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1.
Endocr Pract ; 29(10): 811-821, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-37236353

RESUMO

OBJECTIVE: The incidence of thyroid cancer has significantly increased in recent decades. Although most thyroid cancers are small and carry an excellent prognosis, a subset of patients present with advanced thyroid cancer, which is associated with increased rates of morbidity and mortality. The management of thyroid cancer requires a thoughtful individualized approach to optimize oncologic outcomes and minimize morbidity associated with treatment. Because endocrinologists usually play a key role in the initial diagnosis and evaluation of thyroid cancers, a thorough understanding of the critical components of the preoperative evaluation facilitates the development of a timely and comprehensive management plan. The following review outlines considerations in the preoperative evaluation of patients with thyroid cancer. METHODS: A clinical review based on current literature was generated by a multidisciplinary author panel. RESULTS: A review of considerations in the preoperative evaluation of thyroid cancer is provided. The topic areas include initial clinical evaluation, imaging modalities, cytologic evaluation, and the evolving role of mutational testing. Special considerations in the management of advanced thyroid cancer are discussed. CONCLUSION: Thorough and thoughtful preoperative evaluation is critical for formulating an appropriate treatment strategy in the management of thyroid cancer.


Assuntos
Neoplasias da Glândula Tireoide , Humanos , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/cirurgia , Prognóstico
2.
Am J Otolaryngol ; 43(2): 103374, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35158264

RESUMO

BACKGROUND: Metastases to the parotid nodal basin in patients with high-risk cutaneous squamous cell carcinoma (HRcSCC) impact disease specific survival (DSS) and overall survival (OS). METHODS: A writing group convened by the Salivary Section of the American Head and Neck Society (AHNS) developed contemporary, evidence-based recommendations regarding management of the parotid nodal basin in HRcSCC based on available literature, expert consultation, and collective experience. The statements and recommendations were then submitted and approved by the AHNS Salivary Committee. RESULTS: These recommendations were developed given the wide variation of practitioners who treat HRcSCC in order to streamline management of the parotid nodal basin including indications for imaging, surgery, radiation, and systemic treatment options as well. CONCLUSIONS: This clinical update represents contemporary optimal management of the parotid nodal basin in HRcSCC and is endorsed by the Salivary Section of the AHNS.


Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Parotídeas , Neoplasias Cutâneas , Carcinoma de Células Escamosas/patologia , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Linfonodos/patologia , Estadiamento de Neoplasias , Glândula Parótida/cirurgia , Neoplasias Parotídeas/patologia , Neoplasias Parotídeas/terapia , Estudos Retrospectivos , Neoplasias Cutâneas/patologia , Estados Unidos
3.
Am J Otolaryngol ; 43(1): 103225, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-34571439

RESUMO

PURPOSE: Virtual surgical planning (VSP), with custom made implants and guides represents a recent major advance. Nonetheless, knowledge related to practice patterns is limited. The purpose of this study was to provide data from the AHNS Reconstruction Section related to practice patterns, perceived value of VSP, as well as elucidate specific situations which represent high value for the application of VSP. MATERIALS AND METHODS: A multi-center web-based survey consisting of 30 questions regarding practice patterns related to VSP practices delivered via email to 203 members of the AHNS Reconstructive Surgery Section at institutions across North America. RESULTS: There was a 34% response rate (70/203). A majority of the respondents (96%) used VSP in approximately 50% of their mandibular reconstruction cases, and in 42% of maxillary cases. 46% reported using patient specific implants >75% of cases. Respondents estimated that ~17% of patients received dental implant reconstruction. The majority of respondents (71.0%) did not know the cost of VSP at their institution. The remaining respondents indicated the average cost was $6680 per case. VSP was felt to be necessary as a teaching tool by 55.9%. CONCLUSIONS: Our results demonstrate that a majority of respondents frequently utilize VSP in their practice for head and neck reconstruction. Complex, multi-unit reconstructions were felt to offer the greatest value when utilizing VSP. Future work should focus on increasing the rates of dental implant reconstruction in this population, optimizing value of VSP with careful case selection, and understanding the educational value and costs of these platforms.


