necessary to delineate this association and potential risks of therapy.

Stapedectomy Is Rewarding: But How to Prove It?

OBJECTIVE: To demonstrate that neurotologists enjoy performing stapedectomies. SUBJECTS: A group of survey recipients consisting of 174 neurotologists who perform stapedectomy, a nonoverlapping control group of 145 head/neck oncologists who perform parotidectomy, and a second nonoverlapping control group of 365 pediatric otolaryngologists who perform tonsillectomy. OUTCOME MEASURES: Responses to surveys distributed by electronic mail to the 3 nonoverlapping recipient groups during nonoverlapping 4-week periods. RESULTS: During the 4-week survey periods, 84 of 174 neurotologists (48%) responded, while 33 of 145 oncologists (23%) and 87 of 365 pediatric otolaryngologists (24%) responded. Most neurotologists performed stapedectomy (80/84; 95% of survey responders), while 33 of 33 (100% of survey responders) oncologists performed parotidectomy and 87 of 87 (100% of survey responders) pediatric otolaryngologists performed tonsillectomy. Seventy-six of the 80 neurotologists who performed stapedectomies (95%) enjoyed performing it, slightly more than the 30 of the 33 oncologists who performed parotidectomies (91%) and appreciably more than the 67 of 87 pediatric otolaryngologists who performed tonsillectomies (77%). Twenty-three neurotologists (30%) would sacrifice vacation time to perform additional stapedectomies, slightly more than 8 oncologists (27%) for additional parotidectomies and more than the 7 pediatric otolaryngologists (10%) for additional tonsillectomies. Ten (13%) of the neurotologists, 3 (9%) of the oncologists, and 1 (2%) of the pediatric otolaryngologists would sacrifice 5 or more vacation days to perform more of the procedures. CONCLUSIONS: Our data suggest that neurotologists enjoy performing stapedectomy.

Association Between Sarcopenia and Mortality in Patients Undergoing Surgical Excision of Head and Neck Cancer.

Importance: Sarcopenia, or the loss of muscle mass, is associated with poor treatment outcomes in a variety of surgical fields. However, the association between sarcopenia and long-term survival in a broad cohort of patients with head and neck cancer (HNC) is unknown. Objective: To determine whether sarcopenia is associated with long-term survival in patients undergoing major head and neck surgery for HNC. Design, Setting, and Participants: A retrospective medical records review was conducted at a tertiary care academic hospital. Two hundred sixty patients undergoing major head and neck ablative procedures with cross-sectional abdominal imaging performed within 45 days prior to surgery were included in the analysis. The study was conducted from January 1, 2005, to December 31, 2016. Data analysis was performed from June 1, 2018, to February 28, 2019. Interventions: Measurement of cross-sectional muscle area at the L3 vertebra level. Main Outcomes and Measures: Two- and 5-year overall survival were the primary outcomes. Results: Of the 260 patients included in the study, 193 were men (74.2%); mean (SD) age was 61.1 (11) years. Sarcopenia was present in 144 patients (55.4%). Two-year overall survival was 71.9% of the patients (n = 82) in the sarcopenia group compared with 88.5% of the patients (n = 85) in the nonsarcopenia group (odds ratio [OR], 0.33; 95% CI, 0.16-0.70). At 5 years, overall survival was 36.5% in patients (n = 23) with sarcopenia and 60.5% in patients (n = 26) without sarcopenia (OR, 0.38; 95% CI, 0.17-0.84). On multivariate analysis, sarcopenia was a significant negative predictor of both 2-year (OR, 0.33; 95% CI, 0.14-0.77) and 5-year (OR, 0.38; 95% CI, 0.17-0.84) overall survival. Conclusions and Relevance: Sarcopenia appears to be a significant negative predictor of long-term overall survival in patients with HNC undergoing major head and neck surgery. Sarcopenia may be accurately assessed on cross-sectional imaging and may be useful clinically as a prognostic variable and as an area for intervention to improve treatment outcomes.

Small bowel obstruction after transoral robotic surgery.

