Vallecular cyst causing sleep-disordered breathing in an older child.

Consensus-based recommendations are needed to better guide paediatric otolaryngologists in providing standardised care to children with sleep-disordered breathing (SDB). Here we present a unique case of vallecular cyst found during SDB workup in a patient in their middle childhood (6-12 years old). While the patient underwent successful cyst resection, he was noted to have a suspected recurrence 6 months later. Immediately prior to revision excision, repeat awake flexible fibre-optic laryngoscopy revealed complete resolution of the suspected recurrence. This case underscores the significance of performing a complete upper airway examination, including endoscopic examination, to identify structural and anatomical lesions in older children with SDB.

Rates of Occult Invasive Disease in Patients With Biopsy-Proven Oral Cavity Squamous Cell Carcinoma in Situ.

Importance: The likelihood that an oral cavity lesion harbors occult invasive disease after biopsy demonstrating carcinoma in situ (CIS) is unknown. While de-escalated treatment strategies may be appealing in the setting of CIS, knowing whether occult invasive disease may be present and its association with survival outcomes would lead to more informed management decisions. Objective: To evaluate rate of occult invasive disease and clinical outcomes in patients with oral cavity CIS. Design, Setting, and Participants: This was a retrospective population-based cohort study using the National Cancer Database and included adults with biopsy-proven oral cavity CIS as the first diagnosis of cancer between 2004 and 2020. Data were analyzed from October 10, 2022, to June 25, 2023. Exposures: Surgical resection vs no surgery. Main Outcomes and Measures: Analyses calculated the rate of occult invasive disease identified on resection of a biopsy-proven CIS lesion. Univariate and multivariate logistic regression with odds ratios and 95% CIs were used to identify significant demographic and clinical characteristics associated with risk of occult invasion (age, year of diagnosis, sex, race and ethnicity, oral cavity subsite, and comorbidity status). Kaplan-Meier curves for overall survival (OS) were calculated for both unresected and resected cohorts (stratified by presence of occult invasive disease). Results: A total of 1856 patients with oral cavity CIS were identified, with 122 who did not undergo surgery (median [range] age, 65 [26-90] years; 48 female individuals [39.3%] and 74 male individuals [60.7%]) and 1458 who underwent surgical resection and had documented pathology (median [range] age, 62 [21-90] years; 490 female individuals [33.6%] and 968 male individuals [66.4%]). Of the 1580 patients overall, 52 (3.3%) were Black; 39 (2.5%), Hispanic; 1365 (86.4%), White; and 124 (7.8%), other, not specified. Among those who proceeded with surgery with documented pathology, 408 patients (28.0%) were found to have occult invasive disease. Higher-risk features were present in 45 patients (11.0%) for final margin positivity, 16 patients (3.9%) for lymphovascular invasion, 13 patients (3.2%) for high-grade invasive disease, and 14 patients (3.4%) for nodal involvement. For those patients with occult disease, staging according to the American Joint Committee on Cancer's AJCC Cancer Staging Manual, eighth edition, was pT1 in 341 patients (83.6%), pT2 in 41 (10.0%), and pT3 or pT4 disease in 26 (6.4%). Factors associated with greater odds of occult invasive disease at resection were female sex, Black race, and alveolar ridge, vestibule, and retromolar subsite. With median 66-month follow-up, 5-year OS was 85.9% in patients who proceeded with surgical resection vs 59.7% in patients who did not undergo surgery (difference, 26.2%; 95% CI, 19.0%-33.4%). Conclusions and Relevance: This cohort study assessed the risk of concurrent occult invasion with biopsy-proven CIS of the oral cavity, demonstrating that 28.0% had invasive disease at resection. Reassuringly, even in the setting of occult invasion, high-risk disease features were rare, and 5-year OS was nearly 80% with resection. The findings support the practice of definitive resection if feasible following biopsy demonstrating oral cavity CIS.

Oncologic Safety of Close Margins in Patients With Low- to Intermediate-Grade Major Salivary Gland Carcinoma.

