Transoral non-robotic surgery for oropharyngeal squamous cell carcinoma.

PURPOSE: This retrospective cohort study aims to evaluate the clinical, oncological, and functional outcomes of transoral non-robotic surgery for oropharyngeal squamous cell carcinoma (OPSCC). MATERIALS AND METHODS: Data from 131 patients with surgically treated OPSCC (2010-2022) were analyzed. Patients who underwent exclusively transoral surgery were included in the study. The surgeries were performed under microscopic or endoscopic guidance and either a CO2 laser or an ultrasound/radiofrequency scalpel was used as a cutting instrument, depending on the characteristics and location of the tumor. Functional outcomes were assessed in terms of length of hospital stay, tracheostomy rate, duration of feeding tube dependency and complications. Survival outcomes were assessed in terms of overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS). RESULTS: Of 74 included patients, transoral surgery demonstrated safety with no major complications. Tracheotomy was performed in 51.4 % of cases, and was maintained for a median of 10 days. Complete swallowing recovery was restored in 97.3 % of cases, after a median of 5 days. The median length of hospital stay was 12 days. At 5 years, OS was 68.2 %, PFS was 58.2 % and DSS was 83.6 %. CONCLUSION: The study confirms the safety and efficacy of a transoral approach for OPSCC. Having the capability to utilize and access a variety of tools provides the opportunity to tailor the technique to the individual patient and specific circumstances.

MRI and frozen section evaluation of mylohyoid muscle in determining surgical approach for T2-T3 floor of the mouth cancer.

PURPOSE: The choice of surgical approach for floor of the mouth (FOM) cancer, particularly for intermediate-stage tumors (cT2-cT3), remains controversial. This study aims to evaluate a method considering mylohyoid muscle (MM) invasion as a determinant for surgical approach selection, utilizing magnetic resonance imaging (MRI) preoperatively and frozen section (FS) analysis intraoperatively. METHODS: This observational retrospective cohort study analyzed patients undergoing surgical resection of cT2 and cT3 FOM squamous cell carcinoma (SCC) between January 2013 and June 2023. MM infiltration assessed by preoperative MRI determined the surgical approach: clear infiltration led to compartmental surgery (CS), while doubtful or absent infiltration led to transoral surgery (TOS). Conversion from TOS to CS occurred intraoperatively based on macroscopic evidence or positive FS. Data collected included demographic, clinical, surgical, and pathological variables. Survival analysis was conducted using Kaplan-Meier method. RESULTS: Among 44 patients included, majority had cT2 tumors (59.1%). MM resection was necessary in 22.7% of cases. Overall survival (OS) and progression-free survival (PFS) did not significantly differ between TOS and CS groups. Radiological depth of invasion (rDOI) < 10 mm is correlated with MM preservation in 89% of cases, while rDOI > 10 mm is correlated with MM resection only in 23.8% of cases. Pathological depth of invasion (pDOI) discrepancies were observed in the two groups: in CS group is shown a higher pDOI (> 10 mm) confirmation (90%). Surgical complications and functional outcomes differed between TOS and CS groups. CONCLUSION: Considering MM invasion for surgical approach selection in cT2-cT3 FOM tumors appears oncologically safe, with better functional outcomes in muscle preservation. Preoperative MRI for MM assessment combined with intraoperative FS analysis provides reliable guidance for surgical decision-making.

Impact of time-to-surgery on survival and quality of life in oral cancer.

PURPOSE: To investigate the association between time-to-surgery (TTS) and overall survival (OS), disease specific survival (DSS) and quality of life (QoL) in patients with oral squamous cell carcinoma (OSCC). MATERIALS AND METHODS: 116 patients with OSCC candidate to surgery were examined. TTS intervals starting from diagnosis (TTS-clinical-based) and from histological reports (TTS-biopsy-based) were calculated. The effects of TTS intervals and prognostic factors on 5-year OS and DSS were explored. RESULTS: In our cohort advanced T-categories OSCCs with TTS < 30 days showed a trend to have higher DSS rate (p = 0.049). Patients with TTS-clinical-based < 30 days showed better postoperative QoL. Positive surgical margins, nodal involvement (pN+), DOI >10 mm, invasive surgery and extra-capsular extension in pN+ were found to be significantly associated with a poor OS and DSS. CONCLUSIONS: TTS ≥ 30 days can adversely affect DSS, especially in the advanced T categories. Short TTS intervals resulted associated with a better postoperative QoL.

