Analysis of Opioid Prescribing Trends Following Thyroidectomy and Parathyroidectomy Before and After the 2021 American Academy of Otolaryngology-Head and Neck Surgery Opioid Prescribing Clinical Practice Guidelines.

OBJECTIVE: To evaluate the trends in opioid and nonopioid prescribing for thyroidectomy and parathyroidectomy before and after the publication of guidelines by the American Academy of Otolaryngology-Head and Neck Surgery in April 2021. STUDY DESIGN: Retrospective. SETTING: Eighty-three health care organizations in the United States that contribute to the TriNetX database. METHODS: Deidentified patient data were retrieved from the TriNetX. Patients who were prescribed either opioids or nonopioid analgesic within 1 to 5 days following thyroid surgery and parathyroidectomy were included. Evaluation of the prescription trends was performed by interrupted time series analysis in Statistical Analysis System 9.4 with significance set at P < .05 to assess trends before and after the new opioid prescription guidelines. RESULTS: For thyroid surgery, there was an immediate effect of the guideline change indicated by a 3.3% decrease in the opioid prescription trend (P = .03) and a significant increase in nonopioid use of overtime by 0.13% every 3 months (P < .0001). The opioid prescription trend following parathyroidectomy significantly decreased over time by 0.28% every 3 months (P < .0001), while the nonopioid prescription trend increased by 0.14% (P < .0001). CONCLUSION: There was an associated immediate reduction in the opioid prescribing trend for thyroidectomy, but the change was not sustained overtime. There was an associated decrease in the opioid prescribing trend for parathyroidectomy, but not immediately after the initial publication of the prescription guidelines. LEVEL OF EVIDENCE: Level III.

MAML2-rearrranged sclerosing mucoepidermoid carcinoma of submandibular gland: an incidental finding in a patient with history of recurrent sialadenitis and Sjögren's syndrome.

The Sclerosing subtype of mucoepidermoid carcinoma is rare, with only 39 cases reported in literature. We present a new case of sclerosing mucoepidermoid carcinoma (SMEC) with MAML2 rearrangements. A 49-year-old woman with Sjögren's syndrome experienced recurrent submandibular sialadenitis and sialolithiasis, leading to the removal of her right gland. Postoperative imaging revealed a calcified mass in her left gland which was subsequently resected. The pathologic examination revealed a well-defined tumor with extensive fibrous stroma, predominantly epidermoid cells, and occasional mucinous components. There was a dense lymphocytic and plasma cell infiltrate at the tumor's periphery. Immunohistochemistry was positive for p40 and CK7, few IgG4+ plasma cells. No eosinophils were identified. Fluorescence in situ hybridization (FISH) revealed rearrangement of the MAML2 (11q21) region. Adjuvant radiation was not recommended because of the patient's history of autoimmune diseases and the fact that the tumor was small, localized, and had negative resection margins. The patient was advised to undergo a repeat CT scan of the neck, scheduled for 3 months later. This case highlights the importance of considering SMEC in the differential diagnosis of patients with sialolithiasis or Sjögren's syndrome.

Denosumab-Induced Maxillary Osteonecrosis: A Case Study on Long-Term Complications in Multiple Myeloma Treatment.

Background: Targeted therapies like denosumab have revolutionized multiple myeloma (MM) treatment, improved patient outcomes while introducing long-term complications. This study explores a rare instance of delayed maxillary osteonecrosis post-denosumab therapy, delving into its pathophysiology and management. Methods: A 40-year-old male MM patient who developed a painful palatal lesion post denosumab treatment and diagnosed of maxillary osteonecrosis by computed tomography scan and surgical biopsy is presented. Treatment history, symptom progression, and response to the PENTOCLO protocol were analyzed. Results: Post-denosumab discontinuation osteonecrosis highlights its prolonged impact on bone metabolism. PENTOCLO treatment protocol led to significant improvement. Genetic factors influencing osteonecrosis susceptibility have been discussed and considered. Conclusions: This case underscores the need for vigilance regarding long-term complications in MM survivors, preventive strategies, including regular dental evaluations and reducing invasive dental procedures, are crucial. We advocate for an interdisciplinary approach and further research into tailored prevention and management of osteonecrosis in cancer survivors.

