Zenker's peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker's diverticulum: a multicenter retrospective comparison.

BACKGROUND: Treatment of Zenker's diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM. METHODS: Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker's diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events. RESULTS: 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P < 0.05). CONCLUSIONS: There was no difference in outcomes between the three treatment approaches for symptomatic Zenker's diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.

Primary diffuse large B-cell lymphoma of the major salivary glands: Increasing incidence and survival.

BACKGROUND: Diffuse Large B-Cell Lymphoma (DLBCL) of the major salivary glands is a rare high-grade malignancy that often presents with vague symptoms. This study aimed to evaluate its incidence and prognosis on a population level. METHODS: The Surveillance, Epidemiology, and End Results database was queried for cases of major salivary gland DLBCL. RESULTS: 896 patients had DLBCL affecting the parotid gland (78.3%) or submandibular gland (19.8%). The incidence was increasing at 1.5% (P = 0.005) per year from 1973 to 2016. 24.4% of patients underwent parotidectomy, 16% had biopsy, and the remaining provided no details of diagnostic method. Five-year disease-specific survival increased from 59.8% to 84.0%. Late-stage disease (HR = 1.7, P = 0.003) and female sex (HR = 2.1, P = 0.018) were associated with increased risk of mortality. CONCLUSION: Despite the rising incidence of major salivary gland DLBCL, chemotherapy and radiation treatment has resulted in increasingly favorable survival outcomes. The otolaryngologist - head and neck surgeon continues to play a critical role in establishing the diagnosis of salivary gland DLBCL.

Carcinoma ex pleomorphic adenoma: A review of incidence, demographics, risk factors, and survival.

PURPOSE: Identify variables that are independent predictors of survival in carcinoma ex pleomorphic adenoma (CXPA) of the major salivary glands using a population-based database and evaluate the incidence and management strategies for this rare malignancy. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for all cases of major salivary gland CXPA from 1973 to 2015. RESULTS: Of the 619 patients identified, the parotid gland was the most common site of involvement (76.9%, 476/619). The reported incidence of CXPA has risen in the past decade (2005-2015, 0.24 to 0.63 per 1,000,000). The 2-year and 5-year disease-specific survival (DSS) rates were 90.3% and 80.4%, respectively. On univariate analysis, facial nerve sacrifice was not a statistically significant predictor of survival (HR = 1.213, 95% CI [0.588-2.058], P = 0.602). Patients with a tumor size >4 cm, multiple positive lymph nodes, and distant metastatic disease had a 2 to 4-fold statistically significant increase in mortality using a multivariate analysis. Statistical significance was not demonstrated in the DSS of patients who underwent partial versus total parotidectomy procedures. CONCLUSIONS: CXPA is a rare salivary malignancy that has a reported increased incidence in the last decade. Tumor size >4 cm, multiple positive lymph nodes, and distant metastatic disease are predictors of disease-specific mortality. Further research should be conducted to improve early detection and survival strategies for this salivary cancer. LEVEL OF EVIDENCE: 4.

Racial and Ethnic Disparities in Travel for Head and Neck Cancer Treatment and the Impact of Travel Distance on Survival.

BACKGROUND: Patients who travel a long distance (≥50 miles) for cancer care have improved outcomes. However, to the authors' knowledge, the prevalence of long travel distances for treatment by patients with head and neck squamous cell carcinoma (HNSCC), and the effect of travel distance on overall survival (OS), remains unknown. METHODS: The authors used the National Cancer Data base from 2004 through 2013 to identify patients with HNSCC undergoing definitive treatment. Travel distance for treatment was categorized as short (<12.5 miles), intermediate (12.5-49.9 miles), and long (50-249.9 miles). The primary outcome, OS, was evaluated using Cox shared-frailty modeling. A secondary outcome, factors associated with intermediate and long travel distances, was evaluated using multivariable hierarchical logistic regression. RESULTS: Among 118,000 patients with HNSCC, 62,753 (53.2%), 40,644 (34.4%), and 14,603 (12.4%) patients, respectively, traveled short, intermediate, and long distances for treatment. After adjusting for relevant covariates, long travel distance was associated with treatment at academic and high-volume centers. Patients of black race, of Hispanic ethnicity, with Medicaid insurance, and who were treated with nonsurgical treatment were less likely to travel long distances for treatment (P<.001). Traveling a long distance for treatment was associated with improved OS on multivariable analysis (adjusted hazard ratio, 0.93; 95% confidence interval, 0.89-0.96) compared with a short distance. CONCLUSIONS: Traveling a long distance for HNSCC treatment is associated with improved survival, especially for patients receiving nonsurgical management. Racial and ethnic disparities in travel for HNSCC treatment exist. As regionalization of care continues, future work should identify and address reasons for racial and ethnic disparities in travel that may prevent access to care at high-volume facilities. Cancer 2018;000:000-000. © 2018 American Cancer Society.