BACKGROUND: Head and neck surgery is not often considered a risk factor for intestinal ileus and small bowel obstruction. However, many of these patients may have had prior abdominal surgery, a known risk factor for small bowel obstruction, and may be at risk for bowel obstruction after a surgical procedure of the head and neck. METHODS: We present a case describing a patient who, after undergoing transoral robotic surgery, experienced delayed postoperative ileus and eventual small bowel obstruction requiring exploratory laparotomy and bowel resection. RESULTS: Although the patient required total parenteral nutrition for several days, he eventually was able to resume tube feeds, and after several months was able to tolerate an oral diet. CONCLUSION: Although uncommon complications of head and neck surgery, intestinal ileus and small bowel obstruction can develop as the result of stress/inflammation, postoperative narcotic pain medication, and prior abdominal surgery.

Long-term Functional and Quality-of-Life Outcomes After Transoral Robotic Surgery in Patients With Oropharyngeal Cancer.

IMPORTANCE: In recent years, transoral robotic surgery (TORS) has emerged as a useful treatment for oropharyngeal squamous cell carcinoma (OPSCC). In appropriately selected patients, the use of TORS may allow avoidance of adjuvant chemotherapy and/or radiotherapy, thereby avoiding the long-term adverse effects of these therapies. OBJECTIVE: To compare functional speech, swallowing, and quality-of-life outcomes longitudinally between those undergoing TORS only and those undergoing TORS and adjuvant radiotherapy (TORS+RT) or TORS and chemoradiotherapy (TORS+CRT). DESIGN, SETTING, AND PARTICIPANTS: This prospective, longitudinal cohort study performed from June 1, 2013, through November 31, 2015, included 74 patients undergoing TORS for initial treatment of OPSCC at a single tertiary academic hospital. MAIN OUTCOMES AND MEASURES: Data were collected at baseline, postoperatively (7-21 days), at short-term follow-up (6-12 months), and at long-term follow-up (>12 months). The quality-of-life metrics included the 10-item Eating Assessment Tool and the University of Michigan Head and Neck Quality of Life instrument. Data were also collected on tumor staging, surgical and adjuvant therapy details, patient comorbidities, tracheostomy and feeding tube use, and functional speech and swallowing status using the Performance Status Scale for Head and Neck Cancer Patients. RESULTS: Seventy-four patients were enrolled in the study (mean [SD] age, 61.39 [7.99] years; 68 [92%] male). Median long-term follow-up was 21 months (range, 12-36 months). The response rates were 86% (n = 64) postoperatively, 88% (n = 65) at short-term follow-up, and 86% (n = 64) at long-term follow-up. In all 3 groups, there was a significant worsening in pain and all swallowing-related measures postoperatively. There was subsequent improvement over time, with different trajectories observed across the 3 intervention groups. Postoperative dysphagia improved significantly more quickly in the TORS-only group. At long-term follow-up, weight loss differed between the TORS-only and TORS+RT groups (mean difference, -16.1; 97.5% CI, -29.8 to -2.4) and the TORS-only and TORS+CRT groups (mean difference, -14.6; 97.5% CI, -29.2 to 0) in a clinically meaningful way. In addition, the TORS-only group had significantly better scores than the TORS+CRT group on the Performance Status Scale-Eating in Public scale (mean difference, 21.8; 97.5% CI, 4.3-39.2) and Head and Neck Quality of Life-Eating scale (mean difference, 21.2; 97.5% CI, 4.0-38.3). CONCLUSIONS AND RELEVANCE: Patients who underwent TORS+CRT demonstrated poorer long-term outcomes, with continued dysphagia more than 1 year after surgery. These findings support the investigation of adjuvant de-escalation therapies to reduce the long-term adverse effects of treatment.

Gland Preservation in Patients Undergoing Sialoendoscopy.

