HPV-Associated Head and Neck Cancer: Unique Features of Epidemiology and Clinical Management.

Human papillomavirus (HPV) is a recently identified causative agent for a subset of head and neck cancers, primarily in the oropharynx, and is largely responsible for the rising worldwide incidence of oropharyngeal cancer (OPC). Patients with HPV-positive OPC have distinct risk factor profiles and generally have a better prognosis than patients with traditional, HPV-negative, head and neck cancer. Concurrent chemotherapy and radiation is a widely accepted primary treatment modality for many patients with HPV-positive OPC. However, recent advances in surgical modalities, including transoral laser and robotic surgery, have led to the reemergence of primary surgical treatment for HPV-positive patients. Clinical trials are under way to determine optimal treatment strategies for the growing subset of patients with HPV-positive OPC. Similarly, identifying those patients with HPV-positive cancer who are at risk for recurrence and poor survival is critical in order to tailor individual treatment regimens and avoid potential undertreatment.

Risk of post-tonsillectomy hemorrhage among COVID-19 positive pediatric patients.

OBJECTIVE: COVID-19 infection has been demonstrated to increase risk for post-operative bleeding. This study investigated the impact of COVID-19 infection on post-tonsillectomy hemorrhage in pediatric patients, a potentially devastating complication. STUDY DESIGN: Retrospective cohort study. METHODS: The TriNetX database was queried for pediatric patients who underwent tonsillectomy and evaluated for outcomes of primary and secondary post-tonsillectomy hemorrhage. RESULTS: Among subjects 18 years and younger, 1226 were COVID-19 positive and 38,241 were COVID-19 negative in the perioperative period. There was statistically significant increased risk of bleeding with perioperative COVID-19 infection at postoperative days 1, 5, and 10. Additionally, when assessing the role of COVID-19 infection before or after surgery, the risk of bleeding remained statistically significant at all three time points, however these results did not suggest that infection before surgery confers more/less risk compared to infection after. CONCLUSION: The results of this investigation suggest that the presence of COVID-19 in the perioperative period may pose an increased risk for acute or delayed post tonsillectomy hemorrhage. This study employed a large, diverse population and is the first to address this clinical question.

Impact of Early Research Productivity on Future Academic Output Among Head and Neck Fellows.

OBJECTIVE: To examine the impact of pre-fellowship publications on future research productivity and career placement among head and neck (H&N) surgery fellowship graduates. METHODS: H&N surgery fellowship graduates between 2014 and 2022 were identified from publicly available data. Timing of fellowship graduation, number of publications during each stage of education and training, and number of first authorship publications were analyzed for association with scholarly productivity and academic career placement. RESULTS: In our analysis of 409 H&N fellowship graduates, there was a strong positive correlation between the year of fellowship graduation and the average number of publications in residency (R2 = 0.82) and fellowship (R2 = 0.79). Graduates producing more than the average of 2.37 publications prior to residency had a significantly higher average number of publications during residency and fellowship compared to those who published below average (p < 0.001). A higher number of publications prior to and during residency were both independently associated with a higher likelihood of academic career placement (p = 0.015 and p = 0.002, respectively). More first-author publications prior to residency were associated with a higher number of publications during residency and fellowship (p = 0.015). In sub-analyses, gender did not impact the average number of publications during residency and fellowship. Similarly, the COVID-19 pandemic did not significantly impact the average number of publications during the fellowship when comparing the classes of 2020-2022 to 2017-2019. CONCLUSION: Research productivity among H&N fellowship graduates has increased in recent years. Research productivity in medical school and residency is associated with scholarly output in later stages of training and academic career placement. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3165-3169, 2024.

The impact of COVID-19 and vaccination status on outcomes in veterans with head and neck squamous cell carcinoma.

