The ptotic tongue-imaging appearance and pathology localization along the course of the hypoglossal nerve.

CT and MRI findings of tongue ptosis and atrophy should alert radiologists to potential pathology along the course of the hypoglossal nerve (cranial nerve XII), a purely motor cranial nerve which supplies the intrinsic and extrinsic muscles of the tongue. While relatively specific for hypoglossal nerve pathology, these findings do not accurately localize the site or cause of denervation. A detailed understanding of the anatomic extent of the nerve, which crosses multiple anatomic spaces, is essential to identify possible underlying pathology, which ranges from benign postoperative changes to life-threatening medical emergencies. This review will describe key imaging findings of tongue denervation, segmental anatomy of the hypoglossal nerve, imaging optimization, and comprehensive imaging examples of diverse pathology which may affect the hypoglossal nerve. Armed with this knowledge, radiologists will increase their sensitivity for detection of pathology and provide clinically relevant differential diagnoses when faced with findings of tongue ptosis and denervation.

Active upper aerodigestive tract hemorrhage in patients with head and neck cancers: the "dot-in-sludge" sign.

Active extravasation into the upper aerodigestive tract is a dramatic and potentially life-threatening complication in patients with head and neck cancers. It prompts presentation to the emergency room and subsequent urgent imaging to identify the source of hemorrhage. Imaging of these patients may be complicated by treatment-altered anatomy, posing a challenge to the emergency radiologist who needs to rapidly identify the presence of active hemorrhage and the potential source vessel. This retrospective review summarizes the clinical and imaging findings of 6 oropharyngeal and oral cavity squamous cell cancer (SCC) patients with active upper aerodigestive tract hemorrhage. Most patients had advanced stage disease and prior radiation therapy. All CECT or CTA exams on presentation demonstrated the "dot-in-sludge" sign of active extravasation, as demonstrated by a "dot" of avidly enhancing extravasated contrast material layered against a background "sludge" of non-enhancing debris in the lumen of the upper aerodigestive tract. Common sources of hemorrhage included the lingual, facial, and superior thyroidal arteries. Familiarity with these findings will help radiologists increase their accuracy and confidence in interpreting these urgent, complex examinations.

Comparison of the Seventh and Eighth Edition of American Joint Committee on Cancer (AJCC) Staging for Selected and Nonselected Oropharyngeal Squamous Cell Carcinomas.

OBJECTIVES: The eighth edition American Joint Committee on Cancer (AJCC) Staging incorporates significant changes to the seventh edition in the staging of oropharyngeal squamous cell carcinomas (OPSCC). An important change was the inclusion of OPSCC associated with the human papilloma virus (HPV). Our goal is to compare the performance of both staging systems for patients with HPV-selected and unselected clinical characteristics for OPSCC. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, 2004-2016, we identified patients with likely HPV-associated OPSCC based on surrogate markers (white males aged <65 years old with squamous cell carcinomas of the tonsil and base of tongue), excluding those who underwent surgery. We re-classified these patients using seventh and eighth edition staging for HPV-selected OPSCC and compared the prediction performance of both staging editions for overall survival (OS) and disease-specific survival (DSS). We performed the same analysis for clinically unselected patients with OPSCC. RESULTS: Our analysis included 9554 patients with a median follow-up of 67 months. Comparing the eighth versus seventh edition for our HPV-selected cohort, clinical staging changed for 92.3% of patients and 10-year OS was 62.2%, 61.2%, 35.3%, and 15.5% for Stage I, II, III, and IV, versus 52.9%, 59.2%, 61.6%, 55.1%, 38.3%, and 15.5% for stage I, II, III, IVA, IVB, and IVC, respectively. A similar pattern was observed for 10-year DSS. The concordance statistics for our HPV-selected cohort were improved for both AJCC 7 (0.6260) and AJCC 8 (0.6846) compared with the unselected cohort, 0.5860 and 0.6457 for AJCC 7 and 8, respectively. CONCLUSION: The overall performance of discrimination improved from AJCC 7 to AJCC 8 for both clinically selected and unselected patients, but more notably for our HPV-selected cohort. Despite the lack of statistically significant differentiation between Stages I and II in AJCC 8 in either groups, markedly improved discrimination was observed between Stages I/II, III, and IV in the HPV-selected cohort.

Best Practices: Application of NI-RADS for Posttreatment Surveillance Imaging of Head and Neck Cancer.