Transoral Robotic Surgery for Oropharyngeal and Hypopharyngeal Squamous Cell Carcinoma.

With oropharyngeal cancer incidence rising globally, largely due to human papillomavirus (HPV), and hypopharyngeal cancer known for poor outcomes, innovative treatments are needed. Transoral robotic surgery (TORS) offers a minimally invasive approach that may improve upon traditional open surgery and radiotherapy/chemoradiotherapy (RT/CRT) methods. We conducted a literature review and included 40 PubMed studies comparing TORS, open surgery, and RT/CRT for oropharyngeal and hypopharyngeal squamous cell carcinoma (SCC), focusing on survival rates and swallowing function outcomes. TORS provides favorable survival outcomes and typically results in superior swallowing function post-treatment compared to other therapeutic modalities in both oropharyngeal and hypopharyngeal SCCs. The clinical benefits of TORS, including improved operative precision and minimized tissue disruption, along with the elimination of surgical incision recovery and reduced RT toxicity, suggest it is a valuable surgical approach for head and neck cancers.

Trends and postoperative outcomes of thyroidectomy after expansion and rise of health insurance deductibles in the fiscal year.

BACKGROUND: The purpose of this study is to evaluate a relationship between expansion of High Deductible Health Plans (HDHPs) and the number of thyroid surgery cases with associated postoperative outcomes in the fiscal year. METHODS: Data from TriNetX was used to evaluate the trends in thyroid surgery from 2005 and 2021 between the end of the year (Quarter 4) and the beginning of the year (Quarter 1). Risk of postoperative outcomes were statistically interrogated. RESULTS: The average rate of thyroid surgery in cases/year between Quarter 4 and Quarter 1 was similar after expansion of HDHPs (152; 146; p = 0.64). There was no increased risk of postoperative complications. The rate of surgery decreased significantly for patients with Medicare after implementation of the revised American Thyroid Association (ATA) guidelines (Quarter 4: p = 0.03; Quarter 1: p = 0.02). CONCLUSIONS: Patients are less likely to delay thyroid surgery at the end of the year despite higher deductibles.

Surgical Management of a Large Well-Differentiated Liposarcoma in the Supraclavicular Fossa: A Case Report.

Background: Liposarcomas originating in the supraclavicular fossa are exceptionally rare, with only a few documented cases in the medical literature. Methods: We present a unique case involving a remarkably large indolent, atypical lipomatous tumor or well-differentiated liposarcoma situated in the right supraclavicular region, measuring 18 cm × 18 cm × 17 cm. To our knowledge, this represents the largest liposarcoma found in the supraclavicular fossa reported in the literature. This unique case highlights the effective management of a remarkably large supraclavicular liposarcoma through complete surgical resection. Result and Conclusion: Our findings further support the existing consensus that complete surgical removal is often curative for well-differentiated liposarcoma.

Parental leave and family building experiences among head and neck surgeons in the United States: Career impact and opportunities for improvement.

BACKGROUND: The availability of paid parental leave is an important factor for retention and wellness. The experiences of head and neck surgeons with parental leave have never been reported. METHODS: A survey was electronically distributed to head and neck subspecialty surgeons in the United States. Responses were collected and analyzed. RESULTS: Male surgeons had more children and took significantly less parental leave than women. Thirty percent of respondents reported that parental leave negatively impacted compensation, and 14% reported a delay in promotion due to leave, which impacted women more than men. The vast majority reported they are happy or neutral about covering those on leave. Most respondents utilized paid childcare, and approximately one quarter of respondents spending 11%-20% of their income on childcare. CONCLUSIONS: This study illuminates the current disparities regarding parental leave-taking within the subspecialty of head and neck surgery in the United States. Women surgeons are more likely to be impacted professionally and financially.