BACKGROUND: The impact of both COVID-19 infection and vaccination status on patients with head and neck squamous cell carcinoma (HNSCC) remains unknown. OBJECTIVE: To determine the impact of COVID-19 infection and vaccination status on 60-day mortality, cardiovascular, and respiratory complications in patients with a prior diagnosis of HNSCC. METHODS: This was a retrospective cohort study through the Veterans Affairs (VA) Corporate Data Warehouse of Veterans with HNSCC who were tested for COVID-19 during any inpatient VA medical center admission. A cohort of patients was created of Veterans with a diagnosis of HNSCC of the oral cavity,oropharynx, hypopharynx, larynx, and nasopharynx based on International Classification of Disease (ICD) codes. Data collected included clinical/demographic data, vaccination status, and incidence of 60-day mortality, 60-day cardiovascular complication (including myocardial infarction, venous thromboembolism, cerebrovascular accident), and 60-day respiratory complication (including acute respiratory failure, acute respiratory distress syndrome, and pneumonia). The interactions between COVID-19 infection, vaccination status, morbidity and mortality were investigated. RESULTS: Of the 14 262 patients with HNSCC who were tested for COVID-19 during inpatient admission, 4754 tested positive (33.3%), and 9508 (67.7%) tested negative. Patients who tested positive demonstrated increased 60-day mortality (4.7% vs. 2.0%, respectively; p < 0.001), acute respiratory failure (ARF; 15.4% vs. 7.1%, p < 0.001), acute respiratory distress syndrome (ARDS; 0.9% vs. 0.2%, p < 0.001), and pneumonia (PNA; 20.0% vs. 6.4%, p < 0.001) compared to those who never tested positive, respectively. Patients who received COVID-19 vaccination between 2 weeks and 6 months prior to a positive test demonstrated decreased rates of ARF (13.2% vs. 16.0%, p = 0.034) and PNA (16.7% vs. 20.9%, p = 0.003) compared to the unvaccinated group. A logistic regression of patients with COVID-19 infections who died within 60 days was performed, with no significant survival advantage among patients vaccinated between 2 weeks and 6 months prior to the positive test. CONCLUSION: COVID-19 infection may significantly increase rates of 60-day mortality and respiratory complications in patients with HNSCC. COVID-19 vaccination between 2 weeks and 6 months prior to infection may decrease severity of respiratory complications but did not show significant mortality benefits in this study. These data highlight the need for surveillance of respiratory infection and vaccination in this vulnerable population.

Correcting for Rater Effects in Operating Room Surgical Skills Assessment.

OBJECTIVE: To estimate and adjust for rater effects in operating room surgical skills assessment performed using a structured rating scale for nasal septoplasty. METHODS: We analyzed survey responses from attending surgeons (raters) who supervised residents and fellows (trainees) performing nasal septoplasty in a prospective cohort study. We fit a structural equation model with the rubric item scores regressed on a latent component of skill and then fit a second model including the rating surgeon as a random effect to model a rater-effects-adjusted latent surgical skill. We validated this model against conventional measures including the level of expertise and post-graduation year (PGY) commensurate with the trainee's performance, the actual PGY of the trainee, and whether the surgical goals were achieved. RESULTS: Our dataset included 188 assessments by 7 raters and 41 trainees. The model with one latent construct for surgical skill and the rater as a random effect was the best. Rubric scores depended on how severe or lenient the rater was, sometimes almost as much as they depended on trainee skill. Rater-adjusted latent skill scores increased with attending-estimated skill levels and PGY of trainees, increased with the actual PGY, and appeared constant over different levels of achievement of surgical goals. CONCLUSION: Our work provides a method to obtain rater effect adjusted surgical skill assessments in the operating room using structured rating scales. Our method allows for the creation of standardized (i.e., rater-effects-adjusted) quantitative surgical skill benchmarks using national-level databases on trainee assessments. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Associations Between Race and Survival Outcomes Among Veterans With Head and Neck Cancer in a Racially Diverse Setting.