Imaging surveillance is an important component of posttreatment management of head and neck cancers. There is variability in the surveillance regimen used by various practitioners and institutions, with no official National Comprehensive Cancer Network guidelines for patients showing no symptoms beyond 6 months posttreatment. Moreover, imaging of the neck after treatment is a complex examination with significant interreader heterogeneity, particularly in terms of the manner in which degree of suspicion for disease recurrence is expressed. The Neck Imaging Reporting and Data System (NI-RADS) was introduced by the American College of Radiology (ACR) in 2018 as a practical guide for the interpreting radiologist. NI-RADS is a proposed interpretive framework that can be applied to any standardized or institutional surveillance imaging protocol. NI-RADS simplifies communication between radiologists and referring clinicians and provides management guidance linked to specific levels of suspicion. The ACR NI-RADS Committee also provided general best practice recommendations for imaging surveillance modality and timing in the 2018 white paper. This article will review existing literature regarding choice of modality and timeline for surveillance in treated cancer of the head and neck. NI-RADS will then be presented as an approach to imaging reporting, interpretation, and design of next steps in management.

Smoking, age, nodal disease, T stage, p16 status, and risk of distant metastases in patients with squamous cell cancer of the oropharynx.

BACKGROUND: With an expectation of excellent locoregional control, ongoing efforts to de-intensify therapy for patients with human papillomavirus-associated squamous cell oropharyngeal cancer necessitate a better understanding of the metastatic risk for patients with this disease. The objective of this study was to determine what factors affect the risk of metastases in patients with squamous cell cancers of the oropharynx. METHODS: Under a shared use agreement, 547 patients from Radiation Therapy Oncology Group 0129 and 0522 with nonmetastatic oropharyngeal squamous cell cancers who had a known p16 status and smoking status were analyzed to assess the association of clinical features with the development of distant metastases. The analyzed factors included the p16 status, sex, T stage, N stage, age, and smoking history. RESULTS: A multivariate analysis of 547 patients with a median follow-up of 4.8 years revealed that an age ≥ 50 years (hazard ratio [HR], 3.28; P = .003), smoking for more than 0 pack-years (HR, 3.09; P < .001), N3 disease (HR, 2.64; P < .001), T4 disease (HR, 1.63; P = .030), and a negative p16 status (HR, 1.60; P = .044) were all factors associated with an increased risk of distant disease. CONCLUSIONS: Age, smoking, N3 disease, T4 disease, and a negative p16 status were associated with the development of distant metastases in patients with squamous cell cancers of the oropharynx treated definitively with concurrent chemoradiation.

Making Time for Patients: Positive Impact of Direct Patient Reporting.

OBJECTIVE: Using a novel patient-centric approach, we assessed the impact of direct patient radiology reporting on the patient experience and patient perception of radiologists in a high-volume head and neck clinic. MATERIALS AND METHODS: A single head and neck surgeon at a large academic center identified prospective outpatients who met the following inclusion criteria: having received treatment for head and neck cancer and having recently undergone surveillance imaging using the Neck Imaging Reporting and Data System template at our institution. The surgeon introduced the concept and gave patients a survey with questions before and after the radiology consultation. The radiologist met with the patient in the head and neck clinic's examination room, explaining the role of the radiologist and reviewing imaging findings. RESULTS: Twenty-seven patients completed surveys. An improved understanding of the role of the radiologist was noted (41% of patients before consultation vs 67% after consultation). After the consultation, fewer patients (56-22%) wanted to hear from the referring physician only, and more patients wanted to hear from the radiologist only (26-44%) or from both the referring physician and the radiologist (19-33%). A total of 70-93% of patients had an improved understanding of imaging findings and follow-up recommendations after meeting with the radiologist. Most patients expressed an interest in reviewing future studies with a radiologist (93%) and found the consultation helpful (96%). CONCLUSION: Direct patient reporting by the radiologist is feasible in a high-volume head and neck clinic and has a positive impact on the patient experience. Major factors that enabled direct patient reporting included our embedded reading room and the use of a standardized reporting template. After the consultation, more patients wanted to receive information from the radiologist and had a better understanding of the imaging results.

Radiographic Imaging Does Not Reliably Predict Macroscopic Extranodal Extension in Human Papilloma Virus-Associated Oropharyngeal Cancer.

