Elective nodal dissection for cN0 intermediate-grade parotid mucoepidermoid carcinoma: A NCDB study.

PURPOSE: To determine the occult nodal disease rate and whether elective regional lymph node dissection (RLND) confers any 10-year overall survival (OS) in cN0 intermediate-grade mucoepidermoid carcinoma (MEC) of the parotid gland. MATERIALS & METHODS: The National Cancer Database was reviewed from 2004 to 2016 on adults with cT1-4aN0M0 intermediate-grade parotid MEC undergoing resection with/without RLND. Comparisons between patients with and without RLND were made. Occult nodal rate and 10-year overall survival (OS) were determined. RESULTS: Out of 898 included patients with cN0 intermediate grade parotid MEC undergoing elective RLND, the occult nodal rate was 7.6%. This was significantly different from low-grade (3.9%) and high-grade (25.7%) cN0 disease. When stratified by pT-classification, marginal differences were identified between low-grade and intermediate-grade tumors, whereas high-grade tumors demonstrated increased occult nodal disease with low T-stage (pT1-pT2, 20.4% vs. 5.1%) and high T-stage (pT3-pT4a, 32.1% vs. 17.6%). Patients undergoing elective RLND were more often treated at an academic facility (53.8% vs. 41.2%), had higher pT3-pT4 tumors (19.2% vs. 10.4%), and more frequently underwent total/radical parotidectomy (46.0% vs. 29.9%) with adjuvant radiation therapy (53.8% vs. 41.0%) Cox-proportional hazard modeling did not identify RLND, regardless if stratified by nodal yield or pT-classification, nor nodal positivity as significant predictors of 10-year OS. CONCLUSIONS: The occult nodal disease in intermediate-grade parotid MEC is low and similar to low-grade. Elective RLND may have a limited impact on OS, though its effect on locoregional control remains unknown. LEVEL OF EVIDENCE: III.

Outcomes with culture-directed antibiotics following microvascular free tissue reconstruction for osteonecrosis of the jaw.

OBJECTIVES: Radiation (ORNJ) and bisphosphonate-related (BRONJ) osteonecrosis of the jaw represent challenging entities to treat, with many patients requiring segmental resection and reconstruction with microvascular free tissue transfer (MFTT) in the setting of failed conservative therapy. Microvascular reconstruction is associated with higher post-operative complication rates when performed for advanced osteonecrosis versus oncologic defects. We hypothesize that basing antibiotic therapy on cultures obtained from the healthy bone marrow following resection during MFTT for ORNJ or BRONJ reduces rates of post-operative wound and surgical complications. MATERIALS AND METHODS: In a retrospective cohort study spanning January 2016 to October 2018, 44 patients undergoing MFTT for ORNJ or BRONJ were identified. Patients were categorized into two cohorts: residual healthy marrow culture (n = 11; RHM), treated with antibiotics guided by cultures from healthy appearing mandible, and all others (n = 33; AO), treated with antibiotics guided by cultures from resected necrotic bone or purulent drainage. Patient, reconstruction, and outcome variables were compared via appropriate statistical tools. RESULTS: 81.8% of the RHM cohort versus 24.2% of the AO cohort received long-term IV antibiotics. Rates of post-operative wound complications, including those necessitating operative management, were significantly lower in the RHM cohort. Rates of flap failure were similar across both groups. CONCLUSION: Administration of long-term IV antibiotics directed by native mandible cultures may decrease complication rates following MFTT for ORNJ or BRONJ by treating residual, smoldering infection. Concurrently, transplantation of well-vascularized free tissue likely improves antibiotic delivery. Findings are crucial for the development of a standardized treatment algorithm following microvascular reconstruction for advanced osteonecrosis.

Postoperative Radiation Therapy in Oral Cavity Verrucous Carcinoma.