Objective: There is limited data on the impact of clinical-demographic factors on survival outcomes among veterans with head and neck squamous cell carcinoma (HNSCC). This study was undertaken to evaluate the impact of race and other factors on overall survival (OS) in a population of veterans with HNSCC treated with curative intent. Methods: Demographic and clinical data were collected on veterans with HNSCC treated with curative intent at our institution between 1999 and 2021. The primary outcome was 3-year OS. Secondary outcomes included treatment delay intervals, including time to treatment initiation (TTI), total package time, and duration of chemoradiation (DCRT). Results: Of 260 veterans with HNSCC, black veterans had significantly lower 3-year OS (49.4%) compared to white veterans (65%, P = .019). Black veterans were also more likely to experience delays in treatment initiation (median TTI 46 vs 41 days; P = .047). Black patients were more likely to receive radiation alone (25.8% [black] vs 8.4% [white]; P < .001) and less likely to receive adjuvant therapy if treated surgically (11.1% [black] vs 22.4% [white]; P = .004), despite any statistically significant difference in stage of their tumor at presentation (Stage I: 21.2% [black] vs 19.6% [white]; P = .372); (Stage IV: 44.4% [black] vs 48.6% [white]; P = .487). Other factors associated with worse 3-year OS included older age (P = .023), lower body mass index (P = .026), neurocognitive disorder/dementia (P = .037), mental health disorders (P = .020), hypopharyngeal primary (P = .001), higher stage disease (P = .002), treatment type (P = .001), need for prophylactic gastrostomy tube (P = .048) or tracheotomy (P = .005), recurrent disease (P = .036), persistent disease (P < .001), distant metastases (P = .002), longer TTI (P = .0362), and longer DCRT (P = .004). Discussion: Black race appears to be an independent predictor of 3-year OS in veterans with HNSCC. Further studies are warranted to determine the factors responsible for disparities in survival. Implications for Practice: This study evaluated the ways in which race affects survival for US veterans with head and neck cancer. The authors found that black veterans had an increased risk of death compared to white patients, and also experienced delays when receiving treatment. Level of Evidence: Level IV.

Extracapsular spread in head and neck carcinoma: impact of site and human papillomavirus status.

BACKGROUND: Extracapsular spread (ECS) in cervical lymph node metastases from head and neck squamous cell carcinoma (SCC) is regarded as an adverse prognostic factor and is often used to select patients who may benefit from adjuvant therapy. The prognostic value of ECS was evaluated for patients with oropharyngeal SCC (OPC; with known p16/human papillomavirus [HPV] status) and for patients with SCC of the oral cavity (OCC). METHODS: Disease-specific survival (DSS) was assessed among SCC patients with cervical lymph node metastases (n = 347, including 133 patients with OPC and 214 patients with OCC). All patients were treated surgically between 1983 and 2009. ECS status was determined by pathologists at the time of initial pathologic evaluation and confirmed for this study. HPV status of patients with OPC was determined via immunohistochemistry for p16 and in situ hybridization. RESULTS: Among OCC patients, ECS was a significant, independent factor influencing DSS. For OCC patients with ECS, 3-year DSS was 45% (95% confidence interval [CI], 36%-56%); for those without ECS, 3-year DSS was 71% (95% CI, 62%-81%; P = .0018). The effect of ECS was independent of the number of positive lymph nodes as well as other clinical, pathologic, and treatment variables. Of the 133 OPC patients, 76 (57%) were p16-positive and 57 (43%) were p16-negative. ECS status did not correlate with DSS among p16-positive or p16-negative OPC patients. CONCLUSION: ECS was not associated with worse DSS in p16-positive or p16-negative OPC patients. Adverse prognostic value of ECS in OCC patients was confirmed. Cancer 2013;119:3302-8. © 2013 American Cancer Society.

PIK3CA, HRAS and PTEN in human papillomavirus positive oropharyngeal squamous cell carcinoma.

