Relationship of medial versus superior vocal-cord location of T1 squamous cell carcinoma with tumor recurrence.

OBJECTIVE: To determine if the clinical behavior of T1 glottic squamous cell carcinoma varies by its location on the medial free edge or upper aspect of the vocal cords. STUDY DESIGN: Retrospective cohort. SETTING: Single tertiary university-affiliated medical center. SUBJECTS AND METHODS: Clinical, treatment, and outcome data were collected for 104 patients with T1N0M0 glottic squamous cell carcinoma who were treated and followed at our center in 1995-2013. Findings were compared between those with a tumor on the medial (n=60, 57.7%) or superior (n=44, 42.3%) aspect of the cords. RESULTS: Mean follow-up time was 4.15years. No between-group differences were found in demographic or risk factors. There was a significant association of anterior commissure involvement with disease recurrence (P=0.0012) and of superior (vs medial) location with higher rates of anterior commissure involvement (P<0.001) and recurrence (P=0.01) and shorter time to recurrence (P<0.001). CONCLUSIONS: T1 squamous cell carcinomas on the superior aspect of the vocal cords have a poorer prognosis than medial tumors and should be closely monitored for recurrence.

[ENDOSCOPIC RESECTION OF ZENKER DIVERTICULUM - A SINGLE CENTER EXPERIENCE].

BACKGROUND: Zenker diverticulum (ZD) is a pseudodiverticulum and usually affects males in the 6th-9th decade of life, symptoms include dysphagia, regurgitation, chronic cough, aspiration, halitosis and weight loss. Surgery has been the mainstay treatment of symptomatic ZD and can be divided into external and intraluminal (endoscopic) techniques. METHODS: Charts of all patients who had endoscopic correction of ZD in a tertiary referral center in the last 5 years were retrieved. RESULTS: Twenty patients, 90% were male, with ZD were reviewed with mean age of 68 +/- 9.5 years. The pre-operative mean pouch size was 3.43 +/- 0.9cm. Intraoperative pouch length was 2.55 +/- 1.5 cm. No major complications such as emphysema and mediastinitis were reported. The recurrence rate was 20%; 3 patients had revision endoscopic procedure and 1 had open surgery. CONCLUSIONS: Intraoperative length measure of Zenker diverticulum provides a good estimation of its size, with a more discreet and accurate dissection seeming to decrease the rate of major complications. Recurrence rate seems higher in small diverticulum. However, endoscopic treatment of these small diverticulum is safe with a tremendous impact on the patient's quality of life.

Radiation-Induced Thyroid Cancer: Gender-Related Disease Characteristics and Survival.

BACKGROUND: Radiation exposure is a well-known risk factor for well-differentiated thyroid cancer (WDTC). However, gender disparity in disease characteristics is not completely understood. The purpose of this study was to determine the behavior of radiation-induced thyroid cancer according to gender. METHODS: Charts of all patients diagnosed with WDTC after radiation exposure between the years 1985 and 2013 in a tertiary referral center were retrieved. RESULTS: Forty-three patients were reviewed, 29 females and 14 males. Mean age of exposure for women and men were 17.1 ± 19.5 and 15.5 ± 12.5 years, respectively (P = .78). Age at diagnosis were 47.5 ± 15.5 and 41.5 ± 15 years for women and men, respectively (P = .18). Mean disease-specific survival was 44.1 and 43.7 years for women and men, respectively (P = .50). CONCLUSIONS: Similar disease characteristics, tumor pathology, disease-free survival, and overall survival in both genders. In sporadic well-differentiated thyroid carcinoma, female gender is associated with better tumor behavior and prognosis. However, our results suggest that women are more affected by radiation than men and therefore have the same prognosis as men.

Radiation-Induced Well-Differentiated Thyroid Cancer: Disease Characteristics and Survival.