Is there a role for tumor volume in prediction of prognosis for oral cancer?

PURPOSE: New prognostic factors in oral squamous cell carcinoma (OSCC) (tumor-, host-, and environment-related) have been introduced recently to complete those traditionally considered. Among them, tumor volume (TV) could be the most interesting and applicable in clinical practice, considering the routine use of computed tomography in tumor staging. In this retrospective study we aimed to investigate whether a correlation exists among these new prognostic factors and survival outcomes. METERIALS AND METHODS: We collected data about 140 patients affected by OSCC who underwent primary surgery. Prognostic factors were collected and Overall Survival (OS), Disease Specific Survival (DSS) and Disease Free Survival (DFS) were estimated using Kaplan-Meier method; the Log-Rank test (Mantel-Cox) and Cox regression models were applied to investigate predictors of survival. RESULTS: The 5-year OS, DSS and DFS were 73.6 %, 89.2 % and 75.2 % respectively. Nodal metastasis (pN+), relapse and American Society of Anesthesiologists ASA-II were found independent prognostic factors for OS, and significantly associated to worst DSS (p < 0.001). TV significantly correlated with higher relapse occurrence (p = 0.03). CONCLUSIONS: In our experience, lymph-node status, ASA classification and relapse significantly influenced DSS on univariate analysis. TV could represent an interesting additional parameter, since it significantly influenced DFS. However, prospective studies with standardized TV measurements and a greater number of patients are needed to validate this result.

Oral splint therapy in patients with Menière's disease and temporomandibular disorder: a long-term, controlled study.

PURPOSE: To assess the effect of oral splint therapy on audio-vestibular symptoms in patients with Menière's disease (MD) and temporomandibular disorder (TMD). METHODS: Retrospective case-control study. Treatment group: 37 patients with MD and TMD who received gnatological treatment. CONTROL GROUP: 26 patients with MD and TMD who had never received gnatological treatment. The number of vertigo spells in 6 months (primary endpoint), pure-tone audiometry average (PTA), MD stage, functional level, Dizziness handicap Index (DHI), Tinnitus handicap Index (THI) and Aural Fullness Scale (AFS) were compared at baseline and after 24 months according to groups. Analysis of Covariance was used to determine the treatment effect. RESULTS: Groups were comparable for demographic, clinical data, baseline PTAs and the number of vertigo spells. Analysis of covariance showed a significant effect of gnathological treatment on number of vertigo spells ([Formula: see text] = 0.258, p < 0.001), PTA ([Formula: see text] = 0.201, p < 0.001), MD stage ([Formula: see text] = 0.224, p < 0.001), functional level ([Formula: see text] = 0.424, p < 0.001), DHI ([Formula: see text] = 0.421, p < 0.001), THI ([Formula: see text] = 0.183, p < 0.001), but not for AFS ([Formula: see text] = 0.005, p = 0.582). The treatment group showed vertigo control of class A in 86.5% and class B in 13.5% of patients. In the control group, vertigo control was of class A in 19.2% of patients and class B in 11.5%, class C in 30.8%, class D in 11.5%, class E in 19.2% and class F in 7.7%. Classes of vertigo control differed significantly (X2 test, p < 0.001). CONCLUSIONS: Oral splint therapy could represent a viable treatment in patients with TMD and uncontrolled MD disease. The effects are maintained at least after 2 years.

Relevance of perimarginal nodes for head and neck cancer.