Is imaging of the brain necessary at diagnosis for cutaneous head and neck melanomas?

OBJECTIVE: To evaluate the frequency of brain metastasis at the time of diagnosis for patients with cutaneous head and neck melanoma (CHNM). METHODS: Patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 2010 to 2014 based on a diagnosis of CHNM using ICD O-3 histology codes and primary site location documentation. Patients were also included if they had a "yes" or "no" documented in the "Mets at Dx-Brain" category. RESULTS: In this study, 46 out of 19,066 (0.2%) patients diagnosed with CHNM presented with brain metastasis at diagnosis. Of the 19,066 patients, 14,124 (74.1%) were male. Caucasian race was noted in 18,299 cases (96.0%). 16.8% of patients with AJCC 7 Stage IV/M1 CHNM had brain metastasis at the time of diagnosis as compared to 0% in Stage I-III/M0 lesions (p < .001). CONCLUSIONS AND RELEVANCE: The 2018 NCCN guidelines recommend healthcare providers consider ordering a baseline brain MRI for patients with stage IIIC or greater melanoma. This study demonstrates the very low frequency of brain metastasis at time of diagnosis in patients with CHNM and supports the NCCN recommendations demonstrating that only very advanced stages of CHNM require baseline brain imaging.

Adherence to National Comprehensive Cancer Network guidelines for time to initiation of postoperative radiation therapy for patients with head and neck cancer.

BACKGROUND: Adherence to evidence-based treatment guidelines has been proposed as a measure of cancer care quality. The objective of this study was to determine the rate and predictors of care that does not adhere to National Comprehensive Cancer Network guidelines regarding commencing postoperative radiation therapy (PORT) within 6 weeks of surgery for patients with head and neck squamous cell carcinoma (HNSCC). METHODS: The National Cancer Data Base was reviewed from 2006 to 2014, and patients with HNSCC who underwent curative-intent surgery followed by PORT were identified. Multivariable logistic regression analysis was used to determine the factors associated with nonadherence to guidelines regarding the timing of initiating PORT. RESULTS: In total, 47,273 patients were included in the study. 55.7% of patients (26,340/47,273) failed to commence PORT within 6 week of surgery. The percentage of patients who failed to initiate PORT within 6 week of surgery increased over time. On multivariable analysis, the factors associated with failure to initiate timely, guideline-adherent PORT included black race, public insurance [Medicare, Medicaid] or uninsured status, lower levels of education, increased severity of comorbidity, increased postoperative length of stay, 30-day unplanned hospital readmission, treatment at an academic medical center, and the receipt of surgery and PORT at different facilities. CONCLUSIONS: Over 50% of patients with HNSCC who undergo surgery and PORT receive care that does not adhere to National Comprehensive Cancer Network guidelines with regard to initiating PORT within 6 weeks of surgery. Sociodemographic, oncologic, treatment, and hospital factors are all associated with failure to receive guideline-directed care and should be explored in future studies. Cancer 2017;123:2651-60. © 2017 American Cancer Society.

Effect of postoperative radiotherapy on survival for surgically managed pT3N0 and pT4aN0 laryngeal cancer: Analysis of the National Cancer Data Base.

