High-Risk Cutaneous Squamous Cell Cancer of the Head and Neck: Risk Factors for Recurrence and Impact of Adjuvant Treatment.

OBJECTIVES: The behavior of advanced cutaneous squamous cell carcinoma of the head and neck (HNcSCC) remains poorly understood, with highly variable risk factors and a paucity of data for adjuvant treatment. The objective of our study was to review the oncologic outcomes of patients with high-risk HNcSCC treated with surgery and to identify risk factors for treatment failure. STUDY DESIGN: Retrospective cohort study. METHODS: Retrospective review of patients treated for HNcSCC with definitive surgery involving at least parotidectomy and neck dissection at a tertiary care academic center from 2011 to 2017 was conducted. The primary outcome was disease-free survival (DFS). RESULTS: One-hundred four patients with a median age of 68 years (range = 42-91 years) were reviewed. Twenty-one patients were treated with surgery alone, 45 patients underwent adjuvant radiotherapy (RT), and 38 patients underwent adjuvant chemoradiotherapy (CRT). The 2-year DFS for patients treated with surgery, surgery + RT, and surgery + CRT were 71%, 65%, and 58%, respectively, with no significant difference between the groups (P = .70). On multivariate analyses, tumor size (P = .006) and perineural invasion (PNI, P = .04) independently predicted recurrence. The addition of chemotherapy did not appear to improve DFS, neither for those patients with extranodal extension and/or positive margins (P = .93) nor for the entire cohort (P = .43). CONCLUSIONS: Advanced HNcSCC has a high recurrence rate despite adjuvant treatment. Tumor size >2 cm was a strong independent risk factor for recurrence. Out of the traditional mucosal HNcSCC risk factors, PNI was most strongly associated with worse DFS. There was no observed survival benefit to the addition of chemotherapy. LEVEL OF EVIDENCE: 4. Laryngoscope, 131:E136-E143, 2021.

False-positive reverse transcriptase polymerase chain reaction screening for SARS-CoV-2 in the setting of urgent head and neck surgery and otolaryngologic emergencies during the pandemic: Clinical implications.

BACKGROUND: No reports describe falsepositive reverse transcriptase polymerase chain reaction (RT-PCR) for novel coronavirus in preoperative screening. METHODS: Preoperative patients had one or two nasopharyngeal swabs, depending on low or high risk of viral transmission. Positive tests were repeated. RESULTS: Forty-three of 52 patients required two or more preoperative tests. Four (9.3%) had discrepant results (positive/negative). One of these left the coronavirus disease (COVID) unit against medical advice despite an orbital abscess, with unknown true disease status. The remaining 3 of 42 (7.1%) had negative repeat RT-PCR. Although ultimately considered falsepositives, one was sent to a COVID unit postoperatively and two had urgent surgery delayed. Assuming negative repeat RT-PCR, clear chest imaging, and lack of subsequent symptoms represent the "gold standard," RT-PCR specificity was 0.97. CONCLUSIONS: If false positives are suspected, we recommend computed tomography (CT) of the chest and repeat RT-PCR. Validated serum immunoglobulin testing may ultimately prove useful.

Update on anterior skull base reconstruction.

PURPOSE OF REVIEW: Anterior skull base reconstruction has rapidly evolved over the past few years as endoscopic approaches to resect tumors in this region have become more established. The present review evaluates the robust amount of new literature on this topic over the past year with particular attention to minimally invasive methods for reconstruction. RECENT FINDINGS: Although vascularized local flaps remain the mainstay reconstructive choice when available for the anterior skull base, innovative techniques for all types of reconstruction, ranging from free grafts to free flaps continue to emerge. SUMMARY: Because of the unique challenges and wide variety of options available to repair the anterior skull base with the goal to prevent or treat cerebrospinal fluid leaks, surgical expertise and experience in this field is of utmost importance.

Meta-analysis comparing outcomes of different transoral surgical modalities in management of oropharyngeal carcinoma.