BACKGROUND: Recent genomic evidence suggests frequent phosphatidylinositide 3-kinase (PI3K) pathway activation in human papillomavirus (HPV) positive oropharyngeal squamous cell carcinoma. Mutations/amplification of the gene encoding p110α catalytic subunit of phosphoinositide 3-kinase (PIK3CA), loss of phosphatase and tensin homolog (PTEN) and HRAS mutations are known to activate PI3K pathway. METHODS AND RESULTS: PIK3CA mutations were identified by Sanger sequencing in 23 of 75 (31%) HPV-positive oropharyngeal carcinomas, including exon 9 (p.E545K [n = 10] and p.E542K [n = 5]) or exon 20 (p.H1047Y, n = 2) mutations. Five rare and one novel (p.R537Q) PIK3CA mutations were identified. HRAS mutation (p.Q61L) was detected in 1 of 62 tested cases. PIK3CA amplification by fluorescence in situ hybridization (FISH) was identified in 4 cases (4/21, 20%), while PTEN loss was seen in 7 (7/21, 33%) cases (chromosome 10 monosomy [n = 4], homozygous deletion [n = 3]). CONCLUSIONS: Overall, genetic alterations that likely lead to PI3K pathway activation were identified in 34 of 75 cases (45%) and did not correlate with disease specific survival. These findings offer a molecular rationale for therapeutic targeting of PI3K pathway in patients with HPV-positive oropharyngeal carcinoma.

Upper Airway Manifestations of Monkeypox: A Case Report and Literature Review.

Background: The monkeypox virus (MPXV) has spread globally, causing an infection similar to that of smallpox. In July 2022, MPXV was declared an international public health emergency by the World Health Organization. Although the prodromal and cutaneous symptoms are described, the literature is lacking with regard to the upper airway manifestations of the disease. Methods: This case report describes a 39-year-old gentleman with a history of human immunodeficiency virus who presented to the emergency department with fever, sore throat, and cough. A literature review was also performed to determine the clinical presentation and physical examination findings of patients presenting with MPXV. Results: The patient underwent flexible laryngoscopy on two separate occasions due to his symptoms of fever and sore throat. He was noted to have white plaque-like lesions throughout the upper aerodigestive tract that could not be excised with manipulation. Ultimately, he tested positive for MPXV and was treated with full recovery. Conclusions: To our knowledge, this is the first report describing upper airway manifestations of MPXV. Since patients with MPXV often present initially with pharyngitis, understanding the physical examination findings of MPXV in the upper airway is imperative for early diagnosis and public health awareness.

Distant metastases in human papillomavirus-related oropharyngeal squamous cell carcinoma: Systematic review and meta-analysis.

The prevalence of distant metastases (DM) in human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) remains unknown. A PRISMA systematic review of DM rates in patients with HPV-related OPSCC was performed. PubMed-MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched. The primary outcome was prevalence of DM. Data on demographics, tumor classification, and clinical outcomes were also collected. Meta-analysis of pooled DM rate was determined. Ten articles met inclusion criteria, representing 1860 patients with mean follow-up of 3.6 years. Overall DM rate was 7.0% (95% CI: 5.9-8.2). T3 or T4 classification disease was associated with a 4.88-fold (95% CI: 1.92-12.40) risk of DM compared to T1 or T2 classification disease. This study is the first to systematically review the prevalence of DM among patients with HPV-related OPSCC, where pooled DM rate was found to be 7%.

Predictors of Survival in Veterans with Head and Neck Cancer Treated Surgically.

Background: Squamous cell carcinoma (SCC) accounts for 90% of all head and neck cancers. In veterans, the prevalence of head and neck SCC is nearly twice as high compared with the civilian population. Neck dissection plays an important role in the treatment algorithm for patients with head and neck SCC. The aim of this manuscript was to investigate predictors of survival in patients with head and neck SCC who underwent curative treatment. Methods: Patients with head and neck SCC who underwent treatment with curative intent were included in this study. Data collected included clinical-demographic characteristics, tumor characteristics, and outcome. The primary endpoint was 3-year overall survival (OS), and the secondary endpoints were disease recurrence and distant metastases. Results: A total of 149 patients met inclusion criteria, and most patients were treated with surgery plus adjuvant chemoradiation (52%). The 3-year OS for the entire cohort was 55.7%. There was no statistically significant difference in mortality when comparing the various treatment types. Black patients (hazard ratio [HR] = 1.70, P = .023) and other non-white patients (HR = 3.88, P = .027) had worse 3-year OS compared with white patients. Advanced tumor classification (T4a) was also associated with worse 3-year OS (HR = 3.088, P = .003) and increased risk of cancer recurrence or distant metastases (HR = 3.34, P = .013). Conclusions: Risk factors linked to poor survival among this cohort of veterans with head and neck SCC included non-white race and advanced tumor classification. Neck dissection remains an integral aspect of the treatment algorithm for SCC of the head and neck and can provide regional control of malignant disease.