BACKGROUND: Radiation exposure is a well-known risk factor for well-differentiated thyroid cancer (WDTC). However, disease characteristics, optimal treatment, time from exposure to disease appearance, and the effect of age at initial exposure on the outcome have yet to be determined. OBJECTIVES: To identify the characteristics of radiation-induced thyroid carcinoma. METHODS: We retrieved the charts of all patients previously exposed to radiation who were diagnosed with WDTC between the years 1985 and 2013 in a tertiary referral center. RESULTS: Forty-four patients were reviewed. Median time from radiation exposure to diagnosis was 23 years. These patients had higher rates of aerodigestive symptoms and distant metastases on presentation than seen in non-radiated patients. Patients who were exposed to radiation before age 15 years tended to develop the disease at a younger age but had a longer latency period (34.7 ± 15.3 vs. 16.3 ± 10 years, P < 0.001) and none had significantly higher rates of vocal cord palsy, hoarseness on presentation, or aggressive variants on histology compared to patients exposed to radiation at an older age. Disease-specific survival (DSS) was the same for both groups and were similar to that seen in the general population (95% 20 year DSS). CONCLUSIONS: Radiation-induced thyroid cancer has a more aggressive presentation and the age at exposure affects the presentation of disease. Nonetheless, appropriate treatment leads to a favorable prognosis.

Analysis of failure following transoral laser surgery for early glottic cancer.

This study aimed at clarifying further the clinical behavior of early glottic cancer following transoral laser surgery and to determine, using retrospective analysis, whether the site of tumor involvement along the vocal fold has prognostic significance. The study included all patients treated with transoral laser surgery, for early glottic cancer (T1/T2N0M0) between May 1998 and January 2012 in a university affiliated tertiary care medical center. Data on demographics, site and extent of disease, treatment and outcome were collected and analyzed. Patients with insufficient data and/or follow-up of <2 years were excluded from the study. One-hundred and twenty-one patients were eligible for the study. Mean follow up time was 6.7 years (range 2-12 years). Overall recurrence rate following primary transoral laser surgery was 16.5 %. Histological grade was associated with higher recurrence rate (p = 0.008). Anterior commissure involvement was associated with reduced disease-free survival and tumors extending to the middle third of the true vocal fold were associated with lower recurrence rate. As per the results, anterior extension of glottic tumors is associated with higher recurrence rate compared to middle vocal fold extension, presumably due to earlier detection, better visualization and different biological behavior pattern of middle vocal fold tumors. Patients with higher grade tumors should be closely monitored for disease recurrence.

Insular thyroid carcinoma: a retrospective clinicopathologic study.

BACKGROUND: Poorly differentiated carcinoma is a rare epithelial tumor that falls between well-differentiated thyroid carcinoma and anaplastic thyroid carcinoma in terms of morphologic appearance and biologic behavior. An insular variant was characterized in 1983. Further study of this neoplasm is warranted owing to its high aggressiveness, propensity to local recurrence and distant metastases, and high associated mortality. Since insular thyroid carcinoma may have varied presentations, treatment should be individualized. PURPOSE: To describe the experience of a major tertiary medical center with insular thyroid carcinoma over a 7-year period. MATERIAL AND METHODS: The study sample consisted of 17 patients with poorly differentiated thyroid cancer, insular variant, who were treated and followed at the Department of Otolaryngology, Head and Neck Surgery of Rabin Medical Center, Israel, in 1992-2009. The medical files were reviewed for background data, clinicopathologic features, treatment, and outcome. RESULTS: The study group included 10 men and 7 women with a mean age of 63 years (range 16-78). Initial treatment was total thyroidectomy, in a single session (n=9) or two sessions (n=8), followed by radioiodine ablation. In addition, five patients received postoperative external beam radiation and one patient received chemotherapy. Nine patients had extrathyroidal extension, seven had vascular invasion, and four had multifocal disease. Distant metastases were present in four patients. Follow-up ranged from 6 months to 12 years. At present, 11 patients are alive and well. Five died of disease, and one died of another cause. CONCLUSION: Insular thyroid carcinoma is aggressive and difficult to treat. Surgery remains the mainstay of treatment, though multimodality therapy is usually required.

Post-laryngectomy voice rehabilitation: comparison of primary and secondary tracheoesophageal puncture.