OBJECTIVE: To estimate the prevalence of metastasis in the perimarginal nodes (PMNs) (also known as perifacial, preglandular and retroglandual nodes) in head and neck cancer. METHODS: We recruited 136 patients affected by cancers of the oral cavity, lip, oropharynx, skin and by cáncer of unknown primary (CUP), who were candidates for level IB dissection. PMNs were identified and sent separately for histological analysis. Correlation between metastasis to the PMNs and characteristics of the primary tumour were reported. RESULTS: The incidence of metastasis was 17% from oral cancer, 50% from lip cancer and 12.5% from skin cancer. No metastases were reported for oropharynx cancer or CUP. The only factor that correlated with the incidence of metastases was origin of the tumour from the upper part of oral cavity. CONCLUSION: PMNs represent a frequent site of metastasis in oral and lip cancers. In cancer of the oropharynx, their involvement has not been not reported, while their role in skin cancers remains to be clarified.

Self-reported smell and taste recovery in coronavirus disease 2019 patients: a one-year prospective study.

PURPOSE: The aim of the present study was to estimate the 1 year prevalence and recovery rate of self-reported chemosensory dysfunction in a series of subjects with previous mild-to-moderate symptomatic COVID-19. METHODS: Prospective study based on the SNOT-22, item "sense of smell or taste" and additional outcomes. RESULTS: 268/315 patients (85.1%) completing the survey at baseline also completed the follow-up interview. The 12 months prevalence of self-reported COVID-19 associated chemosensory dysfunction was 21.3% (95% CI 16.5-26.7%). Of the 187 patients who complained of COVID-19 associated chemosensory dysfunction at baseline, 130 (69.5%; 95% CI 62.4-76.0%) reported complete resolution of smell or taste impairment, 41 (21.9%) reported a decrease in the severity, and 16 (8.6%) reported the symptom was unchanged or worse 1 year after onset. The risk of persistence was higher for patients reporting a baseline SNOT-22 score ≥ 4 (OR = 3.32; 95% CI 1.32-8.36) as well as for those requiring ≥ 22 days for a negative swab (OR = 2.18; 95% CI 1.12-4.27). CONCLUSION: A substantial proportion of patients with previous mild-to-moderate symptomatic COVID-19 characterized by new onset of chemosensory dysfunction still complained on altered sense of smell or taste 1 year after the onset.

Disposable chlorine dioxide wipes for high-level disinfection in the ENT department: A systematic review.

BACKGROUND: Nasopharyngoscope reprocessing methods should be effective, rapid and reproducible with moderate cost. Tristel Trio Wipes system (TTWS) is a manual reprocessing method based on chlorine dioxide that has lately emerged in ENT department. This review aims to collect evidence on this system. METHODS: The PubMed, Web of Science and Cochrane Library databases were searched for all the studies on TTWS or one of its components. Data were grouped according to the study type. RESULTS: Ten articles were included in the review. TTWS ensured high-level disinfection in laboratory and clinical setting. Although the limitations of the manual systems, TTWS proved to be faster than automated endoscope reprocessing (AER) and safe for patients and health-care workers. TTWS represented cheaper system than AER or sheaths in low- and medium-volume centers. CONCLUSION: TTWS could be a valid, safe and fast HLD method for nasopharyngoscopes, with reasonable costs for medium-low reprocessing volumes.

Surgical resection of oral cancer: en-bloc versus discontinuous approach.

OBJECTIVES: In the past literature agreed on treating oral carcinomas, using an "en-bloc" resection (EBR) but recently minimally invasive transoral surgery has spread as the preferable treatment for selected cases. This latter technique, which is performed with a discontinuous resection (DR), allows for a satisfactory postoperative quality of life (QoL) maintaining good survival rates. MATERIALS AND METHODS: In this study, we analyzed data about 147 surgically treated patients with oral cancer involving tongue and floor of the mouth. The sample was divided according to the surgical approach: EBR and DR group which were compared in terms of recurrence, overall survival, disease-free survival, and QoL. RESULTS: In the DR group, survival analysis showed better results in term of survival, locoregional control, and postoperative anxiety, while the other QoL scores were similar in the two groups. CONCLUSION: The more invasive approach does not correlate to a better outcome. In selected cases, DR is an oncologically safe technique; EBR is still a valid option to treat advanced oral cancers.

Surgical Anatomy of the Marginal Mandibular Nerve: A Systematic Review and Meta-Analysis.