Complications of eustachian tube balloon dilation: Manufacturer and User Facility Device Experience (MAUDE) database analysis and literature review.

Objective: To provide an analysis of complications following eustachian tube balloon dilation as well as their treatments and outcomes. Data Sources: PubMed, Ovid Embase, and MAUDE Database. Review Methods: A systematic approach following PRISMA guidelines was used to identify publications pertaining to balloon dilation of the eustachian tube from PubMed and Ovid Embase databases was used. Once these publications were critically reviewed, the primary outcome extracted were reported complications. Additional complications were collected in the Manufacturer and User Facility Device Experience (MAUDE) database using the product class "eustachian tube dilation device" and searching through relevant manufacturers. Complications and outcomes were compared between these sources. Results: Fifty five full-length manuscripts involving 7155 patients were included and 98 complications reported for a 1.4% complication rate. The most frequently reported adverse events were subcutaneous emphysema of the head and neck (19%), epistaxis (12%), and acute otitis media (11%). The MAUDE search returned 18 distinct patient entries, of which 12 (67%) reported complications. The most reported complications in the MAUDE database included subcutaneous emphysema (8, 67%) and pneumomediastinum (3, 25%). The most serious complication was a carotid artery dissection reported in one patient in the MAUDE database. Conclusion: Eustachian tube dilation is rarely associated with complications, which nevertheless may lead to morbidity and medical emergencies. Patients and providers should recognize potential risks associated with this intervention as well as methods to manage complications.

Malnutrition universal screening tool predicts postoperative complications following major head and neck cancer surgery.

BACKGROUND: Head and neck cancer patients are at risk for malnutrition, which can impact postoperative outcomes. This study evaluates the Malnutrition Universal Screening Tool (MUST) to predict outcomes in major head and neck surgeries. METHODS: A retrospective chart review included 275 major surgical procedures performed on 242 patients over the age of 18 years between May 2015 and May 2020. RESULTS: The majority of patients had a MUST score of zero (68.7%). Just under 17% scored 2 or greater indicating malnourishment. Having a MUST score of 2 or higher was associated with occurrence of a postoperative complication (p < 0.001). Patients with alcohol use disorder or depression were 5.2 (CI: 2.0-13.7, p = 0.001) and 2.75 (CI 1.1-7.0; p = 0.033) times more likely to develop a postoperative complication, respectively. CONCLUSIONS: Malnutrition and comorbidities were associated with complications in our surgical cohort. MUST is a novel tool to identify patients who may benefit from nutritional interventions.

Perioperative complications among head and neck surgery patients with COVID-19.

BACKGROUND: Patients undergoing surgery for head and neck cancer (HNC) have potentially high perioperative complication rates. Recent studies indicate that preoperative COVID-19 infection poses increased risk for postoperative complications in other fields. However, to date, there has not been data showing the effect of COVID-19 on complication rates for HNC. Here, a large database was employed to assess if perioperative COVID-19 increased the risk of perioperative complications among those undergoing HNC surgery. METHODS: A retrospective investigation was conducted using a multi-institutional research database. Subjects who underwent HNC surgery from January 2020 to September 2022 were identified using the International Classification of Diseases and Current Procedure Terminology codes. Thirty-day surgical and medical complications were assessed for those diagnosed with COVID-19 infection from 7 days before or after surgery compared to those who were COVID-19 negative. Cohorts were propensity scores matched by age, sex, and race. RESULTS: Perioperative COVID-19 was present in n = 208 and absent in n = 15 158 subjects that underwent HNC surgery. For unmatched analyses, there was a statistically significant increased risk in the 30-day postoperative period in COVID-19-positive patients for the following surgical complications: surgical site fistula, free tissue transfer (FTT) complication, FTT failure, and death. Additionally, there was a statistically significant increased risk in the 30-day postoperative period in COVID-19-positive patients for the following medical complications: ventilator support, pneumonia, vasopressor, acute renal failure, and myocardial infarction. CONCLUSION: This large, retrospective populational study suggests HNC patients are at increased risk for death and several perioperative complications. This investigation is the first to address this clinical question.