Assuntos
Procedimentos Cirúrgicos Otorrinolaringológicos/estatística & dados numéricos , Planejamento de Assistência ao Paciente/estatística & dados numéricos , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Realidade Virtual , Cabeça/cirurgia , Humanos , Reconstrução Mandibular/estatística & dados numéricos , Pescoço/cirurgia , Procedimentos Cirúrgicos Ortognáticos/estatística & dados numéricos , Sociedades Médicas , Inquéritos e Questionários
4.
Eur Arch Otorhinolaryngol ; 278(12): 4923-4932, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33646344

RESUMO

BACKGROUND: Subglottic squamous cell carcinoma (SCC) represents less than 5% of all laryngeal cancers. Our objective was to better characterize survival using the National Cancer Database (NCDB) registry from 2004 to 2015. RESULTS: 403 patients met inclusion criteria. 63.8% presented with advanced-stage disease. Treatment regimens were as follows: 15.9% underwent surgery alone, 16.9% underwent surgery followed by adjuvant therapy, and 67.2% underwent primary chemo/radiation (C/RT). Five-year overall survival (OS) was 58.6% for Stage I and II patients, 49.1% for Stage III, and 36.3% for stage IV. Adjusted OS for all-stage patients was worse with C/RT compared to upfront surgery (40.6% vs. 58.4%; HR 1.83 [95%CI 1.29-2.61] p < 0.001) and adjusted OS for stage 4 disease was significantly worse with C/RT compared to surgery (26.0% vs. 45.2%, HR 1.79 [95%CI 1.17-2.73] p = 0.007). CONCLUSION: Majority of patients were treated with primary C/RT. Adjusted survival favors upfront surgery versus C/RT, especially in patients with Stage IV disease.


Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Laríngeas , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/terapia , Terapia Combinada , Humanos , Neoplasias Laríngeas/patologia , Neoplasias Laríngeas/terapia , Estadiamento de Neoplasias , Estudos Retrospectivos , Carcinoma de Células Escamosas de Cabeça e Pescoço/terapia , Taxa de Sobrevida
5.
Cancer ; 126(22): 4895-4904, 2020 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-32780426

RESUMO

BACKGROUND: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes. METHODS: Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high-priority, intermediate-priority, and low-priority indications for surgery were established and subdivided. A point-based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient. RESULTS: A total of 62 indications for surgical priority were rated. Weights for each indication ranged from -4 to +4 (scale range; -17 to 20). The response rate for the validation exercise was 100%. The SPARTAN-HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha, .91 [95% CI, 0.88-0.93]; and rho, 0.81 [95% CI, 0.45-0.95]). CONCLUSIONS: The SPARTAN-HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID-19 era. Formal evaluation and implementation are required. LAY SUMMARY: Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID-19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability. Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden. The current study sought to develop what to the authors' knowledge is the first cancer-specific surgical prioritization tool for use in the COVID-19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID-19 era and provides evidence for the initial uptake of the SPARTAN-HN.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Neoplasias de Cabeça e Pescoço/cirurgia , Recursos em Saúde , Pneumonia Viral/epidemiologia , Triagem/métodos , Algoritmos , COVID-19 , Tomada de Decisão Clínica , Consenso , Infecções por Coronavirus/virologia , Humanos , Cooperação Internacional , Pandemias , Pneumonia Viral/virologia , Reprodutibilidade dos Testes , Projetos de Pesquisa , SARS-CoV-2 , Cirurgiões
6.
Am J Otolaryngol ; 36(6): 729-35, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26545461

