Travel distance: Impact on stage of presentation and treatment choices in head and neck cancer.

OBJECTIVES: The objective was to examine the impact of travel distance on stage of presentation and treatment choices in head and neck squamous cell carcinoma in the rural setting. METHODS: 6029 cases diagnosed from 2002 to 2011 were obtained from the state cancer registry. Travel time was calculated to the nearest academic medical centers, otolaryngologist, and radiation treatment facilities. Multivariate logistic regression was used to examine the association of travel time with stage of presentation as well as the likelihood of appropriate therapy after adjustment for other demographic variables. RESULTS: Patients in the highest quartile for travel distance to academic centers were 33% more likely to present with early stage disease (p = 0.02), and 42% more likely to receive appropriate surgical therapy for oral cavity cancer. Patients were 70% more likely to receive appropriate surgery if they were farthest from the nearest radiation center (p = 0.03). Proximity to otolaryngology care was not significant. CONCLUSION: Increased travel distance to academic medical centers is associated with increased likelihood of proper therapy for surgically treated tumors of the head and neck. Impact on these findings on improvements in access to care is discussed.

Endoscopic CO2 laser management of chemoradiation-related cricopharyngeal stenosis.

OBJECTIVE: Treatment of head and neck cancer with chemoradiation (CRT) can result in strictures of the cervical esophagus, often at the level of the cricopharyngeus. The objective of this study is to assess the feasibility of endoscopic CO2 laser cricopharyngeal myotomy for stricture ablation in the setting of prior CRT. METHODS: A retrospective review of patients who underwent endoscopic CO2 laser cricopharyngeal myotomy for dysphagia after radiation for squamous cell carcinoma of the head and neck (SCCHN). Pre- and postoperative barium swallow and swallowing assessment were performed before and after surgery. Outcomes and complication rates were examined. RESULTS: Endoscopic CO2 laser cricopharyngeal myotomy was performed in 10 patients with dysphagia secondary to cricopharyngeal stenosis/stricture, which developed following treatment for SCCHN with chemoradiation. All patients demonstrated radiographic improvement in stricture, with complete resolution of stricture in 9 of 10 patients. All patients noted improvement in dysphagia with 9 of 10 patients demonstrating significant advancement of diet by modified barium swallow. No complications were observed. CONCLUSION: Endoscopic CO2 cricopharyngeal myotomy can be performed safely in the setting of prior CRT, with significant improvement in swallowing in select patients. Indications and technical considerations will be discussed.

Reconstruction of the through-and-through oral cavity defect with the fibula free flap.

OBJECTIVE: To evaluate our experience with reconstruction of anterior and lateral through-and-through defects of the oral cavity using the fibula osteocutaneous flap. STUDY DESIGN: Case series with chart review. METHODS: Review of patients undergoing reconstruction of through-and-through oral cavity defects between August 2006 and July 2008. Defect size, complications, and need for additional reconstruction were examined. RESULTS: Twelve patients were identified with through-and-through oromandibular defects reconstructed with the fibula. Soft tissue defects were successfully closed using a de-epithelialized segment to create two skin paddles. Four patients required additional pectoralis major flap reconstruction for secondary fibula skin loss (1), neck skin breakdown (1), delayed flap loss (1), and need for additional tissue for closure (1). CONCLUSION: The versatility of the fibula for through-and-through defects of the oral cavity is underestimated, and in most cases it is appropriate to reserve second flaps for salvage reconstruction.

Treatment trends in oropharyngeal carcinoma: Surgical technology meets the epidemic.

OBJECTIVE: To characterize temporal trends in treatment patterns for oropharyngeal carcinoma, and to evaluate the emerging role of surgical therapy in the era of transoral robotic surgery (TORS). METHODS: Patients with oropharynx cancer between 2004 and 2016 identified using the National Cancer Database. Demographics and primary treatment modalities were obtained. Treatment was classified as surgery alone, surgery with radiation/chemotherapy, or primary radiation/chemotherapy. Annual distribution of cases treated by the various modalities was tabulated by site and early (I/II) versus late (III/IV) stage disease (AJCC 7th edition). The "TORS era" was defined as beginning in 2010. RESULTS: 149,534 patients were identified. The majority (56.8%) were treated with radiation ± chemotherapy. 53,069 patients had surgery as part of treatment, 72.6% (N = 38,533) of which received adjuvant therapy. 5293 TORS procedures were performed between 2010 and 2016 with trends away from open and other endoscopic procedures. Despite a 31.0% increase in the number of cases treated surgically from before TORS (2009) to 2016, the percentage of cases treated surgically decreased from 35.0% to 32.7%, with a 44.2% increase in non-surgical therapy. Increases in the percentage of patients treated surgically were observed for base of tongue tumors (24.3-25.2%) and early stage disease (59.9-62.2%). CONCLUSION: Despite the increase in the overall number of patients with oropharynx cancer, the percentages of patients treated surgically remains relatively stable. Notable increases were observed for base of tongue tumors and early stage disease.