BACKGROUND: Radiographic concern for lymphatic extranodal extension (ENE) impacts upfront management decisions for patients with human papilloma virus (HPV) oropharyngeal squamous cell carcinoma (OPSCC). Therefore, we set out to evaluate the accuracy of preoperative contrast-enhanced computed tomography (CECT) to predict major ENE (> 2 mm). METHODS: Twenty-seven consecutive patients with HPV-associated OPSCC who presented at our institutional multidisciplinary tumor board were staged radiographically with positron emission tomography (PET/CT) and CECT, and underwent primary transoral robotic resection and neck dissection. CECT imaging results were correlated with pathologic ENE (pENE). RESULTS: CECT specificity for all pENE was 69 and 75% for radiologist 1 and 2, respectively. For pENE > 2 mm, the sensitivities were 88 and 100%, but specificities were 52.6 and 63.2%. Positive predictive values (PPV) were 43.8 and 53.3%; negative predictive values were 90.9 and 100%. On logistic regression analysis, only size ≥3 cm (OR 4.7-5.4, p < 0.02, 95% CI 1.3-44.0) demonstrated significant correlation with major ENE > 2 mm. CONCLUSIONS: Preoperative imaging for HPV-associated OPSCC had a PPV for pENE > 2 mm of 44-55%, based on any interruption in the capsule or invasion into the perinodal fat. The PPV is low and equipoise in treatment decision making for patients with HPV-associated OPSCC may require other imaging characteristics.

Magnetic Resonance Imaging of Temporomandibular Joints of Children.

PURPOSE: To identify magnetic resonance imaging (MRI) findings of temporomandibular joints (TMJs) in healthy children. MATERIALS AND METHODS: This was a retrospective study of children younger than 18 years undergoing MRI of the head for non-autoimmune indications at Children's Healthcare of Atlanta (Atlanta, GA). Patients with congenital or acquired conditions associated with potential TMJ pathology were excluded. Medical records and MRIs were reviewed to document demographic data. Three neuroradiologists independently recorded specific predetermined MRI findings of the TMJ. The outcome variable was the presence or absence of TMJ findings at MRI. Descriptive and bivariate statistics were used to identify associations (significant at P ≤ .05). RESULTS: Eighty-seven patients (54 boys, 33 girls; mean age, 11.2 yr) met the inclusion criteria. Seventy percent of TMJs had condylar enhancement, 64% of joints had glenoid marginal synovial enhancement, 56% had condylar margin synovial enhancement, and 19% had condylar T1 hyperintense signal. There were no joints with condylar erosion, condylar volume loss, or effusion. Findings of normal marrow development were decreased condylar enhancement and greater condylar T1 signal with increased age. CONCLUSION: This study found a greater than 60% prevalence of synovial enhancement in healthy children. In a healthy child, MRI findings of TMJ synovial enhancement should be carefully correlated with a clinical evaluation.

Redefining normal facial nerve enhancement: healthy subject comparison of typical enhancement patterns--unenhanced and contrast-enhanced spin-echo versus 3D inversion recovery-prepared fast spoiled gradient-echo imaging.

OBJECTIVE: Normal facial nerve enhancement patterns derived from spin-echo (SE) sequences have not been systematically compared on contrast-enhanced 3D inversion recovery-prepared fast spoiled gradient-echo (IR-FSPGR) sequences, now in widespread use. We hypothesize that features unique to IR-FSPGR may engender differences in the appearance of the normal facial nerve, which may confound analysis of pathologic enhancement. We compared unenhanced and contrast-enhanced SE and IR-FSPGR sequences in a cohort of patients without facial nerve pathology. MATERIALS AND METHODS: Twenty-three patients without facial nerve pathology were examined. Unenhanced and contrast-enhanced signal intensity (SI) of seven facial nerve segments was assessed on SE and IR-FSPGR by two neuroradiologists. SI was assigned a value of 0-3 (0, absent; 1, faint; 2, equivalent to brain; 3, equivalent to enhancing dural sinus). Statistically significant differences were assessed for each segment. RESULTS: Significantly higher unenhanced and contrast-enhanced SI was present in most facial nerve segments on IR-FSPGR compared with SE, including cisternal, canalicular, labyrinthine, and geniculate segments (p ≤ 0.01). Enhancement patterns were generally similar; however, significant enhancement of the labyrinthine segment was detected only on SE (p = 0.011). For unenhanced images, mean kappa statistic was 0.32, and for the contrast-enhanced images, mean kappa statistic was 0.04, implying fair and slight agreement between readers, respectively. CONCLUSION: Significantly greater SI is observed in most facial nerve segments on both unenhanced and contrast-enhanced IR-FSPGR among healthy subjects and may be misinterpreted as pathologic when evaluated in the context of existing enhancement paradigms. Examiners should remain cognizant of normal deviations from expected enhancement patterns in IR-FSPGR imaging to avoid misdiagnosis and other interpretive pitfalls.