RESUMO

BACKGROUND: Orbital decompression is frequently performed in the management of patients with sight-threatening and disfiguring Graves' ophthalmopathy. The quantitative measurements of the change in orbital volume after orbital decompression procedures are not definitively known. Furthermore, the quantitative effect of septal deviation on volume change has not been previously analyzed. OBJECTIVES: To provide quantitative measurement of orbital volume change after medial and inferior endoscopic decompression and describe a straightforward method of measuring this change using open-source technologies. A secondary objective was to assess the effect of septal deviation on orbital volume change. METHODS: A retrospective review was performed on all patients undergoing medial and inferior endoscopic orbital decompression for Graves' ophthalmopathy at a tertiary care academic medical center. Pre-operative and post-operative orbital volumes were calculated from computed tomography (CT) data using a semi-automated segmenting technique and Osirix™, an open-source DICOM reader. Data were collected for pre-operative and post-operative orbital volumes, degree of septal deviation, time to follow-up scan, and individual patient Hertel scores. RESULTS: Nine patients (12 orbits) were imaged before and after decompression. Mean pre-operative orbital volume was 26.99 cm(3) (SD=2.86 cm(3)). Mean post-operative volume was 33.07 cm(3) (SD=3.96 cm(3)). The mean change in volume was 6.08 cm(3) (SD=2.31 cm(3)). The mean change in Hertel score was 4.83 (SD=0.75). Regression analysis of change in volume versus follow-up time to imaging indicates that follow-up time to imaging has little effect on change in volume (R=-0.2), and overall mean maximal septal deviation toward the operative side was -0.5mm. Negative values were attributed to deviation away form the operative site. A significant correlation was demonstrated between change in orbital volume and septal deviation distance site (R=0.66), as well as between change in orbital volume and septal deviation angle (R=0.67). Greater volume changes were associated with greater degree of septal deviation away from the surgical site, whereas smaller volume changes were associated with greater degree of septal deviation toward the surgical site. CONCLUSION: A straightforward, semi-automated segmenting technique for measuring change in volume following endoscopic orbital decompression is described. This method proved useful in determining that a mean increase of approximately 6 cm in volume was achieved in this group of patients undergoing medial and inferior orbital decompression. Septal deviation appears to have an effect on the surgical outcome and should be considered during operative planning.


Assuntos
Descompressão Cirúrgica , Endoscopia , Oftalmopatia de Graves/diagnóstico por imagem , Oftalmopatia de Graves/cirurgia , Órbita/diagnóstico por imagem , Humanos , Processamento de Imagem Assistida por Computador , Septo Nasal/diagnóstico por imagem , Órbita/cirurgia , Estudos Retrospectivos , Tomografia Computadorizada Espiral
7.
Head Neck ; 2024 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-38511311

RESUMO

BACKGROUND: The availability of paid parental leave is an important factor for retention and wellness. The experiences of head and neck surgeons with parental leave have never been reported. METHODS: A survey was electronically distributed to head and neck subspecialty surgeons in the United States. Responses were collected and analyzed. RESULTS: Male surgeons had more children and took significantly less parental leave than women. Thirty percent of respondents reported that parental leave negatively impacted compensation, and 14% reported a delay in promotion due to leave, which impacted women more than men. The vast majority reported they are happy or neutral about covering those on leave. Most respondents utilized paid childcare, and approximately one quarter of respondents spending 11%-20% of their income on childcare. CONCLUSIONS: This study illuminates the current disparities regarding parental leave-taking within the subspecialty of head and neck surgery in the United States. Women surgeons are more likely to be impacted professionally and financially.

8.
JAMA Otolaryngol Head Neck Surg ; 150(3): 265-272, 2024 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-38206595