Importance: Postoperative radiation therapy for close surgical margins in low- to intermediate-grade salivary carcinomas lacks multi-institutional supportive evidence. Objective: To evaluate the oncologic outcomes for low- and intermediate-grade salivary carcinomas with close and positive margins. Design, Setting, and Participants: The American Head and Neck Society Salivary Gland Section conducted a retrospective cohort study from 2010 to 2019 at 41 centers. Margins were classified as R0 (negative), R1 (microscopically positive), or R2 (macroscopically positive). R0 margins were subclassified into clear (>1 mm) or close (≤1 mm). Data analysis was performed from June to October 2023. Main Outcomes and Measures: Main outcomes were risk factors for local recurrence. Results: A total of 865 patients (median [IQR] age at surgery, 56 [43-66] years; 553 female individuals [64%] and 312 male individuals [36%]) were included. Of these, 801 (93%) had parotid carcinoma and 64 (7%) had submandibular gland carcinoma, and 748 (86%) had low-grade tumors and 117 (14%) had intermediate-grade tumors, with the following surgical margins: R0 in 673 (78%), R1 in 168 (19%), and R2 in 24 (3%). Close margins were found in 395 of 499 patients with R0 margins (79%), for whom margin distances were measured. A total of 305 patients (35%) underwent postoperative radiation therapy. Of all 865 patients, 35 (4%) had local recurrence with a median (IQR) follow-up of 35.3 (13.9-59.1) months. In patients with close margins as the sole risk factor for recurrence, the local recurrence rates were similar between those who underwent postoperative radiation therapy (0 of 46) or observation (4 of 165 [2%]). Patients with clear margins (n = 104) had no recurrences. The local recurrence rate in patients with R1 or R2 margins was better in those irradiated (2 of 128 [2%]) compared to observed (13 of 64 [20%]) (hazard ratio [HR], 0.05; 95% CI, 0.01-0.24). Multivariable analysis for local recurrence found the following independent factors: age at diagnosis (HR for a 10-year increase in age, 1.33; 95% CI, 1.06-1.67), R1 vs R0 (HR, 5.21; 95% CI, 2.58-10.54), lymphovascular invasion (HR, 4.47; 95% CI, 1.43-13.99), and postoperative radiation therapy (HR, 0.10; 95% CI, 0.04-0.29). The 3-year local recurrence-free survivals for the study population were 96% vs 97% in the close margin group. Conclusions and Relevance: In this cohort study of patients with low- and intermediate-grade major salivary gland carcinoma, postoperative radiation therapy for positive margins was associated with decreased risk of local recurrence. In isolation from other risk factors for local recurrence, select patients with close surgical margins (≤1 mm) may safely be considered for observation.

Clinical predictors of premature radiotherapy terminations in senior adults with oral cavity and laryngeal carcinoma.

INTRODUCTION: The underlying factors that contribute to early radiotherapy (RT) termination are understudied, especially in the era of hypofractionated treatment regimens. In this retrospective investigation, we examined the characteristics and causes of premature RT terminations in senior adults (>70 years old) with oral cavity (OC) and laryngeal carcinomas. METHODS: Hundred and eighty-eight patients treated with RT ± systemic therapy for OC and laryngeal cancer from 2017 to 2022 were identified. Premature termination was defined as completion of less than 95% of the prescribed RT. Logistic regression analysis was performed to examine factors predictive of premature termination, and survival was determined using the Kaplan-Meier method. RESULTS: Twenty patients (10.6%) experienced premature RT terminations. On regression analysis, ECOG score at initiation of RT was the only covariate studied to be independently associated with premature termination (OR 2.00, 95%CI: [1.21, 3.30], p = 0.007). Three-year overall survival (49.1% vs. 77.3%) was significantly reduced in the termination cohort (p < 0.0001). CONCLUSIONS: This analysis demonstrated over 1 in 10 patients had premature RT termination, which prognosticated inferior survival outcomes. Poor performance status may highlight patients at risk for premature termination and thus identify good candidates for hypofractionated protocols.

Allergy History and Immunotherapy Response in Patients With Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma.

OBJECTIVE: This study examines the association between patient-reported allergy history and immune checkpoint inhibition (ICI) response in patients with recurrent or metastatic head and neck squamous cell carcinoma (RMHNSCC). STUDY DESIGN: Retrospective cohort study. SETTING: Academic tertiary care hospital. METHODS: Data were collected from the electronic medical records on baseline age, sex, allergy history, human papillomavirus status, T-stage, N-stage, smoking status, and survival for patients with and without an allergy history. The primary outcome was ICI response defined as complete or partial response by the RECIST criteria. Chi-square and logistic regression analyses were conducted to compare rates and odds of ICI response. Kaplan-Meier analyses were used to compare survival between groups. RESULTS: Our study included 52 patients with an allergy history and 36 patients without an allergy history. The groups were similar in age, sex, HPV status, smoking status, and T- and N-stage. Patients with an allergy history (17/52, 32.1%) had a greater ICI response rate than patients without allergy history (4/36, 11.1%) (P = .02). After adjusting for HPV, patients with allergies had 3.93 (1.19-13.00) times increased odds of ICI response compared to patients without allergies. The median progression-free survival was 6.0 and 4.2 months for patients with and without an allergy history respectively (log-rank, P = .04). The median overall survival was 25.0 and 11.1 months for patients with and without an allergy history respectively (log-rank, P = .002). CONCLUSION: Patient-reported allergy history was associated with ICI response in patients with RMHNSCC, underscoring the potential clinical utility of allergy history in estimating ICI response.