Objective Sialoendoscopy is a minimally invasive technique for the treatment of obstructive sialadenitis. We aim to describe treatment considerations and report our ultimate rate of gland preservation. Study Design Case series with chart review. Setting Academic tertiary hospital. Subject and Methods A total of 128 consecutive sialoendoscopy cases for obstructive sialadenitis between 2009 and 2015 were evaluated. Procedures included endoscopic stricture dilation, basket-assisted stone retrieval, Holmium laser lithotripsy, and combined endoscopic transoral stone excision. Resolution of symptoms, need for additional procedures, and rate of subsequent adenectomy were investigated. Results Sialoendoscopy was completed in 120 of 128 patients (94%). There were 87 parotid gland cases and 41 submandibular gland cases. Endoscopic stricture dilation was attempted in 97 patients and successful in 99%. A sialolith was identified in 31 cases and removed by basket-assisted stone retrieval (10 cases), Holmium:YAG laser stone fragmentation (10 cases), and combined endoscopic transoral stone extraction (4 cases). In 8 cases overall, sialoendoscopy failed, with immediate adenectomy. At a mean follow-up of 18 months, 39 patients (33%) reported recurrence of symptoms, with 90% in the stricture group. For the entire cohort, gland preservation occurred in 112 of 128 patients (88%). Conclusions Sialoendoscopy is an effective technique, with few patients requiring additional procedures. Newer interventional approaches allow for stone retrieval without adenectomy. Patients in the stricture group were more likely to have recurrent symptoms as compared with the sialolithiasis group but often benefit from additional sialoendoscopic procedures, leading to a high overall rate of long-term gland preservation of 91%.

A randomized controlled trial of corticosteroids for pain after transoral robotic surgery.

OBJECTIVE: To determine if an extended perioperative course of corticosteroids will improve pain control following transoral robotic surgery (TORS). STUDY DESIGN: Randomized, double-blind, placebo-controlled trial. METHODS: Patients undergoing TORS for initial treatment of oropharyngeal squamous cell carcinoma received a single intraoperative dose of 10-mg dexamethasone and then were randomized to receive 8-mg dexamethasone every 8 hours, or placebo, for up to 4 days after surgery. Pain, measured by visual analog scale (VAS), was the primary outcome measure. Secondary outcome measures included length of stay, dysphagia assessments, and complications. RESULTS: VAS pain scores were similar between steroid and placebo cohorts on postoperative day (POD) 1, 2, and 7 through 21, although they significantly improved in the steroid cohort on POD 3. The steroid cohort also demonstrated a decreased hospital length of stay (median 1 day) and improvement in diet consistency, as measured by the performance status scale on POD 7 through 21. There was no difference in complications between the steroid and placebo cohorts. CONCLUSION: Extended perioperative corticosteroids after TORS is safe and may allow earlier improvement in diet consistency and decreased length of hospital stay, although postoperative pain appears minimally affected. LEVEL OF EVIDENCE: 1b. Laryngoscope, 127:2558-2564, 2017.

Schwann cell-like differentiation by adult oligodendrocyte precursor cells following engraftment into the demyelinated spinal cord is BMP-dependent.

The development of remyelinating strategies designed to enhance recruitment and differentiation of endogenous precursor cells available to a site of demyelination in the adult spinal cord will require a fundamental understanding of the potential for adult spinal cord precursor cells to remyelinate as well as an insight into epigenetic cues that regulate their mobilization and differentiation. The ability of embryonic and postnatal neural precursor cell transplants to remyelinate the adult central nervous system is well documented, while no transplantation studies to date have examined the remyelinating potential of adult spinal-cord-derived oligodendrocyte precursor cells (adult OPCs). In the present study, we demonstrate that, when transplanted subacutely into spinal ethidium bromide/X-irradiated (EB-X) lesions, adult OPCs display a limited capacity for oligodendrocyte remyelination. Interestingly, the glia-free environment of EB lesions promotes engrafted adult OPCs to differentiate primarily into cells with immunophenotypic and ultrastructural characteristics of myelinating Schwann cells (SCs). Astrocytes modulate this potential, as evidenced by the demonstration that SC-like differentiation is blocked when adult OPCs are co-transplanted with astrocytes. We further show that inhibition of bone morphogenetic protein (BMP) signaling through noggin overexpression by engrafted adult OPCs is sufficient to block SC-like differentiation within EB-X lesions. Present data suggest that the macroglial-free environment of acute EB lesions in the ventrolateral funiculus is inhibitory to adult spinal cord-derived OPC differentiation into remyelinating oligodendrocytes, while the presence of BMPs and absence of noggin promotes SC-like differentiation, thereby unmasking a surprising lineage fate for these cells.