Initial experience with upfront arterial and perfusion imaging among ischemic stroke patients presenting within the 4.5-hour time window.

BACKGROUND: Although perfusion imaging is being evaluated as a tool to select acute ischemic stroke patients who are most likely to benefit from reperfusion therapies beyond the standard time windows, there are limited data on the utility of perfusion imaging within the intravenous (IV) thrombolytic time window. METHODS: A new stroke imaging protocol was initiated at Emory University Hospital including computed tomographic angiography (CTA) and computed tomographic perfusion (CTP). All patients presenting within 4.5 hours from last known normal time with suspected stroke were prospectively identified. Impact of CTA and CTP on the clinical management was recorded prospectively by stroke team members. RESULTS: During the study period, 87 patients met eligibility criteria for the CTA/CTP protocol, of which 83 (95%) underwent this upfront comprehensive imaging protocol and 30 (34%) received IV thrombolytics. Overall, stroke team members reported that CTA and/or CTP aided their clinical management in 39 (47%) cases, including aiding in identification of a nonstroke diagnosis (n = 18), triage to the neurologic intensive care unit (n = 9), early triage to endovascular therapy (n = 4), and initiation of IV thrombolytic for low National Institutes of Health Stroke Scale score with large vessel occlusion (n = 3). Door to needle time ≤60 minutes was achieved in only 18% of patients receiving IV thrombolysis during the study period, but had improved to 44% in the subsequent 6-month period. CONCLUSIONS: An upfront CTA/CTP protocol aided stroke team decision-making in nearly half of cases. Implementation of a CTA/CTP protocol was associated with a learning curve of 6 months before door to needle time ≤60 minutes returned to similar rates as the pre-CTA/CTP protocol.

Factors determining the clinical significance of an "empty" sella turcica.

OBJECTIVE: Although often incidental, the "empty" sella turcica can reflect chronically elevated intracranial pressure (ICP). It is particularly common in the setting of idiopathic intracranial hypertension (IIH). This study evaluated which clinical and MRI findings could be used to differentiate patients with chronically elevated ICP from those with incidental empty sella turcica. MATERIALS AND METHODS: Forty-five patients with definite IIH and 92 patients with "empty sella" reported on brain MRI were evaluated. Measurements of the sella turcica, diaphragm sella, pituitary gland, infundibulum, and scalp and neck soft tissues were made on MR images. These measurements, age, sex, clinical symptoms, and frequency of previously reported orbital findings of IIH were compared between the IIH and incidental empty sella turcica groups. Measurements on MRI were correlated with patient age in each group. RESULTS: The IIH and incidental empty sella turcica groups had statistically similar sellar, pituitary, and infundibular measurements. The patients with IIH were significantly younger than the patients with incidental empty sella turcica (mean age, 36.1 vs 54.3 years, respectively; p < 0.05); were more likely to report headache (93.3% vs 32.6%; p < 0.05) and visual complaints (66.2% vs 28.3%; p < 0.05); showed greater mean scalp thickness (9.0 vs 6.4 mm; p < 0.05) and neck soft-tissue thickness (19.5 vs 13.8 mm; p < 0.05); and were more likely to have an orbital finding suggestive of IIH (93% vs 14%). Age modestly correlated with the width of the diaphragm sella (r = 0.53) in the IIH group only. CONCLUSION: The significance of the MRI finding of an empty sella turcica can be determined using a combination of clinical and imaging findings.

Personalizing Surveillance in Head and Neck Cancer.

Head and neck squamous cell carcinoma (HNSCC) encompasses a spectrum of heterogeneous diseases originating in the oral cavity, pharynx, and larynx. Within the United States, head and neck cancer (HNC) accounts for 66,470 new cases, or 3% of all malignancies, annually.1 The incidence of HNC is rising, largely driven by increases in oropharyngeal cancer.2-4 Recent molecular and clinical advancements, particularly with regard to molecular and tumor biology, reflect the heterogeneity of the subsites contained within the head and neck. Despite this, existing guidelines for post-treatment surveillance remain broad without much consideration given to different anatomic subsites and etiologic factors (such as human papillomavirus [HPV] status or tobacco exposure).5 Surveillance incorporating the physical examination, imaging, and emerging molecular biomarkers is an essential part of care for patients treated for HNC and allows for the detection of locoregional recurrence, distant metastases, and second primary malignancies aiming for better functional and survival outcomes. Additionally, it allows for evaluation and management of post-treatment complications.