Incidence of oral cavity and pharynx cancer in Kentucky.

BACKGROUND: Oral cavity and pharyngeal (OCOP) cancer is strongly associated with tobacco use and alcohol consumption. Kentucky consistently has one of the highest rates of tobacco use in the United States. The purpose of this study was to examine the differences in incidence rates in Kentucky as compared to nationwide data as well as regional differences within the state. METHOD: Oral and pharyngeal cancer incidence data for the years 1995-2004 in Kentucky were obtained from Kentucky Cancer Registry (KCR). Data for the same time period for the United States were approximated using SEER*Stat 6.3.5 provided by the Surveillance, Epidemiology, and End Results (SEER) Program. Age-adjusted incidence rates and smoothed incidence rates by county were examined. RESULTS: The overall incidence of oral cavity and pharyngeal cancer in Kentucky was 12.1/100,000. This was significantly higher than the rate seen in the SEER data of 11.3/100,000 population (p < 0.05). This difference was more pronounced for males in Kentucky, where a 20% higher rate (19.2 vs 16.3/100,000 SEER) was observed. The vast majority of cases (62.1%) had a documented smoking history, and this number was higher in advanced stage disease (73%). Rates were lower in Appalachian regions (11.4/100,000) compared to non-Appalachian regions (12.4/10/ 100,000), p < 0.01, with additional geographic variations observed. CONCLUSION: Kentucky has a higher incidence rate for oral cavity and pharyngeal cancer than the national average. The high prevalence of tobacco use in the state is likely a strong contributing factor. The etiology of regional patterns of incidence rates statewide requires further study.

Transoral robotic resection of a combined laryngocele.

This case report describes the use of trans-oral robotic surgery (TORS) for the excision of a combined laryngocele. Mixed or combined laryngoceles extend from the supraglottic larynx through the thyrohyoid membrane into the neck. Surgical excision for these benign lesions often requires combined external (transcervical) and internal (transoral endoscopic) approaches which carry significant morbidity. We present the case of a 37-year-old male who was diagnosed with a large laryngopyocele and was subsequently managed with a transoral excision using the da Vinci Si surgical robot system. The procedure was without complications and the patient was discharged on the second post-operative day on a full liquid diet supplemented with a naso-gastric feeding tube. Postoperative stroboscopy performed 1 month later demonstrated a well-healed hemilarynx and a normal voice. The patient is on a regular diet and now over three years removed from surgery with no evidence of recurrence. We conclude that TORS is an effective tool in the management of benign laryngeal pathology including combined laryngoceles, resulting in reduced morbidity.

Naloxone reversal of buprenorphine-induced respiratory depression.

In a placebo-controlled, single-blind study we evaluated the ability of three large doses of naloxone (1.0, 5.0, and 10 mg) to antagonize the established respiratory-depressant effects of a common analgesic dose of intravenous buprenorphine (0.3 mg/70 kg). This dose of buprenorphine consistently reduced indexes of CO2 responsiveness to about one half of their control values, much like comparable doses of other opioid analgesics. One milligram of naloxone had little effect on this respiratory depression. Both 5 and 10 mg produced consistent reversal, which was more complete with the larger dose. The reversal effect of naloxone did not occur immediately as is characteristic with morphine and other opioids but rather appeared to reach a maximum 3 hours after reversal. These findings indicate that high doses of naloxone are required to antagonize buprenorphine and naloxone's limited efficacy results not from its short duration of action but rather its relative inability to displace buprenorphine already bound to opioid receptors.

Prolonged blockade of opioid effect with oral nalmefene.

In a placebo-controlled, double-blind study we evaluated the ability of a single 50 mg oral dose of nalmefene to block the effects of intravenous opioid challenge (2 micrograms/kg fentanyl). Fentanyl-induced respiratory depression (CO2 responsiveness), analgesia (tourniquet ischemia), and subjective effects were totally blocked for 48 hours and showed only minimal breakthrough 72 hours after nalmefene. Plasma concentration-time data for nalmefene indicate good oral bioavailability and a prolonged terminal elimination phase (mean t1/2 11.1 hours). These findings suggest that nalmefene could provide prolonged effectiveness in limiting emergence of opioid effects during addiction therapy.

Effect of inhaled glycopyrrolate and atropine in asthma. Precipitated by exercise and cold air inhalation.