Endovascular repair of radial artery non-anastomotic pseudoaneurysm in a radial forearm free flap.

The development of pseudoaneurysm is an uncommon, life-threatening complication of head and neck microvascular surgery. Only a handful of reports have been published describing microvascular pseudoaneurysms, which usually occur at the arterial anastomosis and present as a pulsatile neck mass or as haemorrhage in case of pseudoaneurysm rupture. Management is highly variable, especially in the acute setting. In patients with pseudoaneurysm where flap inosculation is inadequate, endovascular approaches may be appropriate. In this report, we describe a ruptured distal pedicle pseudoaneurysm of a radial forearm free flap salvaged with a flow-diverting stent with complete flap survival and pedicle preservation. We demonstrate further evidence and feasibility of endovascular treatment of a non-anastomotic pseudoaneurysm arising from small vessels when parent vascular integrity is critical to flap survival.

Evaluation and Management of Inflammatory Reactions to Vocal Fold Injection Laryngoplasty with Hyaluronic Acid.

OBJECTIVES: Inflammatory reaction to vocal fold injection laryngoplasty with hyaluronic acid (HA) is a rare condition whose optimal management is not established. In this study, we aim to review the presentation of these reactions and outline an approach for evaluation and management. METHODS: We performed a retrospective review of all patients at our institution who underwent vocal fold injection augmentation with HA during the period extending from August 2018 until October 2022. We then identified patients with postinjection inflammatory reaction and reviewed demographic data, indication for injection, amount of HA injected, setting of procedure, and symptoms. The types of complication, management plan, onset, and time to complete resolution were also recorded. A comprehensive literature search for similar complications was conducted for comparative analysis. Once the available data were aggregated with our institutional experience, we developed an algorithmic approach to manage this condition. RESULTS: We identified 83 patients (124 vocal folds) who underwent vocal fold injection laryngoplasty with HA over a 4-year period. Four patients (4.8%) had a postprocedure inflammatory reaction (5.6% of all vocal folds). Of the four patients, three presented with dyspnea and stridor, while one presented with dysphonia, with onset of symptoms ranging from 24 to 48 hour postinjection. All patients were treated with corticosteroids. For comparative analysis, we identified 24 patients from the literature with reported inflammatory reactions to HA. CONCLUSION: We suggest an algorithmic approach to managing laryngeal inflammation following HA injection. Familiarity with treatment for this rare complication is essential to avoid significant morbidity and achieve optimal outcomes.

Impact of comorbidities on outcomes in patients with advanced head and neck cancer undergoing immunotherapy.

OBJECTIVES: To explore the impact of pre-existing comorbidities on immunotherapy response, overall and progression-free survival, and immune-related adverse events (irAEs) of patients with advanced head and neck cancer (HNC) treated with immunotherapy. PATIENTS AND METHODS: Ninety-three patients treated with immunotherapy were identified and stratified into comorbidity absent or present (CCI < 1 and CCI ≥ 1, respectively) cohorts, and clinical outcomes were compared between these two groups. RESULTS: Patients with no comorbidities had longer overall survival (aHR = 2.74, 95% CI [1.18, 6.40], p = 0.02) and progression-free survival (aHR = 2.07, 95% CI [1.03, 4.16], p = 0.04) and a higher tumor response rate (32% in CCI < 1 vs. 14% in CC ≥ 1, p = 0.05). Risk for irAEs was higher in the comorbidity absent group (p = 0.05). CONCLUSION: Comorbidity should be considered as a significant prognostic factor in clinical decision-making for patients with advanced HNC undergoing immunotherapy.

Laparoscopic Versus Open Ventriculoperitoneal Shunt Placement: A Non-inferiority Study.