BACKGROUND: The current study was conducted to determine the effect of postoperative radiotherapy (PORT) on overall survival in patients with surgically managed pT3-T4aN0 laryngeal squamous cell carcinoma (SCC). METHODS: A review of the National Cancer Data Base from 2004 through 2013 was performed. Patients with surgically managed pT3-4aN0 laryngeal SCC with negative surgical margins were included. Univariable and multivariable Cox regression analyses were used to determine factors associated with survival. RESULTS: A total of 1460 patients were included, 46.2% of whom had pT3N0 disease (674 patients) and 53.8% of whom had pT4aN0 disease (786 patients). Approximately 72.0% of the patients with pT3N0 disease (485 patients) and 50.1% of the patients with pT4aN0 disease (394 patients) received PORT. PORT was not found to be associated with improved overall survival on univariable analysis for patients with pT3N0 disease (hazard ratio [HR], 0.84; 95% confidence interval [95% CI], 0.62-1.14), but was for patients with pT4aN0 disease (HR, 0.57; 95% CI, 0.45-0.71). For patients with pT3N0 SCC of the larynx, in a multivariable Cox regression analysis adjusting for age >65 years, severity of comorbidities, larynx subsite, extent of laryngectomy, and number of lymph nodes removed, PORT was not found to be associated with improved survival (adjusted HR, 0.88; 95% CI, 0.64-1.21). For patients with pT4aN0 disease, the administration of PORT was associated with improved survival on multivariable analysis adjusting for age >65 years, severity of comorbidities, larynx subsite, number of lymph nodes removed, and type of hospital (adjusted HR, 0.58; 95% CI, 0.46-0.73). CONCLUSIONS: For patients with surgically managed pT3N0 laryngeal SCC with negative margins, PORT does not appear to be associated with improved survival. Despite a survival benefit, nearly 50% of patients with pT4aN0 laryngeal SCC and negative surgical margins do not receive standard-of-care PORT. Cancer 2017;123:2248-2257. © 2017 American Cancer Society.

Effect of time to initiation of postoperative radiation therapy on survival in surgically managed head and neck cancer.

BACKGROUND: The objective of this study was to determine the effects of National Comprehensive Cancer Network (NCCN) guideline-adherent initiation of postoperative radiation therapy (PORT) and different time-to-PORT intervals on the overall survival (OS) of patients with head and neck squamous cell carcinoma (HNSCC). METHODS: The National Cancer Data Base was reviewed for the period of 2006-2014, and patients with HNSCC undergoing surgery and PORT were identified. Kaplan-Meier survival estimates, Cox regression analysis, and propensity score matching were used to determine the effects of initiating PORT within 6 weeks of surgery and different time-to-PORT intervals on survival. RESULTS: This study included 41,291 patients. After adjustments for covariates, starting PORT >6 weeks postoperatively was associated with decreased OS (adjusted hazard ratio [aHR], 1.13; 99% confidence interval [CI], 1.08-1.19). This finding remained in the propensity score-matched subset (hazard ratio, 1.21; 99% CI, 1.15-1.28). In comparison with starting PORT 5 to 6 weeks postoperatively, initiating PORT earlier was not associated with improved survival (aHR for ≤ 4 weeks, 0.93; 99% CI, 0.85-1.02; aHR for 4-5 weeks, 0.92; 99% CI, 0.84-1.01). Increasing durations of delay beyond 7 weeks were associated with small, progressive survival decrements (aHR, 1.09, 1.10, and 1.12 for 7-8, 8-10, and >10 weeks, respectively). CONCLUSIONS: Nonadherence to NCCN guidelines for initiating PORT within 6 weeks of surgery was associated with decreased survival. There was no survival benefit to initiating PORT earlier within the recommended 6-week timeframe. Increasing durations of delay beyond 7 weeks were associated with small, progressive survival decrements. Cancer 2017;123:4841-50. © 2017 American Cancer Society.

Esophageal adenocarcinoma and urothelial carcinoma orbital metastases masquerading as infection.

Orbital metastases can masquerade as other orbital processes. We present two cases of orbital metastases, the first being the first reported adenocarcinoma of the esophagus presenting as an orbital metastasis prior to the primary being known, and the other as the first urothelial carcinoma to present as orbital cellulitis. The first patient presented with left upper eyelid pain. CT scan identified a superolateral subperiosteal fluid collection without concomitant sinus disease, which was drained in the operating room. Two weeks later repeat CT scan showed recurrent orbital subperiosteal fluid. It was drained and a biopsy showed necrotic adenocarcinoma. The second case presented with a painless right proptosis, decreased vision, and globally decreased ocular motility 3 days after bladder resection for urothelial carcinoma. CT scan demonstrated pan sinusitis with a soft tissue mass in the apex of the right orbit with extension through the superior orbital fissure. After no improvement on antibiotics endoscopic drainage was performed. Pathology revealed metastatic urothelial carcinoma within the orbital fat.

