Robotic Surgery for Head and Neck Tumors: What are the Current Applications?

BACKGROUND: The journey from radical treatments to the precision of robotic surgery underscores a commitment to innovation and patient-centered care in the field of head and neck oncology. PURPOSE OF REVIEW: This article provides a comprehensive overview that not only informs but also stimulates ongoing discourse and investigation into the optimization of patient care through robotic surgery. The literature on current robotic applications within head and neck region was systematically reviewed. RECENT FINDINGS: Thirty-four studies with a total of 1835 patients undergoing robotic surgery in head and neck region were included. Clinical staging, histological types, operative duration, postoperative complications, functional recovery and survival outcomes were compared and evaluated. Clinical outcomes have shown promising results and thus the indication on the robotic usage has no longer been limited to oropharyngeal region but from skull base to neck dissection. The latest advancement in robotic surgery further refines the capabilities of surgeons into previously difficult-to-access head and neck regions and heralds a new era of surgical treatment for head and neck oncology.

Integrative analysis reveals associations between oral microbiota dysbiosis and host genetic and epigenetic aberrations in oral cavity squamous cell carcinoma.

Dysbiosis of the human oral microbiota has been reported to be associated with oral cavity squamous cell carcinoma (OSCC) while the host-microbiota interactions with respect to the potential impact of pathogenic bacteria on host genomic and epigenomic abnormalities remain poorly studied. In this study, the mucosal bacterial community, host genome-wide transcriptome and DNA CpG methylation were simultaneously profiled in tumors and their adjacent normal tissues of OSCC patients. Significant enrichment in the relative abundance of seven bacteria species (Fusobacterium nucleatum, Treponema medium, Peptostreptococcus stomatis, Gemella morbillorum, Catonella morbi, Peptoanaerobacter yurli and Peptococcus simiae) were observed in OSCC tumor microenvironment. These tumor-enriched bacteria formed 254 positive correlations with 206 up-regulated host genes, mainly involving signaling pathways related to cell adhesion, migration and proliferation. Integrative analysis of bacteria-transcriptome and bacteria-methylation correlations identified at least 20 dysregulated host genes with inverted CpG methylation in their promoter regions associated with enrichment of bacterial pathogens, implying a potential of pathogenic bacteria to regulate gene expression, in part, through epigenetic alterations. An in vitro model further confirmed that Fusobacterium nucleatum might contribute to cellular invasion via crosstalk with E-cadherin/ß-catenin signaling, TNFα/NF-κB pathway and extracellular matrix remodeling by up-regulating SNAI2 gene, a key transcription factor of epithelial-mesenchymal transition (EMT). Our work using multi-omics approaches explored complex host-microbiota interactions and provided important insights into genetic and functional basis in OSCC tumorigenesis, which may serve as a precursor for hypothesis-driven study to better understand the causational relationship of pathogenic bacteria in this deadly cancer.

A single centre experience on the formation of double barrelled uro-colostomy in pelvic exenteration surgery: a cohort study.

BACKGROUND: Double barrelled uro-colostomy (DBUC) is an alternative to traditional ileal conduit (IC) and separate colostomy in patients requiring simultaneous urinary and faecal diversion for reconstruction in pelvic exenteration surgery (PES). METHODS: This cohort study evaluated short- and long-term morbidity and mortality associated with DBUC formation in 20 consecutive adult patients undergoing PES in an Australian Complex Pelvic Surgical Unit. Data were obtained from a prospective database. RESULTS: Mean age 59 years (range 27-76 years). PES was performed for malignant disease in 18 patients (curative intent in 17). Mean operative duration 11.8 h (range 7-17 h). Mean follow-up duration 29.1 months (range 2.6-90.1 months). Early DBUC-related complications occurred in four patients (20.0%): urinary tract infection (UTI)/urosepsis (n = 4) and early ureteric stenosis requiring intervention (n = 1). Late DBUC-related complications occurred in five patients (25.0%): recurrent UTI/urosepsis (n = 4), chronic kidney disease (n = 4), ureteric stenosis (n = 2) and parastomal hernia (n = 4). No mortality occurred secondary to a DBUC complication. CONCLUSION: DBUC is a safe reconstructive option with acceptable morbidity profile in patients requiring simultaneous urinary and faecal diversion.

