Speech and swallowing outcomes after laryngectomy for the dysfunctional irradiated larynx.

PURPOSE: To characterize outcomes of total laryngectomy for the dysfunctional larynx after radiation. METHODS: Retrospective case series of all subjects who underwent total laryngectomy for the irradiated dysfunctional larynx between 2000 and 2018 at an NCI-designated comprehensive cancer center at a single tertiary care academic medical center. Main outcomes included enteral tube feeding dependency, functional tracheoesophageal speech, and number and timing of postoperative pharyngeal dilations. RESULTS: Median time from radiation to laryngectomy was 2.8 years (range 0.5-27 years). Functional outcomes were analyzed for the 32 patients with 1-year follow-up. Preoperatively, 81% required at least partial enteral tube feeding, as compared to 34% 1-year postoperatively (p = 0.0003). At 1 year, 81% had achieved functional tracheoesophageal speech, which was associated with cricopharyngeal myotomy (p = 0.04, HR 0.04, 95% CI 0.002-0.949). There were 34% of subjects who required at least one pharyngeal dilation for stricture by 1 year postoperatively. Over half (60%) of the cohort were dilated over the study period. CONCLUSIONS: Laryngectomy for the dysfunctional larynx improves speech and swallowing outcomes in many patients. Cricopharyngeal myotomy is associated with improved postoperative voice. While the need for enteral feeding is decreased, persistent postoperative swallowing dysfunction is common. Careful patient selection and education regarding functional expectations are paramount.

Elective Paratracheal Lymph Node Dissection in Salvage Laryngectomy.

BACKGROUND: Indications for and efficacy of paratracheal nodal dissection (PTND) in patients undergoing laryngectomy (salvage) for persistent or recurrent laryngeal squamous cell carcinoma are not well-defined. METHODS: A retrospective cohort study was performed for patients undergoing salvage laryngectomy with clinically and radiographically negative neck disease between 1998 and 2015 (n = 210). Univariate and multivariate Cox regression analyses were performed. RESULTS: PTND was performed on 77/210 patients (36%). The PTND cohort had a greater proportion of advanced T classification (rT3/rT4) tumors (78%) than subjects without PTND (55%; p = 0.001). There was a 14% rate of occult nodal metastases in the paratracheal basin; of these, 55% did not have pathologic lateral neck disease. Multivariate analysis controlling for tumor site, tumor stage, and pathologic lateral neck disease demonstrated that PTND was associated with improved overall survival [OS] (p = 0.03; hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.38-0.96), disease-free survival [DFS] (p = 0.03; HR 0.55, 95% CI 0.31-0.96), and distant DFS survival (p = 0.01; HR 0.29, 95% CI 0.11-0.77). The rate of hypocalcemia did not differ between subjects who underwent bilateral PTND, unilateral PTND, or no PTND (p = 0.19 at discharge, p = 0.17 at last follow-up). CONCLUSIONS: PTND at the time of salvage laryngectomy was more common in patients with rT3/rT4 tumors and was associated with improved OS and DFS, with no effect on hypocalcemia. In patients undergoing PTND, the finding of occult paratracheal metastases was often independent of lateral neck metastases.

AluY-mediated germline deletion, duplication and somatic stem cell reversion in UBE2T defines a new subtype of Fanconi anemia.

Fanconi anemia (FA) is a rare inherited disorder clinically characterized by congenital malformations, progressive bone marrow failure and cancer susceptibility. At the cellular level, FA is associated with hypersensitivity to DNA-crosslinking genotoxins. Eight of 17 known FA genes assemble the FA E3 ligase complex, which catalyzes monoubiquitination of FANCD2 and is essential for replicative DNA crosslink repair. Here, we identify the first FA patient with biallelic germline mutations in the ubiquitin E2 conjugase UBE2T. Both mutations were aluY-mediated: a paternal deletion and maternal duplication of exons 2-6. These loss-of-function mutations in UBE2T induced a cellular phenotype similar to biallelic defects in early FA genes with the absence of FANCD2 monoubiquitination. The maternal duplication produced a mutant mRNA that could encode a functional protein but was degraded by nonsense-mediated mRNA decay. In the patient's hematopoietic stem cells, the maternal allele with the duplication of exons 2-6 spontaneously reverted to a wild-type allele by monoallelic recombination at the duplicated aluY repeat, thereby preventing bone marrow failure. Analysis of germline DNA of 814 normal individuals and 850 breast cancer patients for deletion or duplication of UBE2T exons 2-6 identified the deletion in only two controls, suggesting aluY-mediated recombinations within the UBE2T locus are rare and not associated with an increased breast cancer risk. Finally, a loss-of-function germline mutation in UBE2T was detected in a high-risk breast cancer patient with wild-type BRCA1/2. Cumulatively, we identified UBE2T as a bona fide FA gene (FANCT) that also may be a rare cancer susceptibility gene.

