Safety outcomes and patient convenience in outpatient parotidectomy.

BACKGROUND: Parotidectomies have historically been performed on an inpatient basis despite being well-tolerated surgeries with minimal postoperative wound care and low rates of complications at high-volume institutions. Past studies have supported the safety of outpatient surgery for parotidectomy but have been limited to superficial parotidectomy and have not addressed the patient experience surrounding the surgical intervention such as pre-operative and post-operative care and communication. PURPOSE: This study assesses the impact of outpatient superficial, deep, and partial parotid surgery on various parameters including surgical safety, distance traveled for care, utilization of telehealth, and patient-initiated communication. MATERIALS AND METHODS: Retrospective study from January 2020 to October 2021. Patients undergoing superficial lobe, deep lobe, and partial parotidectomies for benign and malignant pathologies were divided into inpatient and outpatient cohorts. A multivariable model examined the relationship between admission status and surgical complications, adjusted for age, sex, and tumor size. RESULTS: 159 patients total, 94 outpatient and 65 inpatients. No statistical difference in rates of surgical complications with the exception of salivary leak. There was an increased rate of salivary leak reported in the inpatient group (OR 5.4, 95 % CI 1.6 to 18.0, p = 0.01). Mean patient travel distance of 354 miles one-way. Post-operatively, 76 % were evaluated via video visit. Following discharge, >55 % of patients initiated communication with the surgical team, which was not statistically different between the groups. CONCLUSIONS: Outpatient parotidectomy is safe and can be more convenient, but telehealth communication must be balanced with rigorous attention to patient education.

Diagnostic Delay in Human Papillomavirus Negative Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVE: Failure to recognize symptoms of non-human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(-)OPSCC) at presentation can delay diagnosis and treatment. We aim to identify patient factors and provider practice patterns that delay presentation and care in HPV(-)OPSCC. METHODS: Retrospective review at a tertiary care center. Patients with HPV(-)OPSCC receiving treatment from 2006 to 2016. Patients were excluded if their date of symptom onset or diagnosis was unknown after thorough review of the electronic medical record or their tissue was not tested for HPV or p16. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations between patient and provider factors and delays in care. RESULTS: Of 70 included patients, 52 (74%) were male and mean age was 60.5 (SD = 9.0). Median time to diagnosis was 69 days (IQR = 32-127 days), with a median latency of 30 days (IQR = 12-61 days) from symptom onset to first presentation and 19.5 days (IQR = 4-46 days) from the first presentation to diagnosis. Most patients visited at least 2 providers (n = 52, 74%) before diagnosis. Evaluation by 3 or more providers prior to diagnosis was associated with significant delays in diagnosis of nearly a year (357.7 days, p < 0.001) and being treated or prescribed analgesia prior to diagnosis was significantly associated with delays in diagnosis (p = 0.004) on univariate regression analysis. CONCLUSIONS: Delays in care related to evaluations by multiple providers and misdiagnosis prolonged time to diagnosis in HPV(-)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(-)OPSCC. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1394-1401, 2023.

Esthesioneuroblastoma (Olfactory Neuroblastoma): Overview and Extent of Surgical Approach and Skull Base Resection.

Esthesioneuroblastoma is a rare malignancy originating from the olfactory epithelium. Treatment consists of surgical resection with strong consideration for adjuvant treatment in advanced Kadish stage and high Hyams grade. In the modern era, overall outcomes for esthesioneuroblastoma are favorable compared with many other sinonasal malignancies with 5-year overall survival estimated to be 80%. When selecting the optimal surgical approach, the surgeon must consider the approach that will allow for a negative margin resection and adequate reconstruction. In appropriately selected patients, endoscopic outcomes appear at least equivalent to open approaches and unilateral endoscopic approach may be used in select olfactory preservation cases.

The role of total parotidectomy in high-grade parotid malignancy: A multisurgeon retrospective review.