A Safety and Feasibility Trial of Ultrasound-Guided Radiofrequency Ablation of Parotid Warthin's Tumor.

OBJECTIVE: To determine if ultrasound-guided (USG) radiofrequency ablation (RFA) of Parotid Warthin's tumor under local anesthesia is a safe and effective procedure. STUDY DESIGN: Safety and feasibility study. SETTING: Tertiary academic medical center. METHODS: This is an IDEAL phase 2a trial in a tertiary referral center. Twenty patients with Parotid Warthin's tumor were recruited. RFA was done between September and December 2021 for all 20 patients using a CoATherm AK-F200 machine with a disposable, 18G × 7 mm radiofrequency electrode. Results and follow-up statistics were compared with a historic sample of patients with parotid Warthin's tumor who underwent parotidectomy between 2019 and 2021 in the same center. RESULTS: Nineteen patients were included in the analysis as 1 patient dropped out after 4 weeks of follow-up. The mean age for the RFA group was 67 years old with most of them being male smokers. At a median of 45 weeks (44-47 weeks) postprocedure there was a 7.48 mL (68.4%) volume reduction compared to baseline. Three patients had transient facial nerve (FN) paresis, 1 recovered within hours, and the other 2 by 12 weeks follow-up. Three patients had great auricular nerve numbness; 1 patient had infected hematoma treated in an out-patient manner. Compared to a historic cohort of parotidectomy patients for Warthin's tumor, there was no significant difference in FN paresis and other minor complications between the 2 treatment modalities. CONCLUSION: The current analysis suggests that USG RFA of Warthin's Tumor is a safe alternative to parotidectomy with shorter operative time and length of stay.

Quality of life and swallowing outcomes after early proactive swallowing rehabilitation by either transcutaneous neuromuscular electrical stimulation or exercise-based swallowing training in patients with nasopharyngeal carcinoma after radiotherapy.

Background: Exercise-based swallowing training (EBST) and transcutaneous neuromuscular electrical stimulation (TNMES) are common modalities used to treat late dysphagia after radiotherapy for nasopharyngeal carcinoma (NPC). We aimed to investigate and compare the efficacies of EBST and TNMES as proactive treatments administered early after radiotherapy. Methods: Patients with early post-radiotherapy NPC (n = 120) underwent either TNMES or EBST. Flexible endoscopic evaluation of swallowing (FEES), quality of life (QOL), and swallowing function questionnaires were completed before the intervention as well as immediately, 6, and 12 months after the intervention. Outcome measures included the scores for the swallowing function score (SFS), penetration and aspiration scale (PAS), dynamic imaging grade of swallowing toxicity (DIGEST), functional oral intake scale (FOIS), swallowing performance status scale (SPSS), pharyngeal motor impairment (PMI), pharyngeal function impairment (PFI), and functional assessment after cancer therapy-nasopharyngeal (FACT-NP) questionnaire. Results: Three months after radiotherapy, 31 and 34 patients underwent TNMES and EBST, respectively, and completed swallowing assessments at all four assessment timepoints. All patients showed post-radiotherapy impairments in the SFS, PAS, DIGEST, PMI, and PFI. Compared with the EBST group, the TNMES group showed significant improvements in the PFI and PMI scores, with small-to-medium effect sizes. Additionally, compared with the EBST group, the TNMES group demonstrated a trend toward slightly better improvements in the PAS, DIGEST, FOIS, and SPSS scores immediately and 6 months after the intervention. The SFS scores improved from baseline in both groups; however, the TNMES group showed an earlier improvement. Finally, the TNMES group showed better QOL according to the FACT-NP than the EBST group. Conclusion: Proactive TMNES and EBST are safe and feasible modalities for improving swallowing in patients with NPC when administered early after radiotherapy. Although TNMES showed better results than EBST, these results should be interpreted with caution given the study limitations. Level of evidence: 1B.

Endoscopic stone management in an ectopic ureter inserting into the prostatic urethra.