Basaloid squamous cell carcinoma of the head and neck: location means everything.

BACKGROUND AND OBJECTIVES: Head and neck basaloid squamous cell carcinoma (BSCC) is increasingly recognized as a malignancy with an evolving duel behavior. Our objective was to describe the site-specific presentation and prognosis of head and neck BSCC in comparison to conventional-type squamous cell carcinoma (SCC) using population-based data. METHODS: A total of 1,083 BSCC patients and 66,929 conventional-type SCC patients, diagnosed between 2000 and 2008, were identified using the Surveillance, Epidemiology, and End Results database. Clinicopathologic data were compared using χ(2) analysis. Kaplan-Meier analysis was used to estimate site-stratified disease-specific survival (DSS). BSCC's independent effect on DSS was assessed by multivariable regression analysis. RESULTS: The oropharynx (61.9%) was the most frequent BSCC site; compared to the larynx (33.3%) in conventional-type SCC. More BSCC patients presented with advanced-stage disease (78.4% vs. 60.1%, P < 0.001). On multivariable analysis, DSS was significantly better in the BSCC group when tumors were located in the oropharynx. Conversely, DSS was worse for BSCC patients with laryngeal tumors. DSS was similar among patients with sinonasal, nasopharyngeal, hypopharyngeal, and oral tumors. CONCLUSIONS: BSCC's propensity for advanced-stage presentation was confirmed in this study. However, BSCC appears to carry a paradoxically similar, or better, prognosis compared to conventional-type SCC in most cases.

Comparison of survival rates between papillary and follicular thyroid carcinomas among 36,725 patients.

OBJECTIVES: We sought to determine the impact of histologic subtype on disease-specific survival (DSS) in cases of differentiated thyroid carcinoma. METHODS: Adult patients with papillary thyroid carcinoma (PTC) or follicular thyroid carcinoma (FTC) were identified from the Surveillance, Epidemiology, and End Results (SEER) Database for the years 1988 to 2003. The patients were grouped according to tumor type (PTC or FTC), and their age, gender, tumor size and extension, and nodal or distant metastases were recorded. The Kaplan-Meier method was used to compare DSS rates on the basis of histologic subtype. RESULTS: We identified 36,725 patients, of whom 77% were female and 23% were male; PTC was diagnosed in 91% of patients, and FTC in the remaining 9%. Patients with PTC were younger, were more likely to be female, and had smaller tumors with higher rates of regional metastases but fewer distant metastases than FTC patients (p < 0.0001 for all). When the cases were stratified by stage, FTC patients had a worse DSS than did PTC patients for all stages - except for stages III/IVA and IVC among patients more than 45 years of age. CONCLUSIONS: Follicular thyroid carcinoma portends a worse DSS than does PTC, even when the cases are controlled for stage. Consideration should be given to individual staging for these subtypes of differentiated thyroid carcinoma.

Spindle cell carcinoma of the upper aerodigestive tract: an analysis of 341 cases with comparison to conventional squamous cell carcinoma.

OBJECTIVES: We sought to better characterize spindle cell carcinoma (SpCC) of the upper aerodigestive tract, a rare and aggressive variant, through comparison of a large cohort of head and neck SpCCs against a cohort of conventional head and neck squamous cell carcinoma (SCC) patients. METHODS: We compared epidemiologic and clinicopathologic characteristics of 341 SpCCs with 67 882 SCCs of the head and neck, drawing data from the SEER national database. We also compared disease-specific survivals (DSS) for SpCC and SCC based on tumor site and mode of treatment. RESULTS: SpCCs were predominantly laryngeal (46.4%, P < .001) and were more likely to be high grade (P > .001). SpCCs were also more likely than SCCs to present at an early stage (P < .001 to P < .05). Rates of distant metastasis were similar between the tumor types. DSS was similar between SpCCs and SCCs, although site-specific survival rates were higher for SpCCs of the larynx (P = .017) and lower for those of the oral cavity (P = .008). CONCLUSION: SpCC of the head and neck is more likely than SCC to present at an early stage, with fewer nodal metastases. Survival rates appear to depend on anatomic site as well.

Melanoma of the ear: results of a cartilage-sparing approach to resection.