BACKGROUND: Voice restoration following total laryngectomy is an important part of patients' rehabilitation and long-term quality of life. OBJECTIVES: To evaluate the long-term outcome of indwelling voice prostheses inserted during (primary procedure) or after (secondary procedure) total laryngectomy. METHODS: The study group included 90 patients who underwent total laryngectomy and tracheoesophageal puncture (TEP) with placement of voice prosthesis at a tertiary medical center during the period 1990-2008. Background, clinical and outcome data were collected by medical file review. Findings were compared between patients in whom TEP was performed as a primary or a secondary procedure. RESULTS: TEP was performed as a primary procedure in 64 patients and a secondary procedure in 26. Corresponding rates of satisfactory voice rehabilitation were 84.4% and 88.5% respectively. There was no association of voice quality with either receipt of adjuvant radiation/chemoradiation or patient age. The average lifetime of the voice prosthesis was 4.2 months for primary TEP and 9.06 months for secondary TEP (P= 0.025). CONCLUSIONS: Primary TEP provides almost immediate and satisfactory voice rehabilitation. However, it is associated with a significantly shorter average prosthesis lifetime than secondary TEP. Chemoradiotherapy and patient age do not affect voice quality with either procedure.

Chondrosarcoma of the larynx.

BACKGROUND: Chondrosarcoma of the larynx is a rare tumor. The most common symptom is hoarseness. Treatment is controversial. OBJECTIVES: To describe six patients with laryngeal chondrosarcoma from a single center. METHODS: The medical records of a major tertiary hospital were reviewed for all patients with laryngeal chondrosarcoma diagnosed and treated from 1959 to 2010. Data on background, clinical treatment and outcome were collected. RESULTS: Six patients, all males with a mean age of 53.3 years, were identified. Partial laryngectomy was performed in three patients, and total laryngectomy, local excision, and partial cricoidectomy in one patient each. Four patients had a permanent tracheostomy after surgery. One patient required postoperative chemotherapy and one radiotherapy. Follow-up time was 12-216 months (mean 102 months). Recurrence developed in two patients 2 and 8 years after initial treatment and was treated by salvage surgery in both patients. One patient died during the follow-up from an unrelated cause. The others are currently alive. CONCLUSIONS: This study supports earlier reports recommending initial treatment with partial or total laryngectomy for laryngeal chondrosarcoma. Long-term follow-up for recurrence is advised. We recommend preserving the larynx, if possible, even if a permanent tracheostomy is necessary.

Expression of MMP-1 in invasive well-differentiated thyroid carcinoma.

The objective of this study is to examine the expression of matrix metalloproteinase 1 (MMP-1) in invasive well-differentiated thyroid carcinoma (WDTC) and its relation to clinicopathological features. This retrospective case study group included 26 patients with invasive WDTC who were treated at our center between January 1985 and May 2007. Clinical data were collected from the medical files. MMP-1 expression was tested in samples from paraffin-embedded tumor by immunohistochemical staining. MMP-1 expression correlated with laryngotracheal invasion (p = 0.032), multifocality of the tumor (p = 0.044), and presence of regional (p = 0.034) and distant metastases (p = 0.048). In conclusion, the expression of MMP-1 in invasive WDTC is consistent with tumor aggressiveness, manifested by laryngotracheal invasion, multifocality, and regional and distant metastases. MMP-1 expression may serve as a prognostic marker and an indicator for the need for more aggressive surgical treatment.

[Fat injection as treatment for vocal cord palsy: our experience in 21 patients].

BACKGROUND: Vocal cord palsy is a known complication after various operations but there are cases in which the paralysis is idiopathic. Patients complain of severe hoarseness and especially coughing, dysphagia and aspirations which can cause recurrent pneumonia. METHODS: In the last 4 years we have been using autogenic fat which is injected into the paralyzed vocal cord, a procedure which causes swelling of the cord toward the healthy cord in order to improve the voice quality and to prevent foreign body aspiration. In this retrospective study, we describe the treatment with fat injections in 21 patients diagnosed at the voice clinic in "Rabin" Medical Center and treated in the Department of E.N.T and Head and Neck Surgery, Campus "Beilinson". RESULTS: Following the treatment, all patients reported that there were no aspirations, there was an improvement of voice quality, and most of them were satisfied with the treatment. Six patients needed an additional fat injection after several months. CONCLUSION: A fat injection to the vocal cord is a simple, quick, and easy procedure, without any skin incision in the neck and with short hospitalization. It is especially suitable for patients with a probability of vocal cord palsy recovery. Most of the patients do not need additional injections.

Histopathological changes of the nasal mucosa induced by smoking.