We report a case of successful endoscopic stone management in a patient with ectopic ureteric insertion. The patient had a complete duplex collecting system, with the upper moiety ureter inserting ectopically into his prostatic urethra, and an obstructing ureteric stone in the distal portion of the ectopic ureter. This made both characterisation of the patient's anatomy and initial emergency stone management challenging.The case offers several learning points for clinicians who may encounter similar situations. By describing the challenges of managing this patient's presentation, we highlight considerations in imaging interpretation and operative approach that may help the reader manage a similar presentation to their practice. Additionally, we remind the urologist to consider the implications of an ectopic duplex ureter on future procedures, such as transurethral resection of the prostate or radical prostatectomy.

Combining Transoral Nasopharyngeal Brush and Plasma Epstein-Barr Virus DNA in Detecting Locally Recurrent Nasopharyngeal Carcinoma.

OBJECTIVE: To evaluate the sensitivities and specificities of Epstein-Barr virus (EBV) DNA in the detection of locally recurrent or persistent nasopharyngeal carcinoma (NPC) through nasopharyngeal (NP) brush biopsy and plasma, respectively, and whether a combination of both would be superior to the individual tests. STUDY DESIGN: A case-control study was conducted from September 2016 to June 2022. SETTING: A multicentre study at 3 tertiary referral centers in Hong Kong was conducted by the Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong. METHODS: Twenty-seven patients with biopsy-confirmed locally recurrent NPC were recruited as study subjects. Magnetic resonance imaging was performed to rule out regional recurrence. The control group consisted of 58 patients with a prior history of NPC who were now disease-free based on endoscopic and imaging findings. Patients underwent both the transoral NP brush (NP Screen®) and blood for plasma Epstein-Barr DNA levels. RESULTS: The sensitivity and specificity of the combined modalities were 84.62% and 85.19%, respectively. The positive predictive value was 73.33% and the negative predictive value was 92.0%. CONCLUSION: The combination of NP brush biopsy and plasma EBV DNA is potentially an additional surveillance modality in detecting the local recurrence of NPC. Further study with a larger sample size would be required to validate the cutoff values.

Convergent dysbiosis of upper aerodigestive microbiota between patients with esophageal and oral cavity squamous cell carcinoma.

The bidirectional association between primary esophageal squamous cell carcinoma (ESCC) and oral cavity squamous cell carcinoma (OSCC) suggests common risk factors and oncogenic molecular processes but it is unclear whether these two cancers display similar patterns of dysbiosis in their upper aerodigestive microbiota (UADM). We conducted a case-control study to characterize the microbial communities in esophageal lavage samples from 49 ESCC patients and oral rinse samples from 91 OSCC patients using 16S rRNA V3-V4 amplicon sequencing. Compared with their respective non-SCC controls from the same anatomical sites, 32 and 45 discriminative bacterial genera were detected in ESCC and OSCC patients, respectively. Interestingly, 20 of them were commonly enriched or depleted in both types of cancer, suggesting a convergent niche adaptation of upper aerodigestive SCC-associated bacteria that may play important roles in the pathogenesis of malignancies. Notably, Fusobacterium, Selenomonas, Peptoanaerobacter and Peptostreptococcus were enriched in both ESCC and OSCC, whereas Streptococcus and Granulicatelia were commonly depleted. We further identified Fusobacterium nucleatum as the most abundant species enriched in the upper aerodigestive SCC microenvironment, and the higher relative abundances of Selenomonas danae and Treponema maroon were positively correlated with smoking. In addition, predicted functional analysis revealed several depleted (eg, lipoic acid and pyruvate metabolism) and enriched (eg, RNA polymerase and nucleotide excision repair) pathways common to both cancers. Our findings reveal a convergent dysbiosis in the UADM between patients with ESCC and OSCC, suggesting a shared niche adaptation of host-microbiota interactions in the pathogenesis of upper aerodigestive tract malignancies.

Characterization of oral microbiota in HPV and non-HPV head and neck squamous cell carcinoma and its association with patient outcomes.