RESUMO

Importance: Oncocytic (Hürthle cell) thyroid carcinoma is a follicular cell-derived neoplasm that accounts for approximately 5% of all thyroid cancers. Until recently, it was categorized as a follicular thyroid carcinoma, and its management was standardized with that of other differentiated thyroid carcinomas. In 2022, given an improved understanding of the unique molecular profile and clinical behavior of oncocytic thyroid carcinoma, the World Health Organization reclassified oncocytic thyroid carcinoma as distinct from follicular thyroid carcinoma. The International Thyroid Oncology Group and the American Head and Neck Society then collaborated to review the existing evidence on oncocytic thyroid carcinoma, from diagnosis through clinical management and follow-up surveillance. Observations: Given that oncocytic thyroid carcinoma was previously classified as a subtype of follicular thyroid carcinoma, it was clinically studied in that context. However, due to its low prevalence and previous classification schema, there are few studies that have specifically evaluated oncocytic thyroid carcinoma. Recent data indicate that oncocytic thyroid carcinoma is a distinct class of malignant thyroid tumor with a group of distinct genetic alterations and clinicopathologic features. Oncocytic thyroid carcinoma displays higher rates of somatic gene variants and genomic chromosomal loss of heterozygosity than do other thyroid cancers, and it harbors unique mitochondrial DNA variations. Clinically, oncocytic thyroid carcinoma is more likely to have locoregional (lymph node) metastases than is follicular thyroid carcinoma-with which it was formerly classified-and it develops distant metastases more frequently than papillary thyroid carcinoma. In addition, oncocytic thyroid carcinoma rarely absorbs radioiodine. Conclusions and Relevance: The findings of this review suggest that the distinct clinical presentation of oncocytic thyroid carcinoma, including its metastatic behavior and its reduced avidity to radioiodine therapy, warrants a tailored disease management approach. The reclassification of oncocytic thyroid carcinoma by the World Health Organization is an important milestone toward developing a specific and comprehensive clinical management for oncocytic thyroid carcinoma that considers its distinct characteristics.


Assuntos
Adenocarcinoma Folicular , Adenoma Oxífilo , Neoplasias da Glândula Tireoide , Humanos , Radioisótopos do Iodo , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/genética , Neoplasias da Glândula Tireoide/terapia , Adenoma Oxífilo/genética , Adenoma Oxífilo/terapia , Metástase Linfática
9.
Otolaryngol Clin North Am ; 56(4): 671-686, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-37164898

RESUMO

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.


Assuntos
Carcinoma de Células Escamosas , Retalhos de Tecido Biológico , Neoplasias Bucais , Procedimentos de Cirurgia Plástica , Humanos , Neoplasias Bucais/cirurgia , Retalhos de Tecido Biológico/cirurgia , Língua/cirurgia , Carcinoma de Células Escamosas/cirurgia
10.
Int J Radiat Oncol Biol Phys ; 117(2): 341-347, 2023 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-37105404

RESUMO

PURPOSE: Patients with locoregional recurrence of squamous cell carcinoma of the head and neck (SCCHN) have relatively poor outcomes; therefore, stereotactic body radiation therapy (SBRT) has been investigated for this patient population. We performed a phase 1 clinical trial to establish a maximum tolerated dose of SBRT with concurrent cisplatin in previously irradiated locoregional SCCHN. METHODS AND MATERIALS: Patients with recurrent SCCHN who had previously undergone radiation therapy to doses ≥45 Gy to the area of recurrence ≥6 months before enrollment and who were not surgical candidates or refused surgery were eligible. SBRT was delivered every other day for 5 fractions. Starting dose level was 6 Gy × 5 fractions, followed by 7 Gy × 5 fractions and 8 Gy × 5 fractions. Chemotherapy consisted of cisplatin given before every SBRT fraction at a dose of 15 mg/m2. Patients were monitored for dose-limiting toxicities (DLT) that occurred within 3 months from the start of SBRT. Secondary endpoints included locoregional failure, distant metastasis, and overall survival. RESULTS: Twenty patients were enrolled, with 18 patients evaluable for endpoints. One patient at dose level 1 (30 Gy) died of unknown causes 2 weeks following completion of treatment. Therefore, an additional 3 patients were accrued to the 30-Gy dose level, with no further DLTs observed. Three patients were then accrued at dose level 2 (35 Gy) and 9 patients at dose level 3 (40 Gy) without DLTs. At a median follow-up of 9.5 months, cumulative incidence of locoregional failure at 2 years was 61% (95% confidence interval [CI], 12%-66%), cumulative incidence of distant metastasis was 11% (95% CI, 74%-100%) at 2 years, and overall survival was 22% (95% CI, 9%-53%) at 2 years. CONCLUSIONS: Concurrent cisplatin and reirradiation with an SBRT dose of ≤40 Gy was safe and feasible in patients with locoregionally recurrent or second primary SCCHN.


Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Radiocirurgia , Reirradiação , Humanos , Cisplatino , Carcinoma de Células Escamosas de Cabeça e Pescoço/terapia , Radiocirurgia/efeitos adversos , Radiocirurgia/métodos , Reirradiação/efeitos adversos , Neoplasias de Cabeça e Pescoço/radioterapia , Recidiva Local de Neoplasia/radioterapia , Carcinoma de Células Escamosas/radioterapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico
11.
JAMA Otolaryngol Head Neck Surg ; 149(3): 253-260, 2023 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-36633855

RESUMO

Importance: Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery. Observation: This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery. Conclusions and Relevance: Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.


Assuntos
Hipoparatireoidismo , Glândulas Paratireoides , Humanos , Glândulas Paratireoides/diagnóstico por imagem , Glândulas Paratireoides/cirurgia , Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/cirurgia , Verde de Indocianina , Imagem Óptica/efeitos adversos , Imagem Óptica/métodos , Tireoidectomia/métodos , Hipoparatireoidismo/etiologia
12.
Am J Otolaryngol ; 33(6): 731-4, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22917952

RESUMO

OBJECTIVES: To report a small case series of an unusual ingested foreign body and a new method for removal of tongue base foreign bodies. METHODS: Three patients were identified with wire bristle foreign bodies between 2009 and 2011 at our academic tertiary medical center. Their medical records were reviewed and are described in this report. RESULTS: Each patient presented to our medical center with progressive pain after ingestion of barbecued food. For 2 patients, the metallic bristle foreign body was imbedded within the lingual tonsil. In these 2 cases, radiofrequency plasma ablation (coblation) assisted partial lingual tonsillectomy was performed to identify the foreign body. In a third case, the foreign body presented as a complex deep space neck abscess and an open trans-cervical approach was required. CONCLUSION: While oropharyngeal and esophageal foreign bodies are common, there are only a few case reports describing this particular foreign body. The presentation of an imbedded wire grill brush bristle can be insidious. Persistent pain and foreign body sensation should be taken seriously in patients with a history of barbecue food ingestion. Intraoperatively, wire bristles can be difficult to localize and extract. Radiofrequency plasma assisted lingual tonsillectomy may be helpful for identifying and removing foreign bodies that are imbedded in the tongue base. Grill brushes should undergo stringent safety regulation, as ingested wire bristles are difficult to localize and remove and may cause significant morbidity.


Assuntos
Corpos Estranhos/cirurgia , Utensílios Domésticos , Laringoscopia/métodos , Faringe/lesões , Adulto , Idoso , Criança , Diagnóstico Diferencial , Ingestão de Alimentos , Feminino , Corpos Estranhos/diagnóstico por imagem , Corpos Estranhos/etiologia , Humanos , Tomografia Computadorizada por Raios X , Tonsilectomia
13.
Head Neck ; 44(3): 698-709, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-34918862

RESUMO

BACKGROUND: Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and outcomes. METHODS: Multi-institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n = 260). RESULTS: Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p = 0.03) and 30-day readmission (p = 0.04). Patients with FF compromise had higher TSH (p = 0.04) and lower albumin levels (p = 0.005). Prealbumin levels were lower in patients who required neck washouts (p = 0.02) or a second FF (p = 0.03). TSH levels were higher in patients undergoing postoperative debridement (p = 0.03) or local flap procedures (p = 0.04). CONCLUSION: Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.