To Scan or Not to Scan: The Dilemma of Posttreatment Imaging Surveillance of Head and Neck Cancer.

Locoregional recurrence remains common after treatment of head and neck cancer, warranting careful surveillance in follow-up. Although randomized data support an initial positron emission tomography/computed tomography several months after treatment, evidence supporting subsequent imaging is limited, and most recurrences ultimately manifest clinically. Cooperative group studies and consensus guidelines vary widely in their recommendations regarding surveillance imaging. Patients with indeterminate findings, new symptoms, or areas difficult to examine in clinic may avoid invasive and potentially morbid interventions with judicious use of subsequent imaging. For any patient undergoing posttreatment imaging, standardized reporting criteria provide a framework for risk-stratification that can enhance communication and potentially guide management.

Comparison of 3D constructive interference in steady state (CISS) and T2 sampling perfection with application optimized contrasts using different flip angle evolution MR imaging of the intracranial trigeminal nerve and central skull base neuroforamina.

BACKGROUND AND PURPOSE: Due to surgical advancements, the accurate detection of perineural disease spread has become increasingly important in the management and prognostication of head and neck cancers, though MR evaluation has thus far been limited by technical and logistic challenges. The purpose of this study was to specifically evaluate the relative capability of 3D CISS and 3D T2-SPACE imaging to delineate the proximal intracranial divisions of the normal trigeminal nerve, an area important in determining the resectability of intracranial perineural disease. MATERIALS AND METHODS: A single center HIPAA-compliant, IRB approved retrospective review of 40 patients with clinical temporal bone/internal auditory canal MR imaging was conducted. 20 patients with 3D CISS images and 20 patients with 3D T2-SPACE images met inclusion criteria. Two radiologists scored the sequences on a 3-point scale based on ability to visualize anatomic structures surrounding the trigeminal nerve in Meckel's cave, intracranial trigeminal divisions, skull base neuroforamina, and proximal extracranial mandibular division. RESULTS: The following anatomic locations scored significantly better in the T2-SPACE sequence compared to the CISS sequence for both raters: intracranial V3 (p < .05), foramen ovale (p < .05), and extracranial V3 (p < .01). The average scores for the anterior Meckel's cave and foramen rotundum were higher for the T2-SPACE sequence, although not significantly. Percent interobserver agreement ranged from 50 to 90% and 65-100% for the different anatomic locations on the CISS and T2-SPACE sequences, respectively. CONCLUSION: 3D T2-SPACE was found to be superior to 3D CISS in the evaluation of the distal intracranial and extracranial portions of the normal trigeminal nerve.

Posttreatment Magnetic Resonance Imaging Surveillance of Head and Neck Cancers.

Treatment strategies and recommended surveillance imaging differ for head and neck cancers depending on subsite and neoplasm type, and pose confusion for referring physicians and interpreting radiologists. The superior soft tissue resolution offered by magnetic resonance imaging is most useful in the surveillance of cancers with high propensities for intraorbital, intracranial, or perineural disease spread, which most commonly include those arising from the sinonasal cavities, nasopharynx, orbits, salivary glands, and the skin. This article discusses recommended surveillance protocoling and reviews treatment approaches, common posttreatment changes, and pearls for identifying disease recurrence in a subsite-based approach.

Initial Referring Physician and Radiologist Experience with Neck Imaging Reporting and Data System.