BACKGROUND: Optimal transoral surgical modality for oropharyneal carcinoma is currently unclear. Transoral laser surgery (TLS), transoral robotic surgery (TORS), and conventional direct transoral (DT) oropharyngectomy are the main current transoral surgical modalities for oropharyngeal carcinoma. METHODS: MEDLINE was systematically searched through PubMed. Reference lists were reviewed. Random-effects models were used to combine studies within each group. Tests for heterogeneity were used to explore difference in effect size between groups in subgroup analysis. RESULTS: Nine studies (404 patients) in TORS arm, five studies (498 patients) in TLS arm, and three studies (335 patients) in DT arm were included. Early T classification (T1-T2) for TORS and DT were higher compared to TLS group (P < .001). There was no significant difference between groups in the rate of invaded margin, post-operative oropharyngeal bleeding, temporary tracheotomy, and gastrostomy dependence. CONCLUSION: The available data do not yet provide clear evidence of superiority of any one modality.

Lymphoepithelial carcinoma of the major salivary glands: Predictors of survival in a non-endemic region.

INTRODUCTION: Lymphoepithelial carcinoma (LEC) of the salivary glands is extremely rare worldwide, with studies limited to small case reports and case series from endemic areas (Southern China, Arctic Inuits) and strong association to Epstein Barr Virus (EBV). Studies on non-endemic regions are even more limited given the reality of only sporadic cases in these areas. Using the National Cancer Database (NCDB), we present the largest study on salivary LEC from a non-endemic region, the United States. METHODS: A retrospective review of the NCDB from 1998-2012 for LEC of the major salivary glands was performed. Demographic and clinical variables were extracted for analysis. Multivariate COX regression was used to assess predictors of survival. RESULTS: Two hundred and thirty-eight cases were identified (0.66% of all salivary cancers). Median age at diagnosis was 62 with peak incidence in ages 50-70. Most patients were Caucasian (81.2%), without gender preference. Regional metastasis was common (45.1%) and did not significantly impact survival. Distant metastasis was rare (2%). Overall survival (OS) at 5- and 10 years was 77% and 56%. Surgery and radiotherapy significantly showed better survival outcomes than surgery alone (p<0.001). Age >62, advanced stage, and dual modality therapy were significant predictors of survival in multivariate analysis. CONCLUSION: Lymphoepithelial carcinoma in the US mostly affects an older, Caucasian demographic. Regional metastasis is common and survival is fair at 5- and 10 years. Surgery and radiation are recommended for early and advanced disease stages. Age, stage, and therapy are significant predictors of survival outcomes.

IL-1 Receptor Antagonist Inhibits Early Granulation Formation.

PURPOSE: Using a functional model of airway granulation tissue in laryngotracheal stenosis, we investigated changes in histopathology and inflammatory markers within granulation tissue in response to an interleukin-1 receptor antagonist (IL-1Ra). This study allows us to further delineate the immune response to wound healing and potentially identify treatment markers. METHODS: Laryngotracheal complexes (LTCs) of donor mice underwent direct airway injury. The LTCs were transplanted into subcutaneous tissue of recipient mice in 2 groups: IL-1Ra treated and untreated. The IL-1Ra-treated arm received daily intraperitoneal injections of IL-1Ra for 3 weeks. The LTCs were then harvested. Granulation formation was measured. The mRNA expression of transforming growth factor (TGF) beta and IL-1 was quantified using real-time reverse transcript polymerase chain reaction. RESULTS: There were statistically significant differences in lamina propria thickness. There were no statistically significant changes in mRNA expression of TGF-ß and IL-1ß between the treated and untreated specimens. CONCLUSIONS: Using a previously described murine model, we delineate inflammatory markers that can be targeted for potential therapy. While the levels of inflammatory markers do not change significantly, the lamina propria thickness shows that the effects of IL-1 have been inhibited. The early use of the IL-1Ra will inhibit the efficacy of IL-1 in the inflammatory cascade and can prevent early granulation formation.

Association of Clinical Risk Factors and Postoperative Complications With Unplanned Hospital Readmission After Head and Neck Cancer Surgery.