Interprofessional education through service-learning: lessons from a student-led free clinic.

The academic community must replicate and strengthen existing models for interprofessional education (IPE) to meet widespread calls for team-based patient-centered care. One effective but under-explored possibility for IPE is through student-led clinics, which now exist in the majority of medical schools. This short report presents the Indiana University Student Outreach Clinic (IU-SOC), which involves seven different professional programs across three institutions, as a model for how IPE can be delivered formally through service learning. Lessons learned, such as nurturing an intentional interprofessional program, structured orientation and reflection, and resource and knowledge sharing between the clinic and academic institutions, can be applied to all student-led clinics, but also can inform other IPE initiatives in health professional curricula.

Portrait of a Surgeon: Artificial Intelligence Reflections.

Text-to-image artificial intelligence (AI) programs are popular public-facing tools that generate novel images based on user prompts. Given that they are trained from Internet data, they may reflect societal biases, as has been shown for text-to-text large language model programs. We sought to investigate whether 3 common text-to-image AI systems recapitulated stereotypes held about surgeons and other health care professionals. All platforms queried were able to reproduce common aspects of the profession including attire, equipment, and background settings, but there were differences between programs most notably regarding visible race and gender diversity. Thus, historical stereotypes of surgeons may be reinforced by the public's use of text-to-image AI systems, particularly those without procedures to regulate generated output. As AI systems become more ubiquitous, understanding the implications of their use in health care and for health care-adjacent purposes is critical to advocate for and preserve the core values and goals of our profession.

Gender Bias in Artificial Intelligence-Written Letters of Reference.

OBJECTIVE: Letters of reference (LORs) play an important role in postgraduate residency applications. Human-written LORs have been shown to carry implicit gender bias, such as using more agentic versus communal words for men, and more frequent doubt-raisers and references to appearance and personal life for women. This can result in inequitable access to residency opportunities for women. Given the known gendered language often unconsciously inserted into human-written LORs, we sought to identify whether LORs generated by artificial intelligence exhibit gender bias. STUDY DESIGN: Observational study. SETTING: Multicenter academic collaboration. METHODS: Prompts describing identical men and women applying for Otolaryngology residency positions were created and provided to ChatGPT to generate LORs. These letters were analyzed using a gender-bias calculator which assesses the proportion of male- versus female-associated words. RESULTS: Regardless of the gender, school, research, or other activities, all LORs generated by ChatGPT showed a bias toward male-associated words. There was no significant difference between the percentage of male-biased words in letters written for women versus men (39.15 vs 37.85, P = .77). There were significant differences in gender bias found by each of the other discrete variables (school, research, and other activities) chosen. CONCLUSION: While ChatGPT-generated LORs all showed a male bias in the language used, there was no gender bias difference in letters produced using traditionally masculine versus feminine names and pronouns. Other variables did induce gendered language, however. ChatGPT is a promising tool for LOR drafting, but users must be aware of potential biases introduced or propagated through these technologies.

Pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest for salvage mandibular reconstruction: Case and technique.

In the era of free flap reconstruction, mandibular defects are routinely reconstructed with osseous free flaps, and non-free flap bony reconstruction options are limited. A patient with T4N0 mandibular squamous cell carcinoma underwent resection with fibula free flap reconstruction of a parasymphyseal to angle defect. After free flap failure due to venous congestion, the flap was explanted. He declined additional free flap reconstruction and elected to proceed with pedicled osteomyocutaneous pectoralis major with rib. In this case presentation, we discuss the technical details of harvest of this flap using the 6th rib. The pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest, which is infrequently described in the literature, remains a viable option for bony reconstruction, particularly in the salvage setting.