Melanoma of the ear is often treated by composite resection of the skin and cartilage and, occasionally, by total auriculectomy. This review analyzes the oncologic, functional, and esthetic results of cartilage-sparing wide local excision for melanoma of the ear. This retrospective study reviewed patients with ear melanoma treated between 1997 and 2002. All patients were treated with cartilage-sparing wide local excision, and ears were reconstructed with skin grafts and/or local flaps. The majority of patients were men (16/18 patients) who ranged in age from 42 to 82 years. The most common sites of occurrence were the helical rim (7/18 patients) and the earlobe (6/18 patients). The average depth of invasion was 2.02 mm (range 0.4-6.0 mm). Sentinel lymph node biopsy was performed in 13 cases, of which only one was positive. The local control rate was 100 %, overall survival was 72 % (13/18 patients), and disease-specific survival was 89 % (16/18 patients). Average follow-up was 30.5 months (range 1-61). The rates for local control, overall survival, and disease-specific survival were excellent. These data indicate that for the majority of ear melanomas, cartilage-sparing wide local excision is an acceptable means of treatment.

Cervical lymph node metastasis and papillary thyroid carcinoma: does the compartment involved affect survival? Experience from the SEER database.

PURPOSE: Determine how the location of cervical lymph node metastases affects survival in papillary thyroid carcinoma (PTC) patients. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients diagnosed with PTC. Disease specific survival (DSS) was estimated according to node status and extent of cervical involvement by Kaplan-Meier analysis. Hazard ratios with 95% confidence intervals to estimate the risk of death were calculated using Cox multivariable regression analysis. RESULTS: We identified 11,453 PTC cases in the SEER database with complete data describing the absence or location of positive nodes. Of these, 40.1% were node-positive; 56.6%, 34.1%, and 9.3% of node-positive patients had metastasis to the central, lateral, and mediastinal compartments, respectively. DSS was worse for node-positive patients age ≥ 45 with lateral/mediastinal involvement relative to those with central metastasis (P<0.001). Node metastasis did not significantly affect survival for patients age <45, regardless of location. CONCLUSIONS: Patients age ≥ 45 with lateral/mediastinal cervical involvement have an increased risk of death from PTC in the initial years after diagnosis. Future studies are needed to elucidate optimal treatment and surveillance protocols for these patients, and also to ascertain the effect of cervical node location on long-term survival and disease-recurrence.

Head and neck soft tissue sarcomas: unique lack of significance of synchronous node metastases.

BACKGROUND: Regional lymph node metastasis (RLNM) has been identified as a poor prognostic indicator for patients with soft tissue sarcomas (STS) of the extremities and trunk. However, the effect of RLNM on survival in patients with STS of the head and neck (HN) has not previously been explored. Our objective was to analyze RLNM as a prognostic indicator in HN-STS, and to compare this cohort to patients with STS of non-head and neck regions (NHN-STS). METHODS: STS patients were identified using the Surveillance, Epidemiology, and End Results database. Only patients without concurrent distant metastasis who underwent surgery and pathologic node staging were included. Patients were categorized based on tumor location: (1) HN-STS and (2) NHN-STS. Clinicopathologic data and disease-specific survival (DSS) were compared between node-negative and node-positive patients in each group. RESULTS: We identified 183 cases of node-positive STS (25 HN-STS, 158 NHN-STS). In the HN-STS group, pN1 status was not associated with any of the clinicopathologic factors that we analyzed. DSS was similar among pN0 and pN1 patients with HN-STS (P = 0.59); however, in the NHN-STS group, node-positivity was significantly associated with disease-specific mortality (P < 0.001). CONCLUSIONS: Synchronous RLNM may not affect DSS in patients HN-STS. Node-positive patients with HN-STS appear to be unique from those with NHN-STS.

Impact of greater auricular nerve sacrifice during parotidectomy on quality of life.