Changes in the histopathology of the respiratory epithelium in response to cigarette smoking have been studied in depth in the lungs, but data on the nasal lining are lacking. The aim of the present retrospective study was to investigate the histological changes that occur in the nasal mucosa of smokers compared with non-smokers. The study group included 47 patients who underwent partial resection of the inferior turbinates. Archival nasal tissue samples were collected and examined by light microscopy: the number of goblet cells was counted, and the degree of inflammation, congestion, and edema was graded as mild, moderate, or severe. Epithelial thickness was measured as well. Findings were compared between smokers (n = 21) and non-smokers (n = 26). On statistical analysis, significant differences were found between the smokers and non-smokers in mean number of goblet cells in the nasal epithelium, 43.43 +/- 16.80 vs. 16.23 +/- 5.65 respectively (p < 0.0001), mean edema grade, 2.43 +/- 0.75 vs. 1.12 +/- 0.33 respectively (p < 0.0001), and mean epithelial thickness, 111.9 +/- 25.8 microm vs. 60.4 +/- 18.4 microm respectively (p < 0.0001). The corresponding mean values of congestion were 2 +/- 0.71 and 1.27 +/- 0.67 (p < 0.001), and of inflammation, 1.81 +/- 0.60 and 1.81 +/- 0.85 (NS). In conclusion, the histopathological findings in the nasal mucosa of smokers resemble reported findings in the bronchial respiratory epithelium. The main differences from non-smokers are greater goblet cell hyperplasia and thicker epithelium.

Cholesterol granuloma in thyroglossal cysts: a clinicopathological study.

Thyroglossal duct cyst (TDC) is a congenital anomaly caused by retention of epithelial remnants from the descent of the thyroid gland during embryological development. Cholesterol granuloma represents a granulomatous reaction to precipitates of cholesterol crystals in tissue, usually related to middle-ear disease. The association of TDC with cholesterol granuloma has hardly been reported. This study describes five patients with TDC and cholesterol granuloma over a 16-year-period. The treatment consisted of excision of the TDC and the mid-portion of the hyoid bone and excision of a core of tissue between the hyoid bone and the foramen cecum (Sistrunk procedure). We speculate that the pathogenesis of cholesterol granuloma in TDC resembles that in the paranasal sinuses, as both sites provide a closed, poorly ventilated hollow structure with slow drainage. Our five patients accounted for 13% of all patients with TDC treated in our center during the same period, indicating that cholesterol granuloma in TDC may not be as rare as previously thought.

Laryngeal carcinoma in nonsmoking patients.

OBJECTIVES: Smoking is a known risk factor for laryngeal carcinoma. We sought to describe the clinicopathologic characteristics and outcomes of nonsmoking patients with laryngeal carcinoma. METHODS: Of 1,443 patients treated for laryngeal carcinoma between 1960 and 2006, 55 (3.8%) were nonsmokers: 40 (73%) had never smoked and 15 (27%) had stopped smoking 12 years or more before diagnosis. Patient characteristics and outcomes were reviewed. RESULTS: The study group consisted of 87% men; the mean age at diagnosis was 67 years. All lesions but one were located in the glottis. The 5-year survival rate for the whole group was 85%. Most tumors were detected early. Of 38 patients (69%) with stage T1 disease, there was no significant difference in prognostic features between those who had never smoked and those who had smoked in the past. CONCLUSIONS: Fewer than 5% of patients with laryngeal carcinoma were nonsmokers. Like smokers, this subgroup was characterized by a male predominance and an approximate age at diagnosis in the seventh decade. Unlike smokers, nonsmokers show a greater predilection for glottic rather than supraglottic disease. There was no difference in prognosis between smokers and nonsmokers, regardless of whether they had smoked in the past.

Assessment of laryngeal cancer in patients younger than 40 years.