The high number of marginal mandibular nerve (MMN) anatomical variants have a well-known clinical significance due to the risk of nerve injury in several surgical procedures. The aim of this study was to find and systematize the available anatomical data concerning this nerve. The PubMed and Scopus databases were investigated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All studies reporting extractable data on the origin, course, splitting, anastomosis and relationship of the MMN with the mandible or the facial vessels were included. We included 28 studies analyzing 1861 halves. The MMN had one (PP = 35% 95% CI:18-54%), two (PP =35% 95% CI:18-54%), three (PP = 18% 95% CI:0-35%), or four branches (PP = 2% 95% CI:0-8%). Anastomosis with the great auricular nerve, transverse cervical nerve, mental nerve, and other branches of the facial nerve were defined. The origin of the MMN in relation to the parotid and the mandible was variable. The MMN nearly always crossed the anterior facial vein laterally (PP = 38% 95% CI:9-72% if single, PP = 57% 95% CI:22-90% when multiple); its relation with other vessels was less constant. At least one branch of the MMN was found below the inferior border of the mandible (IBM), with a PP of 39% (95% CI:30-50%). The MMN has high anatomical variability and it is more often represented by one or two branches; its origin is frequently described at the parotid apex and above the IBM, although in its course at least one branch often runs below the IBM. Its most frequent anastomosis is with the buccal branch of the facial nerve. Clin. Anat., 33:739-750, 2020. © 2019 Wiley Periodicals, Inc.

Perimarginal lymph nodes: an undervalued entity in oral cancer.

PURPOSE: In a previous study, we gave a surgical description of a group of lymph nodes in the submandibular area at risk of remaining undissected during neck dissection (ND) for which we have proposed the term "perimarginal nodes" (PMNs) due to their proximity to marginal mandibular nerve (MMN). The aim of this study is to evaluate prevalence of PMNs involvement in oral cavity squamous cell cancer (OCSCC) and to verify if metastases are related to primary tumor characteristics or to the state of the neck. METHODS: We recruited a total of 39 consecutive patients diagnosed with OCSCC candidate to ND. Histological characteristics of PMNs were analyzed and the incidence of metastases in relation to the primary tumor characteristics were noted. RESULTS: PMNs were found to be involved with metastases in 8 patients (20.5%). No characteristic of the primary tumor seems to influence the metastatic involvement of the PMNs. CONCLUSIONS: PMNs represent a frequent site of micro-metastases in patients diagnosed with OCSCC regardless of other characteristics of the primary tumor.

Narrow-band imaging pattern classification in oral cavity.

OBJECTIVE: Narrow-band imaging is widely used in the diagnostic work-up of oral lesions. Different oral subsites present three epithelial types (1, 2a and 2b), each with a different structure and function. The aim of this study was to analyse and describe the different vascular patterns seen on narrow-band imaging according to oral epithelial type and histology. MATERIALS AND METHODS: The narrow-band imaging photographs of healthy, dysplastic and neoplastic oral mucosa were retrospectively reviewed and divided according to epithelial type and histology. The different narrow-band imaging patterns were analysed, related to the clinical appearance of the specific area, accurately described and drawn by a professional designer. RESULTS: The photographs of 302 patients were considered. Six patterns were identified: Normal mucosa exhibited different appearance in each type of epithelium; dysplastic mucosa presented the same pattern in type 1 and 2a epithelia, which differed from that of type 2b epithelium; in cancer, mucosal appearance was identical irrespective of epithelial type, due to complete vascular destruction. CONCLUSIONS: The proposed classification could serve as a guide for clinicians approaching narrowband imaging, especially at early stages of the learning curve, to differentiate normal mucosa from malignant lesions and possibly reduce the number of unnecessary biopsies.

Tailored resections in oral and oropharyngeal cancer using narrow band imaging.