The osteocutaneous radial forearm free flap: A multidisciplinary review of the evidence.

The osteocutaneous radial forearm (OCRFF) is a versatile free flap option for bony defects of the head and neck, given the thinness and pliability of the forearm cutaneous paddle, pedicle length, reliability, lack of atherosclerosis, and functional concerns common to other osseous donor sites. The OCRFF was once associated with a high risk of radial fracture, in addition to concerns about the quality and durability of bone stock for osseous reconstruction, particularly for the mandible. Following the introduction of prophylactic plating of the radius, the incidence of symptomatic radial fracture has drastically decreased. Furthermore, modifications of the bony osteotomies and other evolutions of this flap harvest have increased the use of the OCRFF throughout the head and neck. Despite these advantages, the OCRFF is not widely utilized by microvascular reconstructive surgeons due to perceived limitations and risks. Herein, we present a multidisciplinary, contemporary review of the harvest technique, outcomes, and perioperative management for the OCRFF.

The osteocutaneous radial forearm free flap: A pictorial essay.

The osteocutaneous radial forearm free flap (OCRFFF) is a versatile flap with the ability to reconstruct complex defects. We detail the techniques necessary to harvest an OCRFFF, including an outline on making 90-degree osteotomies to maximize bone harvest. In this pictorial essay, we provide illustrations of the anatomy and surgical techniques necessary for OCRFFF harvest. Detailed discussion is provided on how to protect the perforators to the bone and the approach to making osteotomies in a 90-degree fashion. The approach for prophylactic plating of the radius to prevent radius fractures is outlined. A case presentation on the real-life utilization of this flap is included. The OCRFFF is an excellent head and neck reconstructive option. While there are limitations to its use for patients requiring dental rehabilitation or long/anterior mandibular defects, for the right patient and indication it has shown great success in reconstructive efforts.

National Trends in 30-Day Readmission Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma.

Importance: As the incidence of oropharyngeal squamous cell carcinoma (OPSCC) continues to rise in the US, an increasing number of patients are being treated with transoral robotic surgery (TORS). Readmission following surgery can potentially delay initiation of adjuvant treatment and affect survival outcomes. Objective: To identify risk factors for 30-day postoperative readmission in patients undergoing TORS for OPSCC. Design, Setting, and Participants: This retrospective, population-based cohort study used data from the Nationwide Readmissions Database from 2010 to 2017. All patients undergoing TORS for OPSCC were identified using International Classification of Diseases codes and included. Exclusion criteria were age younger than 18 years or incomplete information regarding index admission or readmission. The analysis was performed from April to October 2023. Exposure: TORS for OPSCC. Main Outcomes and Measures: Univariate and multivariate analyses were performed to determine factors associated with 30-day readmission. Covariates included demographics and medical comorbidities, socioeconomic factors, hospital characteristics, and surgical details. Trends in readmission over time, reasons for readmission, and characteristics of the readmission were also examined. Results: A weighted total of 5544 patients (mean [SD] age, 60.7 [0.25] years; 4475 [80.7%] male) underwent TORS for OPSCC. The overall readmission rate was 17.5% (n = 971), and these rates decreased over the study period (50 of 211 patients [23.7%] in 2010 vs 58 of 633 patients [9.1%] in 2017). Risk factors associated with readmission included male sex (adjusted odds ratio [AOR], 1.54; 95% CI, 1.07-2.20) and a diagnosis of congestive heart failure (AOR, 2.42; 95% CI, 1.28-4.58). Factors associated with decreased rate of readmission included undergoing concurrent selective neck dissection (AOR, 0.30; 95% CI, 0.22-0.41). Among the 971 readmissions, the most common readmission diagnoses were bleeding (151 [15.6%]), electrolyte and digestive problems (44 [4.5%]), pneumonia (44 [4.5%]), and sepsis (26 [2.7%]). Conclusions and Relevance: In this cohort study, readmission rates following TORS for oropharynx cancer decreased over time; however, a subset of patients required readmission most commonly related to bleeding, infection, and electrolyte imbalance. Concurrent neck dissection may be protective against readmission. Elucidation of risk factors for readmission after TORS for OPSCC offers opportunities for evidence-based shared decision-making, quality improvement initiatives, and improved patient counseling.