OBJECTIVES/HYPOTHESIS: To assess the differences between patients with laryngeal squamous cell carcinoma under 40 years old and those 40 years old or older. A secondary objective was to compare survival outcome between these cohorts. STUDY DESIGN: Retrospective chart review. METHODS: We reviewed the medical charts of all patients treated in our tertiary referral center for laryngeal squamous cell carcinoma from 2005 to 2014. Patients aged < 40 years at diagnosis were compared to older patients. RESULTS: The study group comprised 160 patients. Of them, 13 were aged < 40 years at diagnosis. Mean age was 35 ± 3.9 years and 64.4 ± 11 years for the two groups. Among the younger patients, 38% were smokers (mean pack/day, 2.2) versus 71% in the older group (mean pack/day, 3). The younger group typically had a more advanced stage than the older group at presentation; eight young patients (62%) had stage III or IV versus 49 (33%) in the older group (P = .042). Mean overall survival was 6.7 ± 1 years for those under 40 years old and 7.7 ± 0.2 years for the older patients (P = .2). The 5-year survival rate was 69% for young patients and 90% for the older group (P = .04). However, there was no significant between-group difference in overall survival or 5-year survival rate when stratified for early- and late-stage disease. CONCLUSIONS: There is a lower prevalence of classic risk factors in younger patient with laryngeal carcinoma in this study, suggesting a different etiology compared to our older cohort. The under-40 cohort presented with more advanced disease and had a worse 5-year survival; however, when stratified for early- versus late-stage disease, there was no significant difference in overall or 5-year survival between the groups. This may suggest that, despite a different etiology, laryngeal cancer behaves similarly in older and younger patients. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1602-1605, 2018.

Adaptation of median partial sternotomy in head and neck surgery.

Upper mediastinum involvement in diseases of the head and neck may require a sternal split. This study describes our adaptation of the upper median or "minimal" sternotomy technique for the treatment of head and neck pathologies. Between April 2002 and October 2005, 17 patients aged 4 to 82 years underwent minimal sternotomy in our institution for a variety of head and neck pathologies. The 17 patients included 11 adults with metastatic thyroid disease (six metastatic papillary thyroid carcinoma, two medullary carcinoma, and one Hiirthle cell carcinoma) and huge retrosternal goiter (n = 2), four adults with parathyroid disease (two primary parathyroid adenoma, one secondary hyperplasia, and one parathyroid carcinoma), and two children with lymphangioma and huge thymic cyst (one each). Average hospitalization was 8 days. Four patients needed a thoracic drain for 2 days, one had recurrent laryngeal nerve palsy, and one had phrenic nerve paresis. There were no postoperative deaths. Minimal sternotomy appears to be an excellent alternative for surgical exploration of the mediastinum and may be used in head and neck surgery for a range of indications.

Endoscopic laser surgery for subglottic stenosis in Wegener's granulomatosis.

PURPOSE: Wegener's granulomatosis (WG) is a rare multisystem inflammatory disease, which infrequently involves the subglottic area and trachea. Treatment usually involves the use of immunosuppressive agents with corticosteroids. Some patients, however, continue to have symptoms of airway obstruction after clinical remission following the standard therapeutic regimen. OBJECTIVE: To investigate laser treatment for subglottic stenosis in five patients suffering from WG. MATERIALS AND METHODS: We endoscopically treated 5 patients with subglottic stenosis due to WG and airway obstruction by Nd:YAG and CO2 lasers. One of the patients had preoperative tracheostomy and after treatment was decannulated and could not breathe without dyspnea. Another patient required stenting of the subglottic area. RESULTS: All five patients were able to breathe without dyspnea after the treatment. Three patients were treated with an Nd:YAG laser but needed repeated laser treatment every four to six months, whenever they complained of dyspnea. The other two patients were treated with a CO2 laser; one of these patients had preoperative tracheostomy and was treated twice by CO2 laser and decannulated, with no further difficulty in breathing. The follow-up period was 1-5 years. CONCLUSIONS: Nd:YAG and CO2 lasers are recommended in the treatment of subglottic stenosis (SS) due to WG, particularly when the stenosis is in continuity or close proximity to the vocal cords.

Endoscopic transnasal repair of choanal atresia.

OBJECTIVES: To present our experience with a new endoscopic technique for transnasal repair of choanal atresia. METHODS: Seventeen patients aged 2 months to 13 years with choanal atresia, bilateral in 6 and unilateral in 11, underwent endoscopic repair using a mucoperichondrial flap developed from the nasal septum. The bony stenosis was opened with a surgical curette or drill, and the raw surface was covered by the flap. All patients in these case series with bilateral atresia had been treated with dilatation at birth and had restenosis. RESULTS: A total of 23 choanae were operated. Follow-up ranged from 10 to 60 months. There was one case of complete restenosis and one of partial restenosis, for a success rate of 91%. CONCLUSIONS: Endoscopic repair of choanal atresia is a safe and rapid procedure even in very young children, with no complications and a high rate of success.