OBJECTIVES/HYPOTHESIS: We investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) and its effect on overall survival (OS) for patients with oral cavity verrucous carcinoma (VC). STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study of the National Cancer Database (NCDB) from 2006 to 2015 was performed. Multivariable logistic regression was used to identify independent predictive factors associated with the use of PORT. Cox Regression survival and propensity score analyses were used to evaluate the effect of PORT on mortality. RESULTS: A total of 356 adult patients with primary oral cavity VC who underwent definitive surgical resection were identified. A total of 10.7% of patients underwent definitive surgical resection followed by PORT. Variables associated with PORT included distance to the hospital per 10 miles (adjusted odds ratio [aOR], 0.81 [95% confidence interval (CI), 0.70-0.95]) and stage III-IV disease (aOR, 12.13 and 23.92, respectively). Multivariable Cox regression survival analysis indicated no evidence of survival benefit in patients undergoing PORT compared to surgery alone (adjusted hazard ratio 1.50 [0.74-3.05], P = .23). Propensity score analysis also showed no OS benefit with the use of PORT (P = .41). CONCLUSIONS: Variables associated with the use of PORT on multivariable analysis included closer distance to hospital and stage III-IV disease. No clear survival benefit with PORT was identified on either multivariable survival analysis or propensity score analysis. These results suggest that surgery alone with negative margins may be the optimal treatment for patients with oral cavity VC. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1953-1961, 2022.

Gender and race interact to influence survival disparities in head and neck cancer.

Gender and race disparities in head and neck squamous cell carcinoma (HSNCC) survival are independently well documented, but no prior studies have examined the joint effect of these factors on HSNCC outcomes. We aim to comprehensively estimate the effect of gender and race on overall survival in HNSCC. We constructed a retrospective cohort from the National Cancer Database for primary HNSCC of the larynx, hypopharynx, oral cavity, and oropharynx from 2010 to 2015. We used Kaplan-Meier curves and Cox proportional hazards regressions to calculate hazard ratios adjusting for treatment type, age, insurance, staging classifications, and comorbidities. Oral cavity cancer was significantly more common among Hispanic and White females compared to other sites. Female non-oropharyngeal HNSCC cases had better five-year overall survival than males (56.3% versus 54.4%, respectively), though Black females (52.8%) had poorer survival than both White (56.2%) and Hispanic (57.9%) males. There were significant differences in oropharyngeal cancer by HPV status. Notably, Black females with HPV-positive oropharyngeal OPSCC had far worse survival than any other race and gender group. These results persisted even when adjusting for potential mediating factors. Clearly gender is a significant prognosticator for HNSCC and has meaningful interactions with race. The distinct site distributions across gender and race reveal important insights into HNSCC among females. Taking into account these gender disparities while considering race is essential to providing appropriate care to head and neck patients and accurately counselling these individuals on prognosis and outcomes.

The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature.

BACKGROUND/OBJECTIVES: Microvascular free tissue transfer has become essential to head and neck reconstruction and recent advancements in microvascular surgery have led to excellent surgical outcomes. However, there continues to be controversy and a stigma associated with the use of perioperative intravenous vasopressor agents among both surgeons and anesthesiologists. Due to concern for vasoconstriction of peripheral vasculature flowing to the denervated tissue flap, there remains concerns about potential thrombosis, decreased tissue perfusion and ultimately flap failure. This topic becomes even more important as vasopressors play an essential role in new Extended Recovery After Surgery (ERAS) protocols being put in place to optimize postoperative recovery for patients. The purpose of this study was to comprehensively review the role and safety as well as discuss current trends with intraoperative vasopressor agents in free tissue transfer for head and neck reconstruction. METHODS: A scoping literature review was conducted of all studies that examined the use of vasopressor agents during head and neck free flap tissue transfer. Primary and secondary outcomes included free flap survival, arterial thrombosis, venous congestion, need for revision surgery, and other postoperative complications. RESULTS: One prospective and nine retrospective studies were identified. Phenylephrine and ephedrine were the most common vasopressors reported; the rate of vasopressor use ranged from 53% to 85% and administration methods included both bolus and infusion. The included studies did not show any significant association between the use of vasopressors and free flap failure, pedicle thrombosis, or other flap complications. CONCLUSION: The administration of vasopressors during microvascular free tissue transfer for head and neck reconstruction does not seem to be associated with increased flap failure rates or other postoperative morbidities. Moreover, vasopressors may provide overall improved hemodynamic stability and help to limit overall fluid administration and subsequent postoperative complications. Additional prospective investigation is warranted to further elucidate and establish evidence-based recommendations regarding the type, timing, and dose of vasopressors to further enhance free flap survival and patient outcomes.