PURPOSE: Determine rates of intra-parotid and neck nodal metastasis, identify risk factors for recurrence, and report outcomes in patients with primary high-grade parotid malignancy who undergo total parotidectomy and neck dissection. MATERIALS & METHODS: Retrospective review of patients undergoing total parotidectomy and neck dissection for high-grade parotid malignancy between 2005 and 2015. The presence and number of parotid lymph nodes, superficial and deep, as well as cervical lymph nodes involved with metastatic disease were assessed. Risk factors associated with metastatic spread to the parotid deep lobe were identified and recurrence rates reported. RESULTS: 75 patients with median follow-up time of 47 months. 35 patients (46.7%) had parotid lymph node metastasis. Seven patients (9.3%) had deep lobe nodal metastasis without metastasis to the superficial lobe nodes. Nine patients (12%) had positive intra-parotid nodes without positive cervical nodes. Cervical nodal disease was identified in 49.3% patients (37/75). Local, parotid-bed recurrence rate was 5.3% (4/75). Regional lymph node recurrence rate was also 5.3% (4/75). Rate of distant metastasis was 30.6% (23/75). The overall disease free survival rate for all patients at 2 and 5 years were 71% and 60% respectively. CONCLUSION: Parotid lymph node metastasis occurred at a similar rate to cervical lymph node metastasis (46.7% and 49.3%, respectively). Deep lobe parotid nodal metastasis occurred in nearly a quarter of patients and can occur without superficial parotid nodal metastasis. Rate of recurrence in the parotid bed, which may represent local or regional recurrence, was similar to regional cervical lymph node recurrence. Total parotidectomy and neck dissection should be considered high-grade parotid malignancy regardless of clinical nodal status.

Mucoepidermoid carcinoma of the parotid gland: Twenty-year experience in treatment and outcomes.

BACKGROUND: Parotid gland mucoepidermoid carcinoma (MEC) has published five-year cancer-specific survival (CSS) rates of 77%-97%, with variance related to grade. METHODS: Patients receiving primary surgery for parotid gland MEC from 1995 to 2014 at a tertiary medical center underwent clinical review, histopathologic review, and cytogenetic analysis. Survival outcomes were evaluated. RESULTS: Among 58 patients, T/N/M classification was as follows: T1 in 35 patients, T2 in 14, T4a in 9, N0 in 53, N1 in 2, N2b in 3. Histologic grade was low in 27, intermediate in 17, and high in 12 patients with 98% MAML2 positivity. All patients underwent parotidectomy, and seven patients received adjuvant radiation therapy. CSS was 100% at 5 years and 94.1% at 10 and 15 years. Two patients experienced locoregional recurrence. CONCLUSIONS: Treatment with adequate surgical resection and adjuvant radiation therapy for high-grade or advanced-stage tumors yields excellent survival, independent of clinical stage or pathologic grade.

Disease Profile and Oncologic Outcomes After Delayed Diagnosis of Human Papillomavirus-Associated Oropharyngeal Cancer.

OBJECTIVE: Diagnostic delay in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV(+)OPSCC) is common due to nonspecific symptoms. We aim to describe the disease burden and oncologic outcomes of patients with HPV(+)OPSCC diagnosed >12 months after symptom onset. STUDY DESIGN: This is a retrospective cohort study of HPV(+)OPSCC patients receiving intent-to-cure treatment (including surgery ± adjuvant therapy or primary chemoradiation). SETTING: 2006-2016, tertiary care center. METHODS: Tumor stage was compared between patients with and without delayed diagnosis using χ2 tests. Kaplan-Meier survival analysis with univariate and multivariable Cox regressions were used to determine the effect of diagnostic delay on oncologic outcomes. RESULTS: In total, 664 patients were included. Compared to patients diagnosed <12 months from symptom onset (n = 601), those diagnosed at >12 months (n = 63) were more likely to have T4 disease and higher overall American Joint Committee on Cancer (AJCC) clinical stage at presentation (P < .01 for both). At 5 years, rates of overall survival, cancer-specific survival, progression-free survival, and distant metastases-free survival in the delayed diagnosis cohort were 80%, 90%, 80%, and 89%, respectively. A >12-month delay in diagnosis did not significantly impact overall survival (adjusted hazard ratio [aHR], 1.16; 95% CI, 0.58-2.31), cancer-specific survival (aHR, 0.83; 95% CI, 0.29-2.39), progression-free survival (aHR, 1.15; 95% CI, 0.56-2.37), or distant metastases-free survival (aHR, 1.00; 95% CI, 0.42-2.40) after adjusting for age, sex, and clinical AJCC stage (P > .05 for all). CONCLUSIONS: Delayed diagnosis of HPV(+)OPSCC is associated with greater burden of disease at presentation, but oncologic outcomes remain favorable across treatment modalities. When appropriate, intent-to-cure therapy should be pursued despite diagnostic delay. LEVEL OF EVIDENCE: Level III.