PURPOSE: In a previous pilot study we observed that intra-operative narrow-band imaging (NBI) helps achieve clear superficial resection margins. The aim of this study was to verify if the use of intra-operative NBI can help to obtain tailored resections and if it is influenced by the lesion site, aspects not investigated in our previous study. MATERIALS AND METHODS: The resection margins of 39 oral and 22 oropharyngeal squamous cell carcinomas were first set at 1.5cm from the macroscopic lesion boundary (white light, WL, tattoo). Then, the superficial tumor extension was more precisely defined with NBI, giving rise to three possible situations: NBI tattoo larger than the WL tattoo, NBI tattoo coinciding with the WL tattoo, or NBI tattoo smaller than the WL tattoo. For each of these situations the space comprised between the NBI and WL tattoos was defined "NBI positive", "NBI null", and "NBI negative", respectively. Resections were performed following the outer tattoo. The number of clear superficial resection margins, and the pathological response on the "NBI-positive" and the "NBI-negative" areas were recorded. RESULTS: We obtained 80.3% negative superficial resection margins. NBI provided a more precise definition of superficial tumor extension in 43 patients. Sensitivity, specificity, positive and negative predictive values were 94.4%, 64%, 79.1% and 88.9%, respectively; a test of proportions demonstrated they were not influenced by tumor site. CONCLUSIONS: NBI could allow for real-time definition of superficial tumor extension with possible tailored resections and fewer positive superficial resection margins; it is not influenced by tumor site.

Prognostic role of the MRI-based involvement of superior pharyngeal constrictor muscle in oropharyngeal squamous cell carcinoma.

OBJECTIVES: The aim of this study was to determine the impact of the involvement of the superior pharyngeal constrictor muscle (SPCM) evaluated by magnetic resonance imaging (MRI) on outcome in oropharyngeal squamous cell carcinomas (OPSCCs). METHODS: A retrospective study including consecutive patients with OPSCC treated with curative intent. RESULTS: A total of 82 consecutive patients with OPSCC met inclusion criteria. At multivariate analysis, patients with SPCM infiltration were at significantly higher risk of death (HR: 3.37, CI: 1.21-9.38) and progression (HR: 3.39, CI: 1.38-8.32). In a multivariate model conditioned on HPV status, a significantly higher risk of death and progression was observed by combining both SPCM and HPV status with patients harboring an HPV-negative OPSCC with SPCM infiltration showing the poorest outcome. CONCLUSION: MRI evidence of SPCM involvement significantly and independently increases the risk of death and progression in subjects with OPSCC. Considering both MRI-assessed SPCM infiltration and HPV status significantly improved risk stratification in these malignancies.

HPV impact on oropharyngeal cancer radiological staging: 7th vs 8th edition of AJCC TNM classification.

PURPOSE: To evaluate the agreement between pathological and radiological staging in oropharyngeal cancer by comparing the 7th and the 8th edition of the AJCC TNM system. METHODS: This retrospective cohort study included 57 cases of oropharyngeal cancer with lymph node metastases staged with the 7th and 8th editions of the AJCC TNM system. Comparison between clinical and radiological features and differences in agreement rates were calculated between radiological and pathological staging for the primary tumor (T) and lymph nodes (N) in HPVpos and HPVneg cases. RESULTS: Comparison of HPVpos and HPVneg revealed a significantly different distribution between early and advanced stages in the 8 th edition, with a relevant number of HPVpos patients redefined from advanced stages whit the 7 th ed. to early stages with 8 th ed. (p < 0.01); no significant differences were found when comparing all diagnostic methods for T and N. CONCLUSIONS: The 8th edition of the AJCC TNM seems to lead to better pretreatment staging. For both HPVpos and HPVneg, the agreement between pretreatment radiological and pathological staging.

Impact of lymph node ratio and number of lymph node metastases on survival and recurrence in laryngeal squamous cell carcinoma.

INTRODUCTION: The aim of this study is to assess the impact of lymph node ratio (LNR) and number of positive lymph nodes (NPLN) on mortality and recurrence rates in patients with laryngeal squamous cell carcinoma. MATERIALS AND METHODS: We conducted a retrospective multicenter international study involving 24 Otorhinolaryngology-Head and Neck Surgery divisions. Disease-specific survival (DSS) and disease-free survival (DFS) were evaluated as the main outcomes. The curves for DSS and DFS according to NPLN and LNR were analyzed to identify significant variations and establish specific cut-off values. RESULTS: 2507 patients met the inclusion criteria. DSS and DFS were significantly different in the groups of patients stratified according to LNR and NPLN. The 5-year DSS and DFS based on LNR and NPLN demonstrated an improved ability to stratify patients when compared to pN staging. CONCLUSION: Our data demonstrate the potential prognostic value of NPLN and LNR in laryngeal squamous cell carcinoma.