Ventriculoperitoneal shunt (VPS) insertion into the abdominal cavity had been done for decades via an open approach. Recently, the laparoscopic insertion of the peritoneal portion of the shunt has become an option. The aim of this study is to compare outcomes between these two approaches. We performed a single institution retrospective review of 104 consecutive adult patients between 2015 and 2017. Patients had peritoneal catheters placed either via an open approach by the neurosurgical team, or laparoscopically by general surgeons. Patient demographics and outcomes were compared using a non-inferiority analysis. Independent variables in the analysis included patient age, gender, race, BMI, surgery performed, previous VPS placement, previous abdominal procedures, and VPS indication, while dependent variables included length of stay (LOS), estimated blood loss (EBL), occurrence of shunt failure, and postoperative complications. Cohort analysis included 62 open and 42 laparoscopic cases with similar baseline characteristics. In terms of patient outcomes, EBL and hospital stay duration were shown to be non-inferior in the open group as compared to the laparoscopic group. We could not prove non-inferiority based on risk for overall or distal shunt failure. Neurosurgeons may reasonably continue to place peritoneal shunt catheters using a "traditional" method.

Diagnosis and Management of Common Presentations of Posttraumatic Nasal Deformity: A Narrative Review.

Posttraumatic nasal deformity (PTND) is a surgical challenge for the otolaryngologist and plastic surgeon. Various classifications and management algorithms have been proposed without reaching much consensus in terms of definition and management. Methods: We present a narrative review aimed to define PTND and consolidate current knowledge regarding its diagnosis, subtypes, and treatment options. Results: This report is a clinical overview of PTND. We also review recent studies that characterize different osteotomy approaches and techniques used for patients with PTND. Conclusions: By providing a summary of the main challenges for PTND, we aim to add context to its variable presentation. We hope this broad overview will reinforce more effective communication between providers and promote patient understanding in order to ensure favorable long-term outcomes.

Continuous glucose monitoring reveals similar glycemic variability in individuals with obesity despite increased HOMA-IR.

Background/aims: Continuous glucose monitoring is a well-tolerated and versatile tool for management of diabetes and metabolic disease. While its use appears to be feasible to monitor glycemic profiles in diabetics, there is a paucity of data in individuals with obesity and normal glucose tolerance. The aim of this study is to investigate glucose fluctuations and insulin resistance patterns in normoglycemic participants with obesity vs. without obesity and contextualize these results against leading models for obesity. Materials and methods: We designed a prospective, observational pilot study of two cohorts including 14 normoglycemic participants with obesity and 14 normoglycemic participants without obesity. Participants were monitored with continuous glucose monitoring (CGM) for five consecutive days. Insulin resistance levels were measured and glucometric data were extracted from CGM for all participants. Results: Fasting serum insulin and homeostasis model assessment of insulin resistance (HOMA-IR) were significantly higher in the group with obesity (P < 0.05). While the group with obesity had a higher mean blood glucose (MBG), mean amplitude of glycemic excursions (MAGE), and continuous overall glycemic action-1 h (CONGA-1), these differences were not significant. On univariate linear regression, insulin resistance (HOMA-IR) was associated with body mass index (BMI), waist circumference (WC), cohort with obesity, cohort consuming a high glycemic diet, hemoglobin A1c (HbA1c), and fasting insulin levels. WC and fasting insulin levels remained predictors of HOMA-IR in our multivariable model. Conclusion: While there is much excitement surrounding the use of commercial CGM products in obesity management, our results suggest that fasting insulin and HOMA-IR values may be more clinically useful than CGM data alone.

Improved detection suggests all Merkel cell carcinomas harbor Merkel polyomavirus.

A human polyomavirus was recently discovered in Merkel cell carcinoma (MCC) specimens. The Merkel cell polyomavirus (MCPyV) genome undergoes clonal integration into the host cell chromosomes of MCC tumors and expresses small T antigen and truncated large T antigen. Previous studies have consistently reported that MCPyV can be detected in approximately 80% of all MCC tumors. We sought to increase the sensitivity of detection of MCPyV in MCC by developing antibodies capable of detecting large T antigen by immunohistochemistry. In addition, we expanded the repertoire of quantitative PCR primers specific for MCPyV to improve the detection of viral DNA in MCC. Here we report that a novel monoclonal antibody detected MCPyV large T antigen expression in 56 of 58 (97%) unique MCC tumors. PCR analysis specifically detected viral DNA in all 60 unique MCC tumors tested. We also detected inactivating point substitution mutations of TP53 in the two MCC specimens that lacked large T antigen expression and in only 1 of 56 tumors positive for large T antigen. These results indicate that MCPyV is present in MCC tumors more frequently than previously reported and that mutations in TP53 tend to occur in MCC tumors that fail to express MCPyV large T antigen.