The impact of COVID-19 on presentation and diagnosis of head and neck squamous cell carcinoma.

Objective: To analyze how the COVID-19 pandemic has influenced trends in head and neck squamous cell carcinoma (HNSCC) presentation and diagnosis-including referral patterns, stage at presentation, and time to diagnosis-over a longitudinal time course. Setting: Multicenter tertiary care academic institution. Methods: A retrospective review of patients with HNSCC presenting between January 1, 2019 and December 31, 2020 was performed. Patients were stratified into pre-COVID and COVID cohorts based upon presentation date either before or after the COVID pandemic was declared a national emergency. Data was collected on demographics, referral site, symptoms, tumor characteristics, and time to diagnosis. Results: Of 203 patients with HNSCC identified, 77.3% (157/203) were in the pre-COVID cohort and 22.7% (46/203) were in the COVID cohort. Patients in the COVID cohort were more likely to present through inpatient or ER consultation (26% vs. 11%) than outpatient setting. There was a greater than 50% decrease in new tumor board case presentations per month in the COVID cohort (4.8) relative to the pre-COVID (10.9) cohort. Cancer stage at presentation was similar between cohorts. Time from presentation to diagnosis was similar between the cohorts at approximately 30 days. Conclusions: These results suggest that patients presenting during the COVID pandemic may have unique referral patterns. A significant decrease in tumor board presentations was noted, which may contribute to more delayed presentations that have yet to be observed. Further investigation with a larger sample size is warranted. Lay Summary: The COVID-19 pandemic may have changed where and how patients with head and neck cancer initially seek care. We found that patients with newly diagnosed head and neck cancer more often were initially seen in urgent settings than before the pandemic. Level of Evidence: 3.

Skull Base Regeneration During Treatment With Chemoradiation for Nasopharyngeal Carcinoma: A Case Report.

Background: Advanced cases of nasopharyngal carcinoma can present with skull base invasion. Treatment of these advanced cases with radiotherapy poses a challenge given proximity of tumor to critical neural structures as well as concern that a skull base defect and associated complications could develop with tumor regression. Case Presentation: A 34-year-old male patient presented with a 7-cm nasopharyngeal tumor invading the skull base with destruction of the clivus and intracranial extension. He underwent a course of definitive chemoradiation, requiring use of adaptive radiotherapy, that resulted in complete tumor regression and is free of disease 5 years posttreatment. Imaging done during treatment demonstrated that significant regeneration of bone occurred simultaneously with tumor regression. Conclusions: This case demonstrates that it is possible for bony regeneration to occur simultaneously with tumor regression in a patient with skull base invasion by tumor, precluding the need for neurosurgical intervention.

Increased body mass index predicts prolonged survival in patients with head and neck squamous cell carcinoma.

BACKGROUND: Higher body mass index (BMI) may have a protective effect on survival in patients with head and neck cancer. The aim of this study was to determine the effect of BMI on overall survival (OS) in veterans with head and neck squamous cell carcinoma (HNSCC). METHODS: A cohort of 702 patients diagnosed with HNSCC between 1995 and 2019 were identified at the Washington DC Veterans Affairs Medical Center, and 342 patients were included for analysis. Records were queried for clinical-demographic data, BMI, and outcomes. RESULTS: HNSCC patients categorized as overweight or obese at time of diagnosis had a lower 3-year risk of death (p = 0.033) and improved OS (p < 0.001) compared to patients who were underweight or normal weight. The majority of locoregional recurrences occurred in patients with low or normal pretreatment BMI. CONCLUSIONS: Higher BMI at diagnosis may have a protective effect on OS in veterans with HNSCC.