The genetics of dementia.

Over the past decade, there has been a dramatic evolution of genetic methodologies that can be used to identify genes contributing to disease. Initially, the focus was primarily on classical linkage analysis; more recently, genomewide association studies, and high-throughput whole genome and whole exome sequencing have provided efficient approaches to detect common and rare variation contributing to disease risk. Application of these methodologies to dementias has led to the nomination of dozens of causative and susceptibility genes, solidifying the recognition that genetic factors are important contributors to the disease processes. In this review, the authors focus on current knowledge of the genetics of Alzheimer's disease and frontotemporal lobar degeneration. A working understanding of the genes relevant to common dementias will become increasingly critical, as options for genetic testing and eventually gene-specific therapeutics are developed.

Acute Cricoarytenoid Joint Fixation Following Routine Intubation: A Case Report.

Prolonged intubation is a common cause of injury to the posterior larynx often resulting in cricoarytenoid joint (CAJ) fixation and posterior glottic stenosis (PGS). We present a case of respiratory failure due to acute bilateral CAJ fixation and PGS following only 2 days of intubation for routine cardiac surgery. A tracheostomy was placed due to critical airway obstruction. Clinicians should remain vigilant for laryngeal injury presenting as CAJ fixation and PGS. Prompt surgical consultation is advised as early intervention is associated with reduced morbidity.

Internal jugular vein reconstruction: An algorithm for reconstructive surgeons.

OBJECTIVES: The internal jugular vein (IJV) provides critical drainage from the brain, skull, and deep regions of the face and neck. Compromise to the bilateral IJVs has severe sequelae, but even unilateral IJV sacrifice or thrombosis after treatment can have sequelae. Despite the potential role of IJV reconstruction for head and neck surgeons, information about the indications, technique, and outcomes of the procedure are sparse. PATIENTS AND METHODS: We present a woman who had IJV sacrifice for an oral cavity cancer along with a contralateral selective neck dissection and adjuvant chemoradiation who developed occlusion of the contralateral IJV after her treatment, resulting in unacceptable cervical lymphedema and extensive neck varicosities. An end-to-side bypass from the superior IJV to the ipsilateral external jugular vein was performed. RESULTS: There were no complications from the procedure, which resulted in dissipation of her preoperative symptoms. We describe the literature surrounding IJV reconstruction, considerations for its use, the technique itself, and advice for perioperative management. CONCLUSION: IJV reconstruction is a valuable but underutilized technique for the head and neck microvascular surgeon in cases of bilateral threatened IJV outflow.

Sponsorship in Otolaryngology-Head and Neck Surgery: A Pathway to Equity, Diversity, and Inclusion.

Importance: Sponsorship, distinct from mentorship or coaching, involves advancing the careers of individuals by nominating them for roles, increasing the visibility of their work, or facilitating opportunities. Sponsorship can open doors and enhance diversity; however, achieving desirable outcomes requires equitable approaches to cultivating potential in sponsees and promoting their success. The evidence on equitable sponsorship practices has not been critically examined, and this special communication reviews the literature, highlighting best practices. Observations: Sponsorship addresses an unmet need for supporting individuals who have historically been afforded fewer, less visible, or less effective opportunities for upward career mobility. Barriers to equitable sponsorship include the paucity of sponsors of underrepresented identity; smaller and underdeveloped networks among these sponsors; lack of transparent, intentional sponsorship processes; and structural inequities that are associated with recruitment, retention, and advancement of diverse individuals. Strategies to enhance equitable sponsorship are cross-functional, building on foundational principles of equity, diversity, and inclusion; patient safety and quality improvement; and insights from education and business. Equity, diversity, and inclusion principles inform training on implicit bias, cross-cultural communication, and intersectional mentoring. Practices inspired by patient safety and quality improvement emphasize continuously improving outreach to diverse candidates. Education and business insights emphasize minimizing cognitive errors, appreciating the bidirectional character of interactions, and ensuring that individuals are prepared for and supported in new roles. Collectively, these principles provide a framework for sponsorship. Persistent knowledge gaps are associated with timing, resources, and systems for sponsorship. Conclusions and Relevance: The nascent literature on sponsorship is limited but draws on best practices from various disciplines and has potential to promote diversity within the profession. Strategies include developing systematic approaches, providing effective training, and supporting a culture of sponsorship. Future research is needed to define best practices for identifying sponsees, cultivating sponsors, tracking outcomes, and fostering longitudinal practices that are sustainable at local, regional, and national levels.