OBJECTIVE: To investigate the interplay among the oral microbiota, HPV infection, traditional risk factors and patient outcomes in head and neck squamous cell carcinoma (HNSCC). MATERIALS AND METHODS: A multi-center study of HNSCC patients with paired tumor and control tissues. We characterized the oral microbiota and HPV infection of tissues in 166 Chinese adults by sequencing the bacterial 16S rRNA V3-V4 and HPV L1 regions, respectively, and examined the associations among the oral microbiota, HPV and clinical features. RESULTS: A total of 15.7% of the surveyed HNSCC patients were positive for HPV DNA, with infection rates varying from 66.7% in oropharyngeal SCC to 10.4% in oral cavity SCC (OSCC). No HPV infection was detected in the surveyed hypopharyngeal SCC. HPV16 was largely the predominant type. HPV infection in non-OSCC, especially oropharyngeal SCC, was associated with advanced N stage and superior survival outcomes. Oral microbiota dysbiosis was observed in HNSCC tumors, with differentially abundant taxa mainly associated with HNSCC subtype, T stage, survival/relapse, HPV infection, and smoking. Notably, the enrichment of Fusobacterium in tumor tissues of OSCC patients was associated with no smoking, early T stage, early N stage, and better 3-year disease-specific survival. CONCLUSION: Our findings underscore the involvement of oral microbiota dysbiosis in OSCC pathogenesis, Fusobacterium is involved with improved OSCC patient outcomes, especially in patients lacking traditional risk factors. Understanding the complex interactions among the oral microbiota, HPV infection and other risk factors for HNSCC will provide important insights into the pathogenesis of HNSCC.

Comparison of the performance of conventional and spectral-based tagged stool cleansing algorithms at CT colonography.

OBJECTIVES: To compare the performance of conventional versus spectral-based electronic stool cleansing for iodine-tagged CT colonography (CTC) using a dual-layer spectral detector scanner. METHODS: We retrospectively evaluated iodine contrast stool-tagged CTC scans of 30 consecutive patients (mean age: 69 ± 8 years) undergoing colorectal cancer screening obtained on a dual-layer spectral detector CT scanner. One reader identified locations of electronic cleansing artifacts (n = 229) on conventional and spectral cleansed images. Three additional independent readers evaluated these locations using a conventional cleansing algorithm (Intellispace Portal) and two experimental spectral cleansing algorithms (i.e., fully transparent and translucent tagged stool). For each cleansed image set, readers recorded the severity of over- and under-cleansing artifacts on a 5-point Likert scale (0 = none to 4 = severe) and readability compared to uncleansed images. Wilcoxon's signed-rank tests were used to assess artifact severity, type, and readability (worse, unchanged, or better). RESULTS: Compared with conventional cleansing (66% score ≥ 2), the severity of overall cleansing artifacts was lower in transparent (60% score ≥ 2, p = 0.011) and translucent (50% score ≥ 2, p < 0.001) spectral cleansing. Under-cleansing artifact severity was lower in transparent (49% score ≥ 2, p < 0.001) and translucent (39% score ≥ 2, p < 0.001) spectral cleansing compared with conventional cleansing (60% score ≥ 2). Over-cleansing artifact severity was worse in transparent (17% score ≥ 2, p < 0.001) and translucent (14% score ≥ 2, p = 0.023) spectral cleansing compared with conventional cleansing (9% score ≥ 2). Overall readability was significantly improved in transparent (p < 0.001) and translucent (p < 0.001) spectral cleansing compared with conventional cleansing. CONCLUSIONS: Spectral cleansing provided more robust electronic stool cleansing of iodine-tagged stool at CTC than conventional cleansing. KEY POINTS: • Spectral-based electronic cleansing of tagged stool at CT colonography provides higher quality images with less perception of artifacts than does conventional cleansing. • Spectral-based electronic cleansing could potentially advance minimally cathartic approach for CT colonography. Further clinical trials are warranted.

Restoration of the Oral Microbiota After Surgery for Head and Neck Squamous Cell Carcinoma Is Associated With Patient Outcomes.