Importance: Unplanned hospital readmission is costly and in recent years has become a focus of health care legislation intended to reduce health care expenditures. Greater understanding of which perioperative complications are associated with hospital readmission after surgery for head and neck cancer is needed to reduce unplanned readmissions. Objective: To determine which clinical risk factors and complications are associated with 30-day unplanned readmission after surgery for malignant neoplasms of the head and neck. Design, Setting, and Participants: This retrospective longitudinal claims analysis included data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from January 1, 2012, to December 31, 2014. Patients undergoing surgery for malignant tumors of the head and neck were included; those with a primary diagnosis of thyroid malignant disease and those undergoing free autologous tissue transfer were excluded. Main Outcomes and Measures: Clinical risk factors and complications were analyzed for association with unplanned hospital readmission using multivariable regression analysis. Statistical significance was determined using P < .05. Results: A total of 7605 patients (5007 men [65.8%]; mean [SD] age, 64.2 [0.2] years) were identified and included for analysis. Overall, 1472 complications occurred in 912 cases. Three hundred eighty-eight patients (5.1%) had an unplanned readmission, which was lower than the previously published overall readmission rate for noncardiac surgical procedures in the NSQIP (6.8%). Clinical factors that were independently associated with unplanned readmission were age (adjusted odds ratio [AOR], 1.12; 95% CI, 1.03-1.22), diabetes (AOR, 1.60; 95% CI, 1.01-2.43), preoperative dyspnea at rest (AOR, 2.89; 95% CI, 1.40-5.55) and with moderate exertion (AOR, 1.48; 95% CI, 1.01-2.11), long-term use of corticosteroids (AOR, 2.45; 95% CI, 1.63-3.58), disseminated cancer (AOR, 1.57; 95% CI, 1.14-2.20), and a contaminated wound (AOR, 2.05; 95% CI, 1.05-3.7). When specific complications were examined, superficial incisional surgical site infection (SSI) (AOR, 2.02; 95% CI, 1.14-3.40), deep incisional SSI (AOR, 2.57; 95% CI, 1.26-5.03), organ or space SSI (AOR, 13.27; 95% CI, 6.57-26.61), wound disruption (AOR, 3.58; 95% CI, 1.95-6.31), pneumonia (AOR, 3.39; 95% CI, 1.88-5.96), deep vein thrombosis (AOR, 5.60; 95% CI, 1.90-15.25), pulmonary embolism (AOR, 20.72; 95% CI, 7.86-55.68), urinary tract infection (AOR, 2.66; 95% CI, 1.00-6.34), stroke (AOR, 12.42; 95% CI, 3.99-36.50), sepsis (AOR, 2.64; 95% CI, 1.27-5.30), and septic shock (AOR, 4.12; 95% CI, 1.10-15.81) were all associated with 30-day unplanned hospital readmission. Conclusions and Relevance: This study evaluated clinical factors and postoperative complications to determine which ones were associated with 30-day unplanned hospital readmission among patients undergoing surgery for malignant tumors of the head and neck. Further understanding of which complications are associated with unplanned readmission after head and neck surgery will allow for improved risk stratification and development of postoperative care protocols to reduce unplanned hospital readmission.

Reoperation following Adult Tonsillectomy: Review of the American College of Surgeons National Surgical Quality Improvement Program.

OBJECTIVE: Tonsillectomy remains a common procedure in adults; however, there are few population-level data evaluating risk factors for reoperation. STUDY DESIGN: Retrospective review of national database. SETTING: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005-2013. SUBJECTS AND METHODS: The ACS-NSQIP was queried for patients undergoing tonsillectomy ± adenoidectomy as their primary procedure (CPT 42821 or 42826). Demographic information and indications were reviewed along with complications and reoperation rates. RESULTS: In total, 12,542 cases met inclusion criteria. Patients were predominantly female (66.4%) and white (70.8%), with mean age of 30 ± 12 years (range: 16-90+). Thirty-day mortality was 0.03%, and 4.8% of patients experienced at least 1 complication, including reoperation (3.6%). Risk of complications was associated with male sex (P < .0001; odds ratio [OR], 1.7), diabetes (P = .0002; OR, 2.1), and presence of a bleeding disorder (P = .002; OR, 3.2). Risk factors for reoperation were similar, in addition to older age (P = .002; OR, 0.986). Complications other than reoperation were correlated with older age (P = .001; OR, 1.02) and diabetes (P = .001; OR, 2.59). Procedures were done mostly for infectious/inflammatory (70.4%) versus hypertrophic (16.4%) indications. Indication had no significant effect on the rate of reoperation. Most reoperations occurred after postoperative day 1 (86%; mean, 6.4 ± 4.2 days). CONCLUSION: This review of a large validated surgical database provides an overview of the rates of, and risk factors for, complications and reoperations following tonsillectomy in the adult population.