Accuracy of fine-needle aspiration and frozen section for the detection of squamous metastasis in cystic masses of the lateral neck.

Cystic masses of the lateral neck are mostly benign. However, the incidence of metastatic squamous cell carcinoma (SCC) in cervical cystic masses initially diagnosed as benign is quite high in patients older than 40 years. The aim of this study was to compare the diagnostic accuracy of preoperative cytology and intraoperative frozen section (FS) in detecting malignancy in cystic masses of the neck. We reviewed 61 patients who underwent preoperative ultrasound-guided fine-needle aspiration cytology (FNAC) and neck biopsy of a cystic neck mass, and analysed the concordance between FNAC and intraoperative FS with respect to definitive histology. HPV status was also tested. Of 49 eligible cases, the accuracy of preoperative FNAC was 70.5% (weighted kappa 0.53), meaning moderate agreement between cytology and final diagnosis. Intraoperative FS consultations detected 16 cases of SCC metastasis while the remaining 33 cases were negative for SCC, showing perfect agreement with histology. Since FS results were useful in evaluating cystic neck masses, despite a moderate accuracy of cytology, we suggest intraoperative FS analysis for all cystic neck masses. This technique can allow us to switch to therapeutic neck dissection, multiple upper aerodigestive tract biopsies, tongue base mucosectomy, and bilateral tonsillectomy in the same surgical setting.

Italian validation of the Neck Dissection Impairment Index questionnaire.

Objective: The Neck Dissection Impairment Index (NDII) questionnaire is a useful and validated Quality of Life (QoL) evaluation instrument in patients undergoing major head-neck surgery. Its English version has been used in several studies in the last years. The aim of this work is to validate the NDII in Italian for both patient assessment and future studies. Materials and methods: Cross-cultural adaptation of the NDII was performed using standard techniques. Items of the original NDII were translated into Italian by a professional translator and two bilingual investigators. A final consensus version was obtained and given to two professional translators to produce a literal translation into English. The two translators and an expert committee synthesised the results of the translations in an English back-translated version that was compared with the original to check that they had the same semantic value. Results: Finally, a total of 42 patients completed both copies of the translated questionnaires. Internal consistency proved to be excellent, with Cronbach's alpha = 0.95. Conclusions: The NDII was successfully translated into Italian and its use was easy for patients. The translation of the NDII can represent a useful tool for individual patient assessment and future research.

Prevalence and prognostic impact of retropharyngeal lymph nodes metastases in oropharyngeal squamous cell carcinoma: Meta-analysis of published literature.

BACKGROUND: This systematic review and meta-analysis aims to estimate the prevalence and prognostic impact of retropharyngeal lymph node metastases (RLNMs) in oropharyngeal squamous cell carcinoma (OPSCC). METHODS: This meta-analysis was conducted according to PRISMA guidelines. INCLUSION CRITERIA: studies with more than 20 patients reporting the prevalence or prognostic impact of RLNMs in OPSCC. Whenever available, data on HPV status and subsites were extracted. RESULTS: Twenty-two articles were included. The overall prevalence of RLNMs in OPSCC was 13%, with no significant differences depending on HPV status. The highest prevalence was observed for posterior pharyngeal wall SCC (24%), followed by soft palate (17%), palatine tonsil (15%), and base of tongue (8%). RLNMs were associated with a significantly higher risk of death (HR:2.54;IC95%1.89-3.41) and progression (HR:2.44;IC95%1.80-3.30). CONCLUSIONS: The prevalence of RLNMs in OPSCC was 13%, being higher in tumors of the posterior pharyngeal wall. RLNMs were associated with unfavorable outcomes.