Aberrant Superficial Branch of the Radial Nerve-Radial Forearm Free Flap Considerations.

The superficial branch of the radial nerve (SBRN) is encountered and must be preserved during the harvest of a radial forearm free flap (RFFF). An abnormal course of the SBRN was encountered during the harvest of an RFFF. The nerve had an abnormal course with two branches-in the proximal forearm, one branch was anterior and the second branch was posterior to the brachioradialis muscle and in the distal forearm, both of these nerves merged together. A review of the literature was performed, with no such documented aberrant course of the SBRN being described previously. Knowledge of the SBRN anatomy and its variations is important to note during the RFFF harvest.

Nonsurgical management of human immunodeficiency virus-associated parotid cysts: A systematic review and meta-analysis.

BACKGROUND: The purpose of this clinical review was to analyze the effectiveness of nonsurgical management options for human immunodeficiency virus (HIV)-associated parotid cysts. METHODS: We conducted systematic and meta-analysis reviews. Primary outcomes were complete or partial responses. RESULTS: Systematic review identified 12 relevant studies. The average rates of complete response for antiretroviral therapy (ART), sclerotherapy, and fine-needle aspiration (FNA) were 52.8%, 55.5%, and 33.3%, respectively. Three radiotherapy studies, totaling 104 patients, were included in a meta-analysis. Patients receiving high-dose therapy achieved complete and partial response rates of 65.8% (95% confidence interval [CI] 54.3%-76.2%) and 25.2% (95% CI 16.1%-36.3%), respectively. Patients receiving low-dose therapy achieved complete and partial response rates of 23.2% (95% CI 1.2%-60.9%) and 22.3% (95% CI 5.2%-87.8%), respectively. The rate of complete response was significantly greater for high-dose radiotherapy compared to low-dose (P < .001). CONCLUSION: Among nonsurgical treatment modalities for HIV-associated parotid cysts, radiotherapy has the highest number of reported outcomes in the literature and our analysis suggests that higher dose radiotherapy has higher rates of achieving complete response.

Olfactory Outcomes after Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Meta-analysis.

OBJECTIVE: To use combined pre- and postsurgical olfactory outcomes to assess the impact of endoscopic sinus surgery on chronic rhinosinusitis-related olfactory impairment. DATA SOURCES: CINAHL, Cochrane, OVID, EMBASE, PubMed, and SCOPUS. Each database was searched from inception up to October 2015. REVIEW METHODS: Studies were included that reported subjective or objective olfactory data in chronic rhinosinusitis patients before and after endoscopic sinus surgery. RESULTS: Thirty-one studies were used in the meta-analysis. Weighted mean differences of olfactory measures demonstrated significant improvement in mixed CRS patients (those with and without polyps) through visual analog scales (-0.83, P = .001), altered taste/smell item on Sinonasal Outcome Test (-1.32, P < .00001), 40-item Smell Identification Test (3.49, P = .0010), and Sniffin' Sticks identification (0.34, P = .03). Chronic rhinosinusitis mixed patients demonstrated nonsignificant improvements via Sniffin' Sticks threshold (1.60, P = .16) and Brief Smell Identification Test (0.20, P = .32). When separated, polyp patients and dysosmic patients experienced the highest levels of olfactory improvement. Polyp patients improved by 7.87 (P = .006) on the 40-item Smell Identification test, 11.54 (P < .0001) with the Sniffin' Sticks total score, and 2.57 (P < .00001) through Sniffin' Sticks identification. Dysosmic patients improved by 5.75 via the 40-item Smell Identification Test (P = .0001). CONCLUSION: Endoscopic sinus surgery improves nearly all subjective and objective measures of olfaction in chronic rhinosinusitis patients. Patients with nasal polyposis or preoperative olfactory dysfunction improve to a greater degree.