OBJECTIVE: To evaluate the dynamics of the oral microbiome and associated patient outcomes following treatment of head and neck squamous cell carcinoma (HNSCC). MATERIALS AND METHODS: This was a prospective cohort study at a tertiary academic center in Hong Kong SAR of patients with head and neck squamous cell carcinoma evaluating the oral microbiome in pre- and postsurgery oral rinses (at 1, 3, and 6 months) with 16S rRNA gene V3-V4 amplicon sequencing. RESULTS: In total, 76 HNSCC patients were evaluated. There was a significantly depressed alpha diversities of oral microbial communities observed in HNSCC oral rinse samples within the first 6 months post-surgery when compared to presurgery or healthy controls. Distant clustering between pre- and postsurgery was also observed (p < 0.022). Following treatment, eight oral bacterial genera showed a trend towards the restoration in the relative abundances that approximate healthy persons. In evaluating patient outcomes, the decreased relative abundance of three periodontal bacteria (Capnocytophaga, Prevotella 7, and Leptotrichia) and the increased relative abundance of two commensal bacteria (Streptococcus and Rothia) at 6 months postsurgery compared to presurgery showed a better 3-year disease-specific survival (a cutoff of Kaplan-Meier survival curve test p < 0.3 at 36 months). In particular, the postsurgery restoration of Prevotella 7 was statistically significant in the surveyed patients (survival rate of 84% vs. 56% at 36 months, p = 0.0065). CONCLUSIONS: Oral microbiome dysbiosis associated with HNSCC is dynamic. These dynamics of the oral microbiome postsurgery are also associated with patient treatment and outcomes and may serve as potential biomarkers for patient management in HNSCC.

Proteomic Analysis of Circulating Extracellular Vesicles Identifies Potential Biomarkers for Lymph Node Metastasis in Oral Tongue Squamous Cell Carcinoma.

Lymph node metastasis is the most reliable indicator of a poor prognosis for patients with oral tongue cancers. Currently, there are no biomarkers to predict whether a cancer will spread in the future if it has not already spread at the time of diagnosis. The aim of this study was to quantitatively profile the proteomes of extracellular vesicles (EVs) isolated from blood samples taken from patients with oral tongue squamous cell carcinoma with and without lymph node involvement and non-cancer controls. EVs were enriched using size exclusion chromatography (SEC) from pooled plasma samples of patients with non-nodal and nodal oral tongue squamous cell carcinoma (OTSCC) and non-cancer controls. Protein cargo was quantitatively profiled using isobaric labelling (iTRAQ) and two-dimensional high-performance liquid chromatography followed by tandem mass spectrometry. We identified 208 EV associated proteins and, after filtering, generated a short list of 136 proteins. Over 85% of the EV-associated proteins were associated with the GO cellular compartment term "extracellular exosome". Comparisons between non-cancer controls and oral tongue squamous cell carcinoma with and without lymph node involvement revealed 43 unique candidate EV-associated proteins with deregulated expression patterns. The shortlisted EV associated proteins described here may be useful discriminatory biomarkers for differentiating OTSCC with and without nodal disease or non-cancer controls.

Music during flexible cystoscopy for pain and anxiety - a patient-blinded randomised control trial.

OBJECTIVES: To assess the role of music in reducing the pain and anxiety associated with flexible cystoscopy using a blinded trial design. PATIENTS AND METHODS: A patient-blinded randomised control trial of music during flexible cystoscopy was performed comparing the pain, measured by visual analogue scale (VAS), anxiety, measured by the State-Trait Anxiety Inventory (STAI), and vital signs of 109 patients across two public hospitals in New South Wales, Australia. The purpose and hypothesis of the study was concealed from patients until after results had been collected. RESULTS: There were no statistically significant differences detected between the No Music and Music groups in VAS pain score (mean [SD] 2.04 [1.94] vs 2.10 [1.90], P = 0.86), change in STAI anxiety score (mean [SD] 4.87 [9.87] vs 6.8 [11.07], P = 0.33) or post-procedural vital signs (mean [SD] heart rate 74 [14] vs 72 [13] beats/min, P = 0.66; systolic blood pressure 144 [20] vs 141 [19] mmHg, P = 0.47) between the two groups. CONCLUSION: Music does not appear to decrease perceived pain or anxiety when used during flexible cystoscopy. These findings may differ from the literature due to several factors, most significantly blinding of participants, but also potentially due to the ethnic composition of the study population or lack of choice of music.