Medical Honey in Head and Neck Cancer.

Medical honey has been recognized for its medicinal properties for thousands of years, and several medical honey products have entered the market over the last two decades. In vitro studies have shown that honey has antimicrobial properties, protects against bacterial growth, and improves wound healing. However, these products are not widely used for wound treatment in head and neck surgery. Additionally, honey has been utilized in those undergoing radiotherapy for head and neck cancer (HNC) to treat radiation-induced mucositis. This literature review aims to describe and assess the utility of medical honey for patients undergoing treatment for HNC and thus review publications on medical honey for treating postoperative wounds and preventing radiation-induced mucositis. Ovid (Medicine), PubMed (Medline), and Google Scholar were searched using keywords related to medical honey and HNC. All abstracts retrieved in the search were screened for content relevance. Three randomized controlled trials on wound healing were reviewed and assigned a score using the revised Cochrane risk of bias tool for methodological quality. Three meta-analyses assessing radiation-induced mucositis were reviewed and evaluated. Using medical honey on postoperative wounds was associated with shorter hospital stays, faster healing of palatal graft defects, and reduced pigmentation of thyroidectomy scars. Medical honey had no impact on bacterial culture rates or other aesthetic measures. For patients undergoing radiation for HNC, orally ingested honey was associated with less weight loss and delayed the onset of severe radiation-induced mucositis. However, results across different meta-analyses were mixed. Minimal evidence supporting the use of honey in postoperative wounds for patients with HNC exists. However, the studies reviewed here, combined with in-vitro studies and studies in other anatomical regions, show honey may offer some wound healing benefits. More robust studies are needed to confirm the potential benefits of medical honey in the postoperative wounds of HNC patients. While radiation-induced mucositis continues to be a debilitating adverse effect of HNC treatment, the literature reviewed supports honey as a safe complementary therapy in preventing radiation-induced mucositis.

Laryngeal Sarcomatoid Carcinoma With Rhabdomyoblastic Differentiation: A Potential Pitfall for Misdiagnosis As Rhabdomyosarcoma.

Sarcomatoid carcinoma (SC) of the larynx is an uncommon subtype of squamous cell carcinoma which shows both squamous carcinoma and a sarcomatous component, including heterologous elements. The presence of rhabdomyosarcomatous elements in the larynx is extremely rare. Diagnosis of SC can be particularly challenging when the malignant epithelial component is not evident. We present a case of SC in a 72-year-old man with a superficial exophytic mass in the vocal cord initially misdiagnosed as rhabdomyosarcoma due to a predominant spindle cell component with rhabdomyoblastic features by morphology and immunohistochemistry. This case report aims to increase awareness that a rhabdomyoblastic heterologous component can be present in SC of the larynx and to consider this diagnosis in a mucosal exophytic malignant spindle cell neoplasm, even in the absence of epithelial differentiation.

Survival differences of low-grade versus high-grade head and neck pleomorphic dermal sarcomas and a review of a scalp case.

Objective: To examine survival by tumor grade of pleomorphic dermal sarcomas (PDS) of the head and neck (H&N) and review a scalp PDS case. Methods: Patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1980 to 2016 based on a diagnosis of H&N PDS. Survival estimates were performed using Kaplan-Meier analysis. Additionally, a case of a grade III H&N PDS is presented. Results: Two hundred-seventy cases of PDS were identified. The mean age at diagnosis was 75.1 years (SD: 13.5). Two hundred-thirty-four (86.7%) patients were male. Eighty-seven percent of patients received surgery as a part of their care. The 5-year overall survival rates for grades I, II, III, and IV PDSs were 69%, 60%, 50%, and 42%, respectively (P = 0.03). Conclusions: H&N PDS occurs most commonly in older-age males. Surgical management is frequently a part of H&N PDS care. Survival rates significantly decline based on tumor grade.

