Socioeconomic status, access to care, risk factor patterns, and stage at diagnosis for head and neck cancer among black and white patients.

BACKGROUND: Little is known about how factors combine to influence progression of squamous cell carcinoma of the head and neck (HNSCC). We aimed to evaluate multidimensional influences of factors associated with HNSCC stage by race. METHODS: Using retrospective data, patients with similar socioeconomic status (SES), access to care (travel time/distance), and behavioral risk factors (tobacco/alcohol use and dental care) were grouped by latent class analysis. Relative frequency differences (RFD) were calculated to evaluate latent classes by stage, race, and p16 status. RESULTS: We identified three latent classes. Advanced T-stage was higher for black (RFD = +20.2%; 95% CI: -4.6 to 44.9) than white patients (RFD = +10.7%; 95% CI: 2.1-19.3) in the low-SES/high-access/high-behavioral risk class and higher for both black (RFD = +29.6%; 95% CI: 4.7-54.5) and white patients (RFD = +23.9%; 95% CI: 15.2-32.6) in the low-SES/low-access/high-behavioral risk class. CONCLUSION: Results suggest that SES, access to care, and behavioral risk factors combine to underly the association with advanced T-stage. Additionally, differences by race warrant further investigation.

Access to preventive care services and stage at diagnosis in head and neck cancer.

BACKGROUND: Decreased access to preventive care services has been proposed as a mechanism for the association between low socioeconomic status (SES) and advanced stage at diagnosis in patients with head and neck squamous cell carcinoma (HNSCC). METHODS: Retrospective analysis of patients diagnosed with HNSCC in North Carolina between 2002 and 2006. RESULTS: A total of 1108 patients with HNSCC were included in the study. In the multivariable analysis, use of annual routine dental services (OR 0.7, 95% CI 0.5-0.9) and colonoscopy in the past 10 years (OR 0.7, 95% CI 0.5-0.9) were associated with lower odds of advanced T stage at diagnosis. Having no insurance (OR 1.8, 95% CI 1.1-2.9), an income <$20 000 (OR 1.6 95% CI 1.03-2.6), and >10 pack-years tobacco use (OR 1.5, 95% CI 1.04-2.2) were associated with advanced T stage at diagnosis. CONCLUSION: Use of preventive care services and SES independently predict stage at diagnosis in HNSCC.

How Much Blood Could a JP Suck If a JP Could Suck Blood?

OBJECTIVE: Active surgical drains minimize fluid accumulation in the postoperative period. The Jackson-Pratt (JP) system consists of a silicone drain connected by flexible tubing to a bulb. When air in the bulb is evacuated, negative pressure is applied at the surgical site to aspirate fluid. The objective of this study was to determine if the evacuation method and volume of accumulated fluid affect the pressure generated by the bulb. METHODS: Bulbs were connected to a digital manometer under various experimental conditions. A random number generator determined the initial evacuation method for each bulb, either side-in or bottom-up. Subsequent evacuations were alternated until data was collected in triplicate for each method. Predetermined amounts of water were placed into the bulb; air was evacuated; and pressure was recorded. The digital manometer was allowed to equilibrate for 1 minute prior to data acquisition. RESULTS: The average amount of pressure after a side-in evacuation of a JP bulb was 87.4 cm H2 O compared to 17.7 cm H2 O for a bottom-up evacuation (P < 0.0001). When the drain contained 25 mL, 50 mL, 75 mL, and 100 mL of fluid, the pressure applied dropped to 72.6, 41.3, 37.0, and 35.6 cm H2 O, respectively. CONCLUSIONS: JP drains generate negative pressure in order to reduce fluid accumulation at surgical sites. Although its function is frequently taken for granted, this study demonstrates that both the specific method for evacuating the bulb as well as the amount of fluid in the bulb significantly affect the performance of this device. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1806-1809, 2019.

Incidence of, and risk factors for, mandibular osteoradionecrosis in patients with oral cavity and oropharynx cancers.

OBJECTIVES: To evaluate the incidence of, and risk factors associated with, mandibular osteoradionecrosis (MORN) following radiation therapy (RT) for oral cavity and oropharyngeal cancers. MATERIALS AND METHODS: Patient and treatment records of 252 consecutive patients with oral cavity or oropharynx cancers treated with RT by a single radiation oncologist at a high volume academic institution from August 2009 to December 2015 were retrospectively reviewed. A Cox regression model was used to assess factors associated with the development of MORN. RT dosimetry was compared between patients with MORN and a matched cohort of patients without MORN. RESULTS: MORN developed in 14 patients (5.5%), occurring 3-40 (median 8) months post-RT. Factors associated with MORN on univariable analysis included primary diagnosis of oral cavity vs oropharynx cancer (hazard ratio [HR]: 3.0, p=0.04), smoking at the time of RT (HR: 3.1, p=0.04), mandibular invasion of the primary (HR: 3.7, p=0.04), pre-RT tooth extraction (HR: 4.52, p=0.01), and treatment with 3D-conformal RT vs intensity-modulated RT (HR: 5.1, p=0.003). On multivariable analysis, pre-RT tooth extractions and RT technique remained significant. A dosimetric comparison between patients with and without MORN showed no significant differences. CONCLUSIONS AND RELEVANCE: The incidence of MORN is low in the modern era at a high volume academic center. Modifiable risk factors including pre-RT tooth extractions, smoking, and RT technique are associated with MORN, and the risk should be minimized with appropriate dental evaluation and treatment, smoking cessation efforts, and the use of intensity-modulated RT.