Characteristics and outcome of laryngeal squamous cell carcinoma in young adults.

Laryngeal carcinoma rarely occurs in the young adult population. Therefore, the optimal treatment for this age group is unclear, specifically regarding organ preservation treatment. In order to assess the distinct characteristics of laryngeal squamous cell carcinoma (SCC) in young adults and describe the effect of treatment on survival, a retrospective chart review of all patients aged <40 years, who were treated in a tertiary referral center for laryngeal SCC between January 1960 and December 2013, was performed. Patients who were treated prior to and following the Veterans study, representing an arbitrary point which started the organ preservation era, were compared. A total of 29 patients (male:female ratio, 2.6:1) were identified. The mean age at diagnosis was 35±5 years and 17 patients (59%) were smokers. In total, 12 (41%) of patients were stage I, 4 (14%) were stage II, 8 (28%) were stage III and 5 (17%) were stage IV. Glottic tumors were present in 20 (69%) of patients and supraglottic tumors in 6 (21%); the site of tumor origin could not be determined in 3 (10%) of patients. Surgery was performed in 11 (38%) of patients, radiation in 21 (72%) and chemotherapy in 5 (17%). A comparison between patients treated prior to and following the Veterans study demonstrated a 2-year higher laryngectomy-free survival rate of 53% and 78%, respectively (P=0.299). The 2-year disease-free survival rate was 93% for patients who were treated prior to the Veterans study and 71% for patients who were treated after (P=0.001), with no significant change in overall survival (P=0.413). The results suggest that the characteristics and behavior of laryngeal carcinoma in young adults is similar to older adults. Higher rates of 2-year laryngectomy-free survival were noted in patients treated following the organ preservation era with no significant difference in survival compared with patients who were treated before.

T1 squamous cell carcinoma of the glottis with anterior commissure involvement: Radiotherapy versus transoral laser microsurgery.

BACKGROUND: The optimal treatment method of T1 glottic squamous cell carcinoma (SCC) with involvement of the anterior commissure is still debatable. We compared the outcomes of radiotherapy (RT) and transoral laser microsurgery (TLM). METHODS: Data were retrospectively collected for 54 patients who were treated by RT (n = 38) or TLM (n = 16) from 2006 to 2013. RESULTS: No between-group differences were found in demographic or risk factors. Recurrence was noted in 6 patients of the TLM group and 5 of the RT group. There was a near-significant association of TLM with recurrence (p = .053). Radiation was associated with a higher 5-year disease-free survival (DFS) (87.3% vs 74.9%; p = .037). Both groups had excellent rates for local control (75% and 97%, respectively), and overall survival (78.9 and 87.5%, respectively). There were no significant differences in outcome parameters by tumor classification. CONCLUSION: TLM is associated with higher recurrence rates and lower DFS. Both patients with T1a and T1b disease had the same outcome parameters. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1101-1105, 2017.

Phase II organ-preservation trial: Concurrent cisplatin and radiotherapy for advanced laryngeal cancer after response to docetaxel, cisplatin, and 5-fluorouracil-based induction chemotherapy.

BACKGROUND: The optimal treatment for locally advanced laryngeal cancer remains controversial. The purpose of this trial was to determine if the response to induction chemotherapy could select patients for organ preservation protocols, and improve larynx-preservation rates without compromising overall survival (OS). METHODS: The cohort comprised 12 patients with T3 disease and 14 with T4. Induction chemotherapy consisted of docetaxel, cisplatin, and 5-fluorouracil (TPF). Response to the first cycle was determined by examination and positron emission tomography (PET)-CT. Responders (>50% tumor reduction) underwent chemoradiation, whereas nonresponders underwent laryngectomy. RESULTS: Eighty-three percent of the patients had a response and 17% had stable or progressive disease. At 2 years, the median OS was 80%, the larynx-preservation rate was 83%, and the disease-specific survival rate was 86%. Response to a single TPF cycle was associated with 2-year OS (92% vs 50%; p = .02). The T classification was not predictive of survival. CONCLUSION: Response to a single TPF-based cycle may identify patients with advanced laryngeal cancer who are amenable to organ preservation treatment. © 2016 Wiley Periodicals, Inc. Head Neck 39: 227-233, 2017.