Neoadjuvant dabrafenib and trametinib for functional organ preservation in recurrent BRAF V600E-mutated papillary thyroid cancer.

OBJECTIVES: To describe the first reported use of neoadjuvant dabrafenib and trametinib specifically to permit organ conservation surgery in locally advanced recurrent differentiated thyroid carcinoma. PATIENTS AND METHODS: A patient presented with locally recurrent, radioiodide-resistant DTC with a BRAF V600E mutation invading the laryngotrachea. Definitive treatment would require a total laryngectomy. She was offered neoadjuvant dabrafenib and trametinib prior to surgery. RESULTS: A significant radiographic response permitted partial laryngectomy, enabling preservation of voice, early resumption of oral feeding, and avoidance of permanent tracheostomy. At 9 months, she remained free of disease. CONCLUSION: Neoadjuvant tyrosine kinase inhibitor treatment prior to definitive surgery for locally-invasive recurrent DTC is a potential approach that may limit the degree of surgery and associated morbidity.

Impact of applicant and program factors on preference signaling outcomes in otolaryngology.

Objectives: To assess the impact of applicant and program characteristics on preference signaling outcomes during the 2021 and 2022 application cycles in otolaryngology. Methods: The Texas Seeking Transparency in Applications to Residency survey was used for otolaryngology applicants during the 2021 and 2022 match years. The primary outcome of interest was signal yield, defined as the number of interviews at signaled programs divided by the total number of signals sent. Associations with applicant-reported characteristics, geographic connections to programs, and program reputation were assessed. Results: On average 59.5% of signals resulted in an interview (signal yield). There was a positive correlation between the number of signals sent to a program with a reported geographic connection and signal yield, with each additional signal resulting in a 3.4% increase in signal yield (p = .03). Signal yield was positively associated with number of publications (p < .001); number of abstracts, posters, and presentations (p = .04); and whether the applicant took a research year (p = .003). Applicants with higher USMLE Step 1 (p = .01) and Step 2 (p = .003) scores, publications (p = .03), volunteer (p = .008) and leadership (p = .001) experiences received a lower percentage of their total interviews from signaled programs whereas applicants from the 3rd (p < .001) and 4th (p = .03) cumulative class ranked quartiles received a higher percentage of their total interviews from signaled programs. Conclusions: Signal yield appears to have a significant association with geographic connections to programs and applicant competitiveness. This study may help applicants, advisors, and programs maximize the benefit of the preference signaling system.Levels of evidence: Level 4.

Sponsorship and Negotiation for Women Otolaryngologists at Midcareer: A Content Analysis.

OBJECTIVE: To explore challenges and opportunities for supporting midcareer women otolaryngologists in the areas of negotiation and sponsorship. STUDY DESIGN: Qualitative approach using semistructured interviews. SETTING: Online multi-institutional interviews. METHODS: This study was performed from June to August 2021. Women otolaryngologists representing diverse subspecialties, training, and practice environments were recruited via a purposive criterion-based sampling approach. Semistructured interviews were transcribed, coded, and analyzed via an inductive-deductive approach to produce a thematic content analysis. RESULTS: Among the 12 women interviewees, who represented 7 subspecialties, the majority were Caucasian (58%) and in academic practice (50%). The median residency graduation year was 2002 (range, 1982-2013). Participants expressed several challenges that women otolaryngologists face with respect to negotiation, including the absence of systematic formal negotiation training, gendered expectations that women experience during negotiations, and a perceived lack of power in negotiations. Obstacles to effective sponsorship included difficulty in the identification of sponsors and the influence of gender and related systemic biases that hindered sponsorship opportunities. CONCLUSION: Notable gender disparities exist for negotiation and sponsorship in the midcareer stage for women otolaryngologists. Women start at a disadvantage due to a lack of negotiation training and access to sponsors, which is exacerbated by systemic gender bias and power differentials as women advance in their careers. This study highlights opportunities to improve negotiation and sponsorship for women, with the goal of promoting a more diverse workforce.