BACKGROUND: Greater auricular nerve (GAN) sacrifice can alter sensation; however, the impact on quality of life (QoL) is unclear. OBJECTIVE: The aim of this study was to evaluate patients' QoL following GAN sacrifice versus preservation. METHODS: Patients who underwent parotidectomy from 2010 to 2019 at a single institution completed two QoL surveys. Results between GAN-sacrificed versus preserved cohorts and short (≤ 1 year) versus long-term (> 1 year) follow-up were compared. RESULTS: Of 404 patients, 67 with known GAN status completed the surveys. GAN-sacrificed patients more frequently experienced sensation loss of the lobule and concha than GAN-preserved patients (P = .042 and P = .041, respectively). Interference with daily activities or amount of regained sensation was not different based on GAN status. Short-term follow-up patients had a higher number of symptoms and affected areas than long-term follow-up patients (P = .014 and P = .002, respectively). CONCLUSION: GAN sacrifice leads to sensation loss of the lobule and concha; however, it does not significantly impair QoL.

Neoadjuvant presurgical PD-1 inhibition in oral cavity squamous cell carcinoma.

Oral cavity squamous cell carcinoma (OCSCC) is a prevalent surgically treated subset of head and neck cancer with frequent recurrence and poor survival. Immunotherapy has demonstrated efficacy in recurrent/metastatic head and neck cancer. However, whether antitumor responses could be fostered by neoadjuvant presurgical immunotherapy remains unclear. Using a Simon's two-stage design, we present results of a single-arm phase-II trial where 12 patients with stage II-IVA OCSCC received 3 to 4 biweekly doses of 3 mg/kg nivolumab followed by definitive surgical resection with curative intent. Presurgical nivolumab therapy in this cohort shows an overall response rate of 33% (n = 4 patients; 95% CI: 12%-53%). With a median follow up of 2.23 years, 10 out of 12 treated patients remain alive. Neoadjuvant nivolumab is safe, well-tolerated, and is not associated with delays in definitive surgical treatment in this study. This work demonstrates feasibility and safety for incorporation of nivolumab in the neoadjuvant setting for OCSCC (ClinicalTrials.gov: NCT03021993).

Transcutaneous Electrical Stimulation Therapy in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the treatment efficacy of transcutaneous electrical nerve stimulation (TENS) in patients with obstructive sleep apnea (OSA). DATA SOURCES: Primary studies were identified though PubMed, Scopus, OVID, and Cochrane Library. REVIEW METHODS: Systematic review was conducted by querying databases for articles published through July 2019. The search identified randomized controlled trial, randomized comparison, or observational studies pertaining to TENS treatment for OSA. Meta-analysis was performed on pre- and posttreatment apnea-hypopnea index (AHI), mean oxygen saturation (SaO2), lowest oxygen saturation (LSAT), and arousal index (AI). RESULTS: Literature search identified 10 studies that reported sufficient outcome measures to be considered for analysis. A total of 198 patients were identified with a mean age of 50.9 years with a male to female ratio of 1.6:1. Average body mass index (BMI) of the cohort was 29.8 kg/m2. Treatment with TENS demonstrated reduction in AHI by 12.9 points (95% confidence interval, -22.3 to -3.43; P = .008). The mean differences in SaO2, LSAT, and AI did not reach statistical significance. CONCLUSION: The TENS treatment of upper airway dilator muscles resulted in reduction of AHI in patients with OSA. However, its effects on SaO2, LSAT, and AI were equivocal. Its impact on patients' quality of life could not be assessed due to heterogeneity in outcome measures. Future randomized controlled trials with generalizable standardized outcome measures are needed to assess the efficacy and compliance of TENS.

Incidence and survival trends of parotid malignancies over 42 years.

BACKGROUND: There is a paucity of information regarding the incidence and survival of parotid malignancies over time. METHODS: The Surveillance, Epidemiology, and End Results population-based cancer registry was queried for parotid malignancies from 1973 to 2015. RESULTS: The age-adjusted incidence of parotid malignancies has increased by 58.1% (7.87-12.44 per 1 000 000). Analysis of histologic type revealed an increased annual percent change (APC) of acinar cell carcinoma (1.38) and squamous cell carcinoma (1.58), but decreased APC of adenoid cystic carcinoma (-1.63) and adenocarcinoma NOS (-0.86) (P < .05). The disease-specific survival of mucoepidermoid carcinoma, adenocarcinoma NOS, and squamous cell carcinoma significantly improved (P < .05) over time. CONCLUSION: The incidence of parotid cancer is rising steadily since 1973, while the incidence of overall head and neck cancer has decreased. Further research is necessary to understand the etiology, risk factors, and pathophysiology of parotid cancer to curb its rising incidence. LEVEL OF EVIDENCE: 4.