Label-Free Imaging and Histo-Optical Evaluation of Head and Neck Cancers with Multiphoton Autofluorescence Microscopy.

Depth-resolved label-free optical imaging by the method of multiphoton autofluorescence microscopy (MPAM) may offer new ways to examine cellular and extracellular atypia associated with epithelial squamous cell carcinoma (SCC). MPAM was evaluated for its ability to identify cellular and microstructural atypia in head and neck tissues from resected discarded tumor tissue. Three-dimensional image volumes were obtained from tissues from the floor of the mouth, tongue, and larynx, and were then processed for histology. MPAM micrographs were evaluated for qualitative metrics of cell atypia and quantitative measures associated with nuclear pleomorphism. Statistical analyses correlated MPAM endpoints with histological grade from each imaged site. Cellular overcrowding, discohesion, anisonucleosis, and multinucleated cells, as observed through MPAM, were found to be statistically associated with dysplasia and SCC grading, but not in histologically benign regions. A quantitative measure of the coefficient of variance in nuclear size in SCC and dysplasia was statistically elevated above histologically benign regions. MPAM also allowed for the identification of cellular heterogeneity across transitional areas and other features, such as inflammatory infiltrates. In the future, MPAM could be evaluated for the non-invasive detection of neoplasia, possibly as an adjunct to traditional conventional examination and biopsy.

Laryngectomy: Social media analysis of patient perception.

BACKGROUND: Social media continues to grow as a relevant information source for the lay public and medical professionals. METHODS: A search of posts on Facebook and Instagram was conducted using the hashtag #laryngectomy. Posts were categorized based upon perspective, media type, timeframe, topic, tone, and popularity. RESULTS: Final analysis included 929 Instagram posts and 355 Facebook posts. Most Facebook posts were made by companies (38%) and physicians (17%) with information (30%) and advertisements (22%) being common topics. Patients (40%) were the largest group of Instagram authors with lifestyle (39%) being the most common topic. Greater than 90% of posts were either neutral or positive in tone across both platforms. CONCLUSIONS: Patient perspective was most commonly represented on Instagram, whereas Facebook more commonly included posts by physicians and companies. The majority of posts carried a neutral or positive tone, which is consistent with positive quality of life patients have shown postoperatively.

Transradial embolization of a life-threatening tooth extraction socket hemorrhage and pseudoaneurysm.

Embolization of oral hemorrhages due to tooth extraction, although rare, has been previously described.1-4 In this video we present a unique case in which a life-threatening tooth extraction hemorrhage was incontrollable with local compression or surgical cauterization. The patient underwent emergent transradial coil embolization5 of the posterior lateral nasal branches of the sphenopalatine artery. However, the patient returned 11 days later with a lower volume bleed at the original site. Computed tomography angiography showed a pseudoaneurysm at the orthognathic surgery crater retrogradely recanalized through the greater palatine arcade. Surgical options were deemed too invasive, and the decision was made to attempt percutaneous direct puncture embolization. This was unsuccessful and repeat embolization with Onyx was performed through the contralateral greater palatine artery. The patient had complete resolution of symptoms.

Synchronous tonsillar tumors with differing histopathology: A case report and review of the literature.