Droplet digital PCR of tumor suppressor gene methylation in serial oral rinses of patients with head and neck squamous cell carcinoma.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) currently lacks sensitive approaches to detect cancer-related traits in body fluid. METHODS: Methylation of tumor suppressor genes (TSGs) (PAX5, EDNRB, and DCC) were measured in the oral rinses from 50 HNSCC and 58 control subjects using droplet digital PCR (ddPCR). Diagnostic accuracies in detecting HNSCC and the detection rate of recurrence in the post-treatment monitoring were analyzed. RESULTS: ddPCR TSG methylation detection in oral rinses for diagnosis of HNSCC had an AUC of 0.892 for PAX5, 0.753 for EDNRB, and 0.729 for DCC. Significant drop of TSG methylation was observed after completion of surgery (p < 0.01). 76.9% of the relapse cases had a pre-emptive rebound of methylation above presurgery levels in at least one of the tested markers before confirmed recurrence. CONCLUSIONS: Utilizing ddPCR for TSG methylation detection in oral rinses shows potential for detection and monitoring of HNSCC.

Optimization of imaging parameters in chest CT for COVID-19 patients: an experimental phantom study.

BACKGROUND: With the global outbreak of coronavirus disease 2019 (COVID-19), chest computed tomography (CT) is vital for diagnosis and follow-up. The increasing contribution of CT to the population-collected dose has become a topic of interest. Radiation dose optimization for chest CT of COVID-19 patients is of importance in clinical practice. The present study aimed to investigate the factors affecting the detection of ground-glass nodules and exudative lesions in chest CT among COVID-19 patients and to find an appropriate combination of imaging parameters that optimize detection while effectively reducing the radiation dose. METHODS: The anthropomorphic thorax phantom, with 9 spherical nodules of different diameters and CT values of -800, -630, and 100 HU, was used to simulate the lesions of COVID-19 patients. Four custom-simulated lesions of porcine fat and ethanol were also scanned at 3 tube potentials (120, 100, and 80 kV) and corresponding milliampere-seconds (mAs) (ranging from 10 to 100). Separate scans were performed at pitches of 0.6, 0.8, 1.0, 1.15, and 1.49, and at collimations of 10, 20, 40, and 80 mm at 80 kV and 100 mAs. CT values and standard deviations of simulated nodules and lesions were measured, and radiation dose quantity (volume CT dose index; CTDIvol) was collected. Contrast-to-noise ratio (CNR) and figure of merit (FOM) were calculated. All images were subjectively evaluated by 2 radiologists to determine whether the nodules were detectable and if the overall image quality met diagnostic requirements. RESULTS: All simulated lesions, except -800 HU nodules, were detected at all scanning conditions. At a fixed voltage of 120 or 100 kV, with increasing mAs, image noise tended to decrease, and the CNR tended to increase (F=9.694 and P=0.033 for 120 kV; F=9.028 and P=0.034 for 100 kV). The FOM trend was the same as that of CNR (F=2.768 and P=0.174 for 120 kV; F=1.915 and P=0.255 for 100 kV). At 80 kV, the CNRs and FOMs had no significant change with increasing mAs (F=4.522 and P=0.114 for CNRs; F=1.212 and P=0.351 for FOMs). For the 4 nodules of -800 and -630 HU, CNRs had no statistical differences at each of the 5 pitches (F=0.673, P=0.476). The CNRs and FOMs at each of the 4 collimations had no statistical differences (F=2.509 and P=0.125 for CNRs; F=1.485 and P=0.309 for FOMs) for each nodule. CNRs and subjective evaluation scores increased with increasing parameter values for each imaging iteration. The CNRs of 4 -800 HU nodules in the qualified images at the thresholds of scanning parameters of 120 kV/20 mAs, 100 kV/40 mAs, and 80 kV/80 mAs, had statistical differences (P=0.038), but the FOMs had no statistical differences (P=0.085). Under the 3 threshold conditions, the CNRs and FOMs of the 4 nodules were highest at 100 kV and 40 mAs (1.6 mGy CTDIvol). CONCLUSIONS: For chest CT among COVID-19 patients, it is recommended that 100 kV/40 mAs is used for average patients; the radiation dose can be reduced to 1.6 mGy with qualified images to detect ground-glass nodules and exudation lesions.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

The Intersection between Oral Microbiota, Host Gene Methylation and Patient Outcomes in Head and Neck Squamous Cell Carcinoma.