OBJECTIVES/HYPOTHESIS: Neck Imaging Reporting and Data System (NI-RADS) is a radiology reporting system developed for head and neck cancer surveillance imaging, using standardized terminology, numeric levels of suspicion, and linked management recommendations. Through a multidisciplinary, interdepartmental quality improvement initiative, we implemented NI-RADS for the reporting of head and neck cancer surveillance CT. Our objective is to summarize our initial experience from the standpoints of head and neck cancer providers and radiologists. STUDY DESIGN: Quality improvement study. METHODS: Before and 3 months post-implementation, surveys were offered to referring physicians (n = 21 pre-adoption; 22 post-adoption) and radiologists (n = 17 pre- and post-adoption). NI-RADS utilization was assessed over time. RESULTS: Survey response rates were 62% (13/21) and 73% (16/22) for referring physicians pre- and post-adoption, respectively, and 94% (16/17) for radiologists pre- and post-adoption. Among post-adoption provider respondents, 100% (16/16) strongly agreed or agreed with "I want our radiologists to continue using NI-RADS," "The NI-RADS numerical rating of radiologic suspicion is helpful," and "The language and style of NI-RADS neck CT reports are clear and understandable." Among radiologist respondents, 88% (14/16) strongly agreed or agreed with "NI-RADS improves consistency among our radiologists in the reporting of surveillance neck CTs." Radiologist NI-RADS utilization increased over time (46% month 1; 72% month 3). CONCLUSIONS: Most referring physicians and radiologists preferred NI-RADS. Head and neck cancer providers indicated that NI-RADS reports are clear, understandable, direct, and helpful in guiding clinical management. Radiologists indicated that NI-RADS improves radiologist consistency in the reporting of surveillance neck CT, and radiologists increasingly used NI-RADS over time. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:349-355, 2022.

The impact of operability status on outcomes in patients with T4 larynx cancer undergoing larynx preservation.

BACKGROUND: Large analyses of T4 larynx cancer (LC) have raised concerns that larynx preservation (LP) contributes to reduced survival compared with laryngectomy (LGX). The role of operability has not been previously considered as a confounder. METHODS: We queried the National Cancer Database for T4M0 LC diagnosed 2004-2015. Patients were categorized as undergoing LGX, chemoradiotherapy but operable (LP-operable), and chemoradiotherapy inoperable (LP-inoperable). Overall survival (OS) was estimated by Kaplan-Meier. Cox multivariate analysis (MVA) identified variables associated with OS. RESULTS: We identified 1405 LGX, 164 LP-operable and 1969 LP-inoperable patients. Compared with LGX, MVA demonstrated worse OS among LP-inoperable (HR 1.28 95%CI 1.17-1.40, p < 0.01) but not LP-operable patients (HR 1.12 95%CI 0.91-1.39, p = 0.28). CONCLUSIONS: LP-operable patients did not have significantly worse OS than those undergoing LGX.

Central Skull Base Anatomy and Pathology: A Review.

The central skull base is an anatomically complex region of the head and neck which hosts a variety of neoplastic, vascular, infectious, inflammatory, and developmental pathologies. Evaluation of its intricate anatomy requires dedicated and complementary imaging modalities of MRI and CT. This article will provide a brief review of the anatomy of the central skull base, followed by an overview of common pathologies encountered in this region and their characteristic radiological characteristics.

Incidence trends of squamous cell carcinoma of the head and neck (SCCHN) in the aging population--A SEER-based analysis from 2000 to 2016.

BACKGROUND: Tobacco and alcohol use are risk factors for Squamous Cell Carcinoma of the Head and Neck (SCCHN); however, there is growing recognition of HPV as a risk factor for SCCHN. HPV-related SCCHN is thought to affect mostly middle-aged individuals but as the US population ages, it is important to evaluate the change in incidence of HPV- and non-HPV-related SCCHN in individuals who are ≥65 years old. METHODS: This was a retrospective study using data from a population-based cancer registry (SEER) to identify individuals ≥65 years old diagnosed with SCCHN between 2000 and 2016 also stratified by sex, race, and birth cohort. The subgroups of HPV-associated and non-HPV associated sites were analyzed independently. The incidence per year was calculated and joinpoint detection was used to identity significant changes in incidence trends and annual percent change (APC). RESULTS: For HPV-associated sites from 2000 to 2016, there was an average annual rate of 10.8 per 100,000 individuals with an APC of 2.92% (p = <0.05). For HPV- and non-HPV-related SCCHN males had a higher annual rate compared to females, 54.5 versus 18.0 in non-HPV-related and 19.1 versus 4.4 in HPV-related sites. For non-HPV-related sites there was a decrease in APC across all stratified groups. For HPV-related sites there was an increase in APC across all stratified groups, especially males (APC 8.82% 2006-2016 p < 0.05) and White individuals (APC 8.19% 2006-2016 p < 0.05). When stratified by birth cohort, HPV-related SCCHN sites had a higher APC in ages 65-69 (8.38% p < 0.05) and 70-74 (8.54% p < 0.05). CONCLUSION: Among the population ≥65 years old from 2000 to 2016, the incidence rate for HPV-related SCCHN sites has increased across all stratified groups, especially in White individuals, males, and age groups 65-74. The incidence rate for non-HPV-related sites has decreased across all stratified groups during this time.