Do Attending and Trainee Surgeons Agree on What Happens in the Operating Room During Septoplasty?

Background: Surgeons must select cases whose complexity aligns with their skill set. Objectives: To determine how accurately trainees report involvement in procedures, judge case complexity, and assess their own skills. Methods: We recruited attendings and trainees from two otolaryngology departments. After performing septoplasty, they completed identical surveys regarding case complexity, achievement of goals, who performed which steps, and trainee skill using the septoplasty global assessment tool (SGAT) and visual analog scale (VAS). Agreement regarding which steps were performed by the trainee was assessed with Cohen's kappa coefficients (κ). Correlations between trainee and attending responses were measured with Spearman's correlation coefficients (rho). Results: Seven attendings and 42 trainees completed 181 paired surveys. Trainees and attendings sometimes disagreed about which steps were performed by trainees (range of κ = 0.743-0.846). Correlation between attending and trainee responses was low for VAS skill ratings (range of rho = 0.12-0.34), SGAT questions (range of rho = 0.03-0.53), and evaluation of case complexity (range of rho = 0.24-0.48). Conclusion: Trainees sometimes disagree with attendings about which septoplasty steps they perform and are limited in their ability to judge complexity, goals, and their skill.

Aspirin use predicts prolonged survival in patients with oropharyngeal cancer: Nationwide Veterans Affairs database study.

BACKGROUND: Single-institution studies suggest that aspirin reduces the risk of death in head and neck cancer. The aim of this study was to investigate the effect of aspirin use on overall survival (OS) in veterans with oropharyngeal cancer (OPC). METHODS: A total of 23 083 veterans with OPC were identified between 2005 and 2018 from the Veterans Health Administration Corporate Data Warehouse. Records were queried for clinical-demographic data, aspirin prescriptions, and outcomes. Three-year OS was estimated. A Cox model was used to estimate hazard ratios (HR) for aspirin use. RESULTS: Among the 23 083 identified veterans, 17 206 veterans met inclusion criteria. 21.8% used aspirin. Three-year OS was prolonged for aspirin users (66%) compared to nonaspirin users (54%; P < .001). Adjusted HR for death for nonaspirin users was 1.75 (95% confidence interval (CI) [1.60-1.91]). The average treatment effect of aspirin on survival using inverse probability weighting was 10% (95% CI [0.08-0.11]). CONCLUSION: Aspirin use following OPC diagnosis was independently associated with improved 3-year OS among veterans nationwide.

The distribution of parotid gland neoplasms in a veteran population.

OBJECTIVE: Salivary gland tumors account for 6%-8% of head and neck neoplasms with the parotid gland as the most common primary site. Pleomorphic adenomas (PA) are considered the most common benign parotid gland neoplasms, followed by Warthin tumors (WT). The goal of this study was to investigate the distribution of parotid gland neoplasms among a United States veteran population. DESIGN: Retrospective chart review. SETTING: Washington DC Veterans Affairs Medical Center. PARTICIPANTS: Veterans who underwent fine needle aspiration (FNA) for a parotid gland mass from 2000 to 2018 were included. Medical records were reviewed for gender, age, tobacco use, surgery date, and pathology results. MAIN OUTCOME MEASURES: Changes in the distribution of parotid neoplasms and tobacco use over an 18-year period. RESULTS: Of 141 patients with parotid gland masses, 86.5% (n = 122) were benign, 9.9% (n = 14) were malignant, and 3.5% (n = 5) were indeterminate. Of benign tumors, WT accounted for the majority at 51.6%, followed by PA at 40.2%. When stratified by decade (2000-2009 and 2010-2018), the proportion of WT compared to all other benign and malignant neoplasms increased from 31.6% to 53.6%, whereas the proportion of PA decreased from 36.8% to 33.3%. The rate of tobacco use was unchanged at approximately 32.0% among our cohort from 2000 to 2018. CONCLUSION: Among our cohort of veteran patients, WT was the most common benign parotid tumor and has increased in incidence over the last two decades despite an unchanged smoking rate.