Demographic and Academic Productivity Trends Among American Head & Neck Society Fellows Over a 20-Year Period.

Importance: Historical data reveal that, compared with women, men are more likely to pursue a head and neck surgical oncology fellowship, but little is known about possible gender differences in academic productivity. Objective: To assess demographic trends and academic productivity among American Head & Neck Society (AHNS) fellowship graduates. Design, Setting, and Participants: This cross-sectional study used electronically published data from the AHNS on fellowship graduates in the US and Canada from July 1, 1997, to June 30, 2022. Scopus was used to extract h-indices for each graduate. Exposure: Scholarly activity. Main Outcomes and Measures: Main outcomes were changes in demographic characteristics and academic productivity among AHNS graduates over time. Data analysis included effect size, η2, and 95% CIs. Results: A total of 691 AHNS fellowship graduates (525 men [76%] and 166 women [24%]) were included. Over the study period, there was an increase in the number of programs offering a fellowship (η2, 0.84; 95% CI, 0.68-0.89) and an increase in the absolute number of women who completed training (η2, 0.66; 95% CI, 0.38-0.78). Among early-career graduates pursuing an academic career, there was a small difference in the median h-index scores between men and women (median difference, 1.0; 95% CI, -1.1 to 3.1); however, among midcareer and late-career graduates, there was a large difference in the median h-index scores (midcareer graduates: median difference, 4.0; 95% CI, 1.2-6.8; late-career graduates: median difference, 6.0; 95% CI, 1.0-10.9). A higher percentage of women pursued academic positions compared with men (106 of 162 [65.4%] vs 293 of 525 [55.8%]; difference, 9.6%; 95% CI, -5.3% to 12.3%). Conclusions and Relevance: This cross-sectional study suggests that women in head and neck surgery begin their careers with high levels of academic productivity. However, over time, a divergence in academic productivity between men and women begins to develop. These data argue for research to identify possible reasons for this observed divergence in academic productivity and, where possible, develop enhanced early faculty development opportunities for women to promote their academic productivity, promotion, and advancement into leadership positions.

Hypothyroidism as an Independent Predictor of 30-day Readmission in Head and Neck Cancer Patients.

OBJECTIVES: To define the role of hypothyroidism and other risk factors for unplanned readmissions after surgery for head and neck cancer. STUDY DESIGN: Retrospective cohort study. METHODS: The Nationwide Readmission Database (NRD) was used to identify patients who underwent surgery for mucosal head and neck cancer (oral cavity, oropharynx, larynx, and hypopharynx) between 2010 and 2017. Univariate and multivariate logistic regression were performed to determine patient, tumor, and hospital related risk factors for 30-day readmission. Readmitted patients were stratified by preoperative diagnosis of hypothyroidism to compare readmission characteristics. RESULTS: For the 131,013 patients who met inclusion criteria, the readmission rate was 15.9%. Overall, 11.91% of patients had a preoperative diagnosis of hypothyroidism. After controlling for other variables, patients with a preoperative diagnosis of hypothyroidism had 12.2% higher odds of readmission compared to those without hypothyroidism (OR: 1.12, 1.03-1.22, p = 0.008). Patients with hypothyroidism had different reasons for readmission, including higher rates of wound dehiscence, fistula, infection, and electrolyte imbalance. Among readmitted patients, the length of stay for index admission (mean 10.5 days vs. 9.2 days, p < 0.001), readmission (mean 7.0 vs. 6.6 days, p = 0.05), and total hospital charge were higher for hypothyroid patients ($137,742 vs. $119,831, p < 0.001). CONCLUSION: Hypothyroidism is an independent risk factor for 30-day readmission following head and neck cancer resection. Furthermore, hypothyroid patients are more likely to be readmitted for wound complications, infection, and electrolyte imbalance. Targeted interventions should be considered for hypothyroid patients to decrease readmission rates and associated patient morbidity, potentially leading to earlier initiation of adjuvant treatment. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2988-2998, 2023.