The role of oral microbiota in head and neck squamous cell carcinoma (HNSCC) is poorly understood. Here we sought to evaluate the association of the bacterial microbiome with host gene methylation and patient outcomes, and to explore its potential as a biomarker for early detection or intervention. Here we performed 16S rRNA gene amplicon sequencing in sixty-eight HNSCC patients across both tissue and oral rinse samples to identify oral bacteria with differential abundance between HNSCC and controls. A subset of thirty-one pairs of HNSCC tumor tissues and the adjacent normal tissues were characterized for host gene methylation profile using bisulfite capture sequencing. We observed significant enrichments of Fusobacterium and Peptostreptococcus in HNSCC tumor tissues when compared to the adjacent normal tissues, and in HNSCC oral rinses when compared to healthy subjects, while ten other bacterial genera were largely depleted. These HNSCC-related bacteria were discriminative for HNSCC and controls with area under the receiver operating curves (AUCs) of 0.84 and 0.86 in tissue and oral rinse samples, respectively. Moreover, Fusobacterium nucleatum abundance in HNSCC cases was strongly associated with non-smokers, lower tumor stage, lower rate of recurrence, and improved disease-specific survival. An integrative analysis identified that enrichment of F. nucleatum was associated with host gene promoter methylation, including hypermethylation of tumor suppressor genes LXN and SMARCA2, for which gene expressions were downregulated in the HNSCC cohort from The Cancer Genome Atlas. In conclusion, we identified a taxonomically defined microbial consortium associated with HNSCC that may have clinical potential regarding biomarkers for early detection or intervention. Host-microbe interactions between F. nucleatum enrichment and clinical outcomes or host gene methylation imply a potential role of F. nucleatum as a pro-inflammatory driver in initiating HNSCC without traditional risk factors, which warrants further investigation for the underlying mechanisms.

A useful landmark to locate the external branch of the superior laryngeal nerve during thyroidectomy.

BACKGROUND: To determine whether the insertion of the sternothyroid muscle onto the oblique line of the thyroid cartilage can be used to reliably locate the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy. METHODS: This is a prospective descriptive case series. The EBSLN was identified and confirmed with a nerve stimulator during thyroid surgery. The entry point of the EBSLN into the inferior constrictor/cricothyroid muscle was measured in relation to the insertion and anterior border of the sternothyroid muscle. The perpendicular distance from the insertion of the sternothyroid muscle onto the oblique line was designated the vertical distance (VD) of the nerve entry point (NEP), and the perpendicular distance from the anterior border of the sternothyroid muscle was designated the horizontal distance. RESULTS: Ninety patients underwent 130 thyroid lobectomies (60 female, 30 male) (mean age 53.5 years, range, 18-91 years). An attempt to identify the nerve was made in 127 thyroid lobectomies. The EBSLN was identified in 111 cases (87.4%). The mean VD of the NEP from the muscle insertion was 1.1 mm (SD 1.1 mm, range, 0-5 mm) and the mean horizontal distance (HD) was 9.5 mm (SD 3.8 mm, range, 2-21 mm). CONCLUSIONS: The EBSLN muscle entry point usually lies 1.1 mm from the sternothyroid insertion onto the oblique line, and 5-12 mm from the anterior border of the muscle. These useful landmarks allow the nerve to be consistently located, identified and preserved during thyroid surgery prior to ligating the superior thyroid vessels.

Care of Patients With a Laryngectomy During the COVID-19 Pandemic.

Patients with a laryngectomy are at increased risk for droplet-transmitted diseases and, therefore, COVID-19, which has now caused a worldwide pandemic. Adaptive measures to protect patients with a laryngectomy and their families were designed and implemented in the Hong Kong SAR (HK). Driven by the fear of severe acute respiratory syndrome in 2003, hospitals in HK have since modified infection control routines to prevent a repeat public health nightmare. To face COVID-19, caused by SARS-CoV-2, we have adapted guidelines for our patients with a laryngectomy. Contact precautions, droplet precautions with physical barriers, and hand and equipment hygiene are our mainstays of prevention against COVID-19, and sharing these routines is the aim of this article. The COVID-19 pandemic is still roaring ahead. Awareness and precautions for patients with a laryngectomy who may be at higher risk are outlined here and should be maintained during the current pandemic.