Endoscopic Approaches to the Craniovertebral Junction.

The endoscopic endonasal approach provides a direct surgical trajectory to anteriorly located lesions at the craniovertebral junction. The inferior limit of surgical exposure is predicted by the nasopalatine line, and the lateral limit is demarcated by the lower cranial nerves. Endoscopic endonasal odontoidectomy allows preservation of the soft palate, and patients can restart an oral diet on the first postoperative day. Treating the condition at the craniovertebral junction using this approach requires careful preoperative planning and endoscopic endonasal surgical experience with a 2-surgeon 4-handed approach combining expertise in otolaryngology and neurosurgery.

Endoscopic transpterygoid nasopharyngectomy: correlation of surgical anatomy with multiplanar CT.

BACKGROUND: Oncologic resection of the nasopharynx is challenging due to its complex and deep-seated nature. We aimed to illustrate the anatomic landmarks of endoscopic nasopharyngectomy and design a surgical training model that could facilitate learning of this technique. METHODS: An endoscopic endonasal dissection of the nasopharynx was completed in fresh cadaveric specimens under conditions similar to those of our operating suite. Digital data from a high-resolution CT scan were imported to an image guidance system to be used during the dissections. RESULTS: We expanded the sinonasal corridor, harvested a contralateral nasoseptal flap, and exposed the pterygopalatine and infratemporal fossae. A detailed anatomic dissection of the nasopharynx was correlated to multiplanar images provided by the image guidance system, highlighting appropriate bony, neural, and vascular landmarks. CONCLUSIONS: Understanding the anatomy-based endoscopic modular approaches facilitates planning and safe execution of an oncologic nasopharyngectomy. Clinical experience remains mandatory because anatomic models fall short of clinical scenarios.

Transpalatal greater palatine canal injection: Radioanatomic analysis of where to bend the needle for pediatric sinus surgery.

BACKGROUND: The greater palatine canal (GPC) local injection is used to limit posterior bleeding during sinus surgery in adults. Given the potential for causing iatrogenic damage to the intraorbital contents, this procedure is not commonly used in the pediatric population. No studies have described the anatomic development of the GPC during facial growth. By using age-stratified radioanatomic analysis, the dimensions of the GPC and the clinical implications are described for pediatric patients. An age-stratified radioanatomic study was performed. METHODS: High-resolution computed tomography measurements included the thickness of the mucosal plane overlying the GPC, the length of the GPC, and the distance between the base of the pterygopalatine fossa (PPF) and the orbital floor. Mean distance and standard deviation were calculated for each age cohort and compared using the one-way ANOVA test. RESULTS: The GPC length correlated directly with patient age. It varied from 9.14 ± 0.11 mm in the youngest age group (<2 years) to 19.36 ± 2.76 mm in adults (18-64 years). The height of the orbit relative to the hard palate approximated the adult dimensions described in the literature by 12-13 years (49.58 ± 1.72 mm). CONCLUSION: These radioanatomic results suggest that the GPC injection described for adult patients may be safely administered to selected pediatric patients. For patients >12 years old, we recommend bending the needle 45° and inserting it 25 mm. For patients 6-12 years old, the needle should be inserted 20 mm to enter into the PPF. In patients <6 years old, the needle may safely be placed 12 mm into the GPC. Each of these descriptions is based on the minimal distance required to effectively access the PPF but with maximal safety in regard to the orbit. Further clinical correlation of these findings is necessary through future investigation.

Defining the nasopalatine line: the limit for endonasal surgery of the spine.

OBJECTIVES: The expanded endoscopic endonasal approach (EEA) to the odontoid process is performed for decompression of the brainstem and to access tumors at the foramen magnum. Caudal exposure is limited by the nasal bones anteriorly and the hard palate posteriorly. We define the line connecting these two points as the nasopalatine line (NPL) and the nasopalatine angle (NPA) as the angle between the nasopalatine line and the plane of the hard palate. STUDY DESIGN: This study was a retrospective cohort study. METHODS: Pre and post-operative computed tomographic (CT) scans of 17 patients who underwent transodontoid EEA were reviewed. The position of the odontoid and the inferior extent of the tumor and surgical dissection were compared to the NPL. Factors affecting the posterior projection of the NPL, including basilar invagination and head position, were examined. RESULTS: The mean NPA was 27.1 degrees (range 21-31 degrees ). The NPL intersects the spinal column at 8.9 mm (range -9.0-8.7 mm) above the base of the C2 body. The base of the odontoid process and the inferior extent of surgical dissection were always above this line. Both basilar invagination and head position affect the relative position of the NPL. Patients with basilar invagination demonstrated a significantly lower posterior projection of the NPL than those without (P < .01). Maximal cervical flexion afforded more caudal exposure than cervical extension. CONCLUSIONS: The NPL accurately predicts the most inferior extent of surgical dissection. Further caudal dissection may require the use of angled instruments or a transoral approach.