We compared the effects of inhaled glycopyrrolate (G), 1.3 mg, and atropine (A), 2.6 mg, and placebo on FEV1 and specific conductance (sGaw) before and after exercise in six men with exercise-induced asthma. Subjects exercised with cold air (-2 degrees C) 30 and 120 minutes after each aerosol treatment. Spirometry was performed and sGaw determined before aerosol treatment (baseline) and before and after exercise. Decreased airway tone was noted before exercising with A and G but not with placebo. The decreases in FEV1 and sGaw resulting from exercise were not significantly different among the three treatment groups at either exercise session. Postexercise FEV1 and sGaw were significantly higher after A and G compared to P. Dry mouth, flushing, and resting tachycardia were prominent with group A. Symptoms in G did not differ from those in P. This study suggests that A and G do not prevent bronchoconstriction induced by exercise and cold air but improve postexercise pulmonary function by achieving preexercise bronchodilation. Systemic side effects were minimal with G compared to A.

Reconstruction after temporal bone resection.

Reconstruction of soft tissue defects after temporal bone resection can vary from simple closure of the external auditory canal to complex flap coverage of extensive defects. Between 1987 and 1996, 34 patients underwent lateral skull base resections and reconstruction for invasive carcinoma of the temporal bone. Seven underwent sleeve resection and/or radical mastoidectomy. Sleeve resection was managed with tympanoplasty, canalplasty, or obliteration of the external auditory canal (10). There were 24 lateral temporal bone resections and four subtotal temporal bone resections. Larger defects created by lateral and subtotal temporal bone resections required closure with a combination of temporalis flaps and local rotational cutaneous flaps (13). Lower island trapezius flaps (five), free flaps (four), and pectoralis major flaps (two) were also used. Indications and efficacy of each method are discussed, and treatment outcomes are presented.

Radiation effects on osteoblasts in vitro: a potential role in osteoradionecrosis.

OBJECTIVE: To evaluate the factors involved in bone remodeling and wound healing that may be altered by radiation therapy. DESIGN: A prospective, controlled study of biochemical activity in vitro. SUBJECTS: MC3T3-E1 mouse osteoblasts. INTERVENTIONS: Cells were irradiated at 0, 2, 4, or 6 Gy. Specimens were harvested at 1, 7, 14, 28, and 42 days following irradiation for immunohistochemical analysis of transforming growth factor beta(1) expression and transforming growth factor beta(1) type I and II receptor expression. Collagen production was measured at 1, 7, 28, 35, and 49 days after irradiation. The effects of dexamethasone on collagen production and cell proliferation were also examined. RESULTS: Irradiated cells demonstrated decreased cell proliferation and a dose-dependent, sustained reduction in collagen production when compared with control cells. An increase in transforming growth factor beta(1) type I and II receptor expression was noted in irradiated cells when compared with controls. CONCLUSION: Radiation-induced alterations of factors related to bone remodeling and wound healing have a potential role in the pathogenesis of osteoradionecrosis.

Factors affecting survival for floor-of-mouth carcinoma.

OBJECTIVES: The treatment of extensive floor-of-mouth carcinoma has remained a challenging problem for head and neck surgeons. We have reviewed our experience in the surgical management of floor-of-mouth cancer in an attempt to identify factors influencing survival. METHODS: A total of 144 patients with cancer involving the floor of the mouth were treated between March 1988 and November 1995. A retrospective chart review was conducted that captured information including clinical staging, therapeutic modalities, pathologic findings, and patient follow-up. Factors affecting survival were assessed by nonparametric analysis and analysis of variance. RESULTS: There was no statistical significance for the effects of vascular invasion (P = 0.4019), lymphatic invasion (P = 0.3430), bone invasion (P = 0.1548), or positive margins (P = 0.1113) on survival. Extranodal extension and recurrent disease were strongly suggestive of influencing survival but were not statistically significant (P = 0.0650 and P = 0.0504, respectively). Nodal disease significantly affected survival (P = 0.0138) but did not affect recurrence (P = 0.451). CONCLUSION: Mean survival for this cohort was 30.6 months. Positive node status significantly affected mean overall survival in this series, whereas extracapsular disease did not. These data suggest that aggressive surgical management of neck disease is mandated to maximize survival.

Assessment of plate use for mandibular reconstruction: has changing technology made a difference?

Reconstruction of mandibular defects with a variety of alloplastic materials during a 22-year period was reviewed. Outcomes were examined to determine whether specific plating technology affected the incidence of plate-related complications including plate exposure, plate fracture, and plate removal. Repair with the miniplate, reconstruction plate, titanium hollow screw reconstruction plate, and locking reconstruction plate was evaluated. Although the incidence of plate fractures has decreased, there was no significant change in the rate of plate exposure. Recurrent disease was noted to be a significant contributing factor in the development of plate-related complications.