BACKGROUND: Tonsillar squamous cell carcinoma (TSCC) due to human papillomavirus (HPV) infection has seen a dramatic increase in recent years. Bilateral tonsillar squamous cell carcinoma (biTSCC) has a much lower incidence than unilateral TSCC and three main hypotheses of biTSCC pathogenesis prevail: field carcinogenesis, single-clone, and multiple HPV infections. CASE: A 49-year-old Male with a remote history of chewing tobacco presented with symptoms of spitting up tissue and occasional hemoptysis. Physical exam showed a sole left tonsillar mass which was confirmed to be TSCC on biopsy. The patient's computed tomographic (CT) scan was consistent with this finding; however, positron emission tomography (PET) scan indicated a second tumor in the contralateral right tonsil. Surgical resection of both masses and selective neck dissection was performed, and the specimens were sent for further pathological analysis. No complications of surgery were noted and the final diagnosis of synchronous biTSCC was made. The tumors were a T2N0M0 left poorly differentiated TSCC (p16+, EGFR+, bcl2+) with basaloid features, and a T1N0M0 right well to moderately differentiated TSCC (p16+, EGFR+, bcl2-). CONCLUSION: Our present case was notable for differing tumor pathology and karyotype analysis between the right and left masses, directly supporting the multiple HPV infections hypothesis of biTSCC pathogenesis. Further genetic characterization of tonsillar tumors is needed to better characterize TSCC and best guide medical/surgical therapy.

Combined large cell neuroendocrine carcinoma and squamous cell carcinoma of the oropharynx: A collision course of tumors.

Combined large cell neuroendocrine carcinoma (LCNEC) and squamous cell carcinoma (SCC) of the H&N are exceptionally rare. We present the case of combined p16 negative SCC and LCNEC of the oropharynx treated with combination chemotherapy. This is the third reported case of combined neuroendocrine carcinoma and SCC of the oropharynx.

Kimura Disease: A Rare and Difficult to Diagnose Entity.

Kimura disease (KD) is a rare inflammatory disorder which involves the head and neck. Due to its rarity and various findings, definitive diagnosis can be difficult to ascertain. Kimura disease is distinguished from other conditions, including angiolymphoid hyperplasia, by histopathological features including follicular hyperplasia, reactive germinal centers, abundant eosinophilia, eosinophilic microabscesses, preserved nodal architecture, Warthin-Finkeldy polykaryocytes, and capsular fibrosis. Herein, we describe the clinical presentation, pathology, and diagnosis of a single case of a 39-year-old treated at an academic center in Texas.

American College of Surgeons National Surgical Quality Improvement Program assessment of risk factors for 30-day unplanned readmission in patients undergoing head and neck surgery requiring free tissue reconstruction.

BACKGROUND: Unplanned readmissions have become a metric for measuring quality of care. We analyzed the factors associated with 30-day unplanned readmission (30dUR) following head and neck cancer resections that included free tissue reconstruction (FTR). METHODS: The 2012-2014 ACS-National Surgical Quality Improvement Program (NSQIP) data set was queried. Univariate and multivariate logistic regression analyses were performed. RESULTS: Out of 1114 cases, 121 had a 30dUR. The most common reasons were wound complications, including incisional infections, hematoma, and hemorrhage. A significant independent risk factor for 30dUR included a clean/contaminated wound class (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.20-4.76). Patients receiving an osseous FTR had lower readmission rates (OR, 0.51; CI, 0.27-0.91). Discharge destination had no statistical significance. CONCLUSIONS: Based on the NSQIP data set, 10.9% of patients receiving an FTR for head and neck malignancy had a 30dUR. Although large, population-based data sets have limitations, these results elucidate that these patients are at an increased risk for unplanned readmissions, which can guide patient expectations and discharge planning.

Reconstruction of the mandible for osteoradionecrosis.

PURPOSE OF REVIEW: To describe current standard of care for osteoradionecrosis (ORN) of the mandible and report possible future trends. RECENT FINDINGS: Cutting guides may be used to reduce surgical time and possibly improve outcomes. There has also been recent investigation into the use of pentoxifylline and tocopherol or pentoxifylline, tocopherol and clodronate (a well known conservative medial regime) as a prevention for development of ORN after dental extractions and the first randomized controlled study is upcoming. Augmented reality has shown promise as a comparable and inexpensive possible alternative to cutting guides. SUMMARY: Current standard of care involves conservative/supportive therapy with antioxidants, antibiotics, steroids, and pain control for low-grade ORN with surgery reserved for high-grade/progressive ORN with refractory to conservative therapy and with significant oral dysfunction.