Barriers to Obtaining a Timely Diagnosis in Human Papillomavirus-Associated Oropharynx Cancer.

OBJECTIVE: Failure to recognize symptoms of human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) at presentation can delay diagnosis and treatment. This study aims to identify patient factors and provider patterns that contribute to delayed diagnosis. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care center. METHODS: Patients with HPV(+)OPSCC receiving intent-to-cure treatment from 2006 to 2016. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations. RESULTS: Of 703 included patients, 627 (89%) were male, and mean (SD) age at diagnosis was 59 (9) years. The mean (SD) delay to diagnosis was 148.8 (243.51) days, with an average delay of 63 (154.91) days from symptom onset to first presentation and 82.8 (194.25) days from first presentation to diagnosis. Most patients visited at least 2 providers (n = 546, 78%) before diagnosis and saw their primary care physician at first presentation (n = 496, 71%). The most common imaging and biopsy obtained before diagnosis was neck computed tomography (n = 391, 56%) and neck fine-needle aspiration (n = 423, 60%), respectively. On multivariable linear regression, being a homemaker, being a current smoker, seeing 3 or more providers, and getting a magnetic resonance imaging scan were associated with significant delays in diagnosis (P < .01, all). Treatment with antibiotics and a suspicion for HPV(+)OPSCC at first presentation were associated with decreased delays in diagnosis (P < .01, both). CONCLUSIONS: Patient delays in seeking medical attention and provider delays in recognizing the appropriate diagnosis both contribute to delays of care in HPV(+)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(+)OPSCC.

The prognostic role of medical comorbidities in surgically treated human papillomavirus-associated oropharyngeal squamous cell carcinoma.

OBJECTIVE: Prognostic factors specific to surgically managed human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) are not fully understood. Medical co-morbidities may have an impact on survival after surgical treatment. We aimed to identify co-morbidities associated with distant metastases-free survival (DMFS) and cancer-specific survival (CSS) in HPV(+)OPSCCs. METHODS: This is a retrospective case series of HPV(+)OPSCC patients at a tertiary referral center from 2007 to 2016. All patients in the study underwent primary intent-to-cure transoral resection with concomitant neck dissection ± adjuvant radiation ± chemotherapy. Exclusion criteria included a history of previous head and neck cancer or distant metastases at diagnosis. Associations with DMFS and CSS were evaluated using univariable and multivariable Cox regression and summarized with hazard ratios (HRs). RESULTS: 406 patients were included in the cohort (100% HPV(+), 90% Male). All had tumors of the tonsil (62%) or base of tongue (38%). Median follow-up for the cohort was 4.0 years (IQR: 2.6-6.2). Higher tumor stage and a higher Adult Comorbidity Evaluation-27 score were significantly associated with worse DMFS and CSS (p < 0.02 for all). A history of diabetes mellitus (N = 36, 9%) was significantly associated with DMFS (HR 3.05 [95%CI 1.26-7.37], p = 0.014) and CSS (HR 4.82 [95%CI 1.84-12.61], p = 0.001). On multivariable analysis, after adjusting for tumor stage, diabetes remained significantly associated with worse DMFS (HR 2.58 [95%CI 1.06-6.26], p = 0.037). CONCLUSION: Diabetes mellitus may be associated with worse DMFS and CSS in surgically managed HPV(+)OPSCC.