Risk factors associated with hypothyroidism after laryngectomy.

Hypothyroidism is a well-documented complication after treatment of head and neck cancer and is particularly significant among patients undergoing laryngectomy. The objective of this study was the identification of factors associated with the development of hypothyroidism in this population. Records of 136 patients treated with laryngectomy were retrospectively reviewed in an attempt to define a risk factor profile for patients in whom hypothyroidism is most likely to develop after laryngectomy. The Cox proportional hazards model was used to identify factors significantly related to an increased risk for development of hypothyroidism. The actuarial method was used to estimate the period of greatest risk for the development of hypothyroidism. Increased risks were found for patients who were female (P = 0.0049), received preoperative radiation therapy (P = 0.0022), had invasion of the thyroid gland by tumor (P = 0.0003), had presence of cervical metastases (P = 0.0022), and had postoperative fistula (P = 0.0095). From the actuarial method, we estimated that the period of time when patients were at greatest risk for development of hypothyroidism was between 0 and 14 months after surgical intervention. Wound complications were twice as frequent in hypothyroid patients. Perioperative awareness of risk factors associated with the development of hypothyroidism in patients undergoing laryngectomy allows for early recognition and management of hypothyroidism and may reduce the number of complications related to wound healing and fistula.

Auricular carcinoma with temporal bone invasion: outcome analysis.

Invasion of the temporal bone by cutaneous carcinoma of the auricle and periauricular skin is an ominous prognostic sign. Management includes aggressive resection of cutaneous disease as well as resection of temporal bone to obtain a medial margin. Analysis of data from 21 patients with temporal bone invasion caused by cutaneous malignancy is presented. Overall survival is approximately 63%. Cumulative survival is significantly decreased in patients with squamous cell carcinoma when compared with other invasive malignancies. Univariate and covariate analyses demonstrate that nodal status, positive microscopic soft tissue margins, and persistent perineural disease at the skull base did not significantly affect survival in this series. There is a trend toward increased survival in patients receiving postoperative radiation in this series.

Brain stem auditory evoked potential monitoring during profound hypothermia and circulatory arrest.

The effects of decreased temperature on brain stem auditory evoked potentials (BAEP) have been previously described in mild to moderate hypothermia. This report describes BAEP monitoring during profound hypothermia (11 degrees C) and circulatory arrest for repair of an aortic arch aneurysm. Recording of BAEP were interpretable during cooling to 14 degrees C, and demonstrated increasing interpeak (I-V) latency compatible with prolongation of brain stem conduction time. The changes rapidly returned to normal during rewarming from profound hypothermia, in a fashion similar to that seen after mild hypothermia, and therefore appear to be completely reversible.

Radial forearm free flap.

The unique attributes of the radial forearm flap for head and neck reconstruction make it a primary choice from the reconstructive ladder. As more surgeons become familiar and comfortable with microvascular techniques and recognize the ease of its harvest, the popularity of this flap will increase. The radial forearm free flap should not be used for every head and neck defect. Flap choice should be dictated by the needs of the patient and those of the site to be reconstructed.

Microvascular reconstruction after intra-arterial chemotherapy with concomitant radiation.

OBJECTIVE: While the success of microvascular reconstruction is well established, even in the setting of prior radiotherapy, the outcomes in the setting of prior chemoradiation are less well documented. We present our experience with microvascular reconstruction in a unique cohort of patients previously treated with concomitant hyperfractionated radiation and intra-arterial chemotherapy (HYPERRADPLAT). Despite the observation in prior studies of minimal vessel damage in this setting, the hypothesis of this study is that in the late setting of most salvage surgical therapy, either for recurrence or osteoradionecrosis, a different, progressive level of vessel injury may be encountered. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral academic medical center practice. SUBJECTS AND METHODS: Eighty-four patients received primary treatment for advanced head and neck squamous cell carcinoma with HYPERRADPLAT. Of these, 8 patients (10%) underwent free tissue transfer reconstruction and a total of 11 free flaps. RESULTS: Wound breakdown, fistula, or both occurred postoperatively in 50% (4/8) of these patients. No complications of the venous anastomoses occurred. Fifty percent (4/8) of patients required return to surgery for arterial failure due to thrombosis of the anastomosis. Two cases of these flaps could not be salvaged. CONCLUSION: Microvascular reconstruction following HYPERRADPLAT appears to result in a high number of arterial related complications. This experience implies an important delayed treatment effect of HYPERRADPLAT occurs upon recipient arteries. The manner in which this effect may occur in recipient arteries in the setting of more conventional chemoradiation requires further study.