Assuntos
Retalhos de Tecido Biológico , Neoplasias de Cabeça e Pescoço , Osteorradionecrose , Procedimentos de Cirurgia Plástica , Retalhos de Tecido Biológico/efeitos adversos , Neoplasias de Cabeça e Pescoço/complicações , Neoplasias de Cabeça e Pescoço/radioterapia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Osteorradionecrose/etiologia , Osteorradionecrose/cirurgia , Complicações Pós-Operatórias/etiologia , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos
14.
JAMA Otolaryngol Head Neck Surg ; 148(6): 547-554, 2022 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-35476816

RESUMO

Importance: Surgical site infections (SSIs) after vascularized reconstruction of the upper aerodigestive tract (UADT) are associated with considerable morbidity. The association between perioperative prophylaxis practices, particularly topical antisepsis, and SSIs remains uncertain. Objective: To assess the association between perioperative topical antisepsis and SSIs in patients undergoing vascularized reconstruction of the UADT. Design, Setting, and Participants: This cohort study included patients from 12 academic tertiary care centers over an 11-month period, from July 1, 2020, to June 1, 2021. Patients undergoing open surgical procedures requiring a communication between the UADT and cervical skin with a planned regional pedicled flap, free flap, or both were included. Patients with an active infection at the time of surgical procedure were excluded. Main Outcomes and Measures: The primary outcome measure was an SSI within 30 days of surgery. The association of demographic characteristics, perioperative antibiotic prophylaxis, surgical technique, and postoperative care with SSIs was assessed using univariable and multivariable analyses. The relative risk ratio and 95% CIs for developing SSI were calculated for each of the variables based on predetermined categories. Variables for which the relative risk 95% CI did not include the value of zero effect (relative risk = 1.00) were included in the multivariable model. Results: A total of 554 patients (median age, 64 years; range, 21-95 years; 367 men [66.2%]) were included. Cancer ablation was the most frequent reason for surgery (n = 480 [86.6%]). Overall, the SSI rate was 20.9% (n = 116), with most infections involving the head and neck surgical site only (91 [78.4%]). The median time to SSI diagnosis was 11 days (range, 1-28 days). Topical antisepsis mucosal preparation was performed preoperatively in 35.2% (195) and postoperatively in 52.2% (289) of cases. Ampicillin and sulbactam was the most common systemic antibiotic prophylaxis agent used (n = 367 [66.2%]), with 24 hours being the most common duration (n = 363 [65.5%]). On multivariable analysis, preoperative topical antisepsis mucosal preparation (odds ratio [OR], 0.49; 95% CI, 0.30-0.77) and systemic prophylaxis with piperacillin and tazobactam (OR, 0.42; 95% CI, 0.21-0.84) were associated with a decreased risk of a postoperative SSI. The use of an osseous vascularized flap was associated with an increased risk of postoperative SSI (OR, 1.76; 95% CI, 1.13-2.75). Conclusions and Relevance: Findings of this study suggest that preoperative topical antisepsis mucosal preparation was independently associated with a decreased risk of SSIs in a 12-center multi-institutional cohort. Further investigation of the association between individual perioperative practices and the incidence of postoperative SSIs is necessary to develop evidence-based protocols to reduce SSIs after UADT reconstruction.


Assuntos
Retalhos de Tecido Biológico , Infecção da Ferida Cirúrgica , Antibioticoprofilaxia , Antissepsia , Estudos de Coortes , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
15.
Otolaryngol Clin North Am ; 54(2): 343-355, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33583597

RESUMO

Systemic therapy for patients with head and neck cutaneous squamous cell carcinoma (HNCSCC) generally is used for patients with advanced disease and most often employed for patients in the palliative setting when disease is unresectable and/or widely metastatic. Cytotoxic agents and epidermal growth factor receptor pathway targeted therapy have been utilized most commonly, with few clinical data to support their efficacy. Adjuvant postoperative chemoradiation with platinum has been called into question based on recent data. Programmed cell death protein 1 receptor immune checkpoint inhibitors have demonstrated profound activity in HNCSCC, and cemiplimab and pembrolizumab now are approved for use for unresectable/metastatic disease.


Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Cutâneas , Carcinoma de Células Escamosas de Cabeça e Pescoço , Carcinoma de Células Escamosas/tratamento farmacológico , Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Humanos , Imunoterapia , Neoplasias Cutâneas/tratamento farmacológico
16.
Head Neck ; 43(11): 3522-3529, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34459517

RESUMO

BACKGROUND: Burnout has been previously assessed in head and neck microvascular reconstructive surgeons (HNMVS), but not in the context of modifiable workplace factors. METHODS: Anonymous, cross-sectional survey. The Abbreviated Maslach Burnout Inventory - Human Services Survey for Medical Personnel (aMBI-HSS) was utilized to assess emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). Modifiable risk factors were also evaluated. RESULTS: High risk of burnout by EE, DP, and PA was demonstrated in 24%, 9%, and 27% of respondents, respectively. EE was associated with <10% dedicated research time, lack of autonomy over clinic schedule, inadequate inpatient support, and lack of supportive clinical partner. DP was associated with >3 operative days, difficulty balancing academic commitments, and lack of supportive clinical partner. Dedicated research time and two or fewer days of block time were protective. CONCLUSIONS: Burnout was associated with several modifiable workplace factors. Addressing these may prevent moderate to severe burnout in HNMVS.


Assuntos
Esgotamento Profissional , Otolaringologia , Cirurgiões , Esgotamento Profissional/epidemiologia , Estudos Transversais , Humanos , Inquéritos e Questionários , Local de Trabalho
17.
Cancers (Basel) ; 13(5)2021 Mar 09.
Artigo em Inglês | MEDLINE | ID: mdl-33803335

RESUMO

We hypothesized the combination of cetuximab and nivolumab would improve survival in recurrent and/or metastatic (R/M) HNSCC by providing synergy in cancer control and evaluated toxicities and efficacy of the combination. Effects of sequential administration of cetuximab and anti-Programmed Cell Death-1 checkpoint inhibitors (CPI) were also explored. Patients who failed at least one line of palliative treatment for incurable HNSCC were treated with cetuximab 500 mg/m2 IV on Day (D)-14 as a lead-in followed by cetuximab 500 mg/m2 IV and nivolumab 240 mg/m2 IV on D1 and D15 every 28-D cycle. Electronic health record-derived real-world data (RWD) were used to explore sequential treatment effects of CPI and cetuximab. A total of 45 evaluable patients were analyzed, and 31/45 (69%) patients had prior exposure to either CPI or cetuximab. The only grade 4 treatment-related adverse event was cetuximab infusion reaction in one patient. The 1-year progression-free survival (PFS) and overall survival (OS) rates were 19% and 44%, respectively. Although patients with no prior CPI (23/45, 51%) showed a trend for more favorable PFS relative to patients with prior CPI (22/45, 49%), the improvement in the 1-year OS did not reach the statistical threshold. For evaluation of sequential CPI and cetuximab treatment effects, we selected RWD-cetuximab cohort with 173 patients and RWD-CPI cohort with 658 patients from 6862 R/M HNSCC. Our result suggested patients treated with RWD-cetuximab after RWD-CPI had worse OS compared to no prior RWD-CPI (HR 1.81, 95% CI 1.02-3.16). Our data suggest the combination of cetuximab and nivolumab is well tolerated. Optimal sequencing of cetuximab and CPI may have an impact in prognosis and requires further evaluation.

18.
Head Neck ; 42(6): 1168-1172, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32329923

RESUMO

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has caused rapid changes in head and neck cancer (HNC) care. "Real-time" methods to monitor practice patterns can optimize provider safety and patient care. METHODS: Head and neck surgeons from 14 institutions in the United States regularly contributed their practice patterns to a shared spreadsheet. Data from 27 March 2020 to 5 April 2020 was analyzed. RESULTS: All institutions had significantly restricted HNC clinic evaluations. Two institutions stopped free-flap surgery with the remaining scheduling surgery by committee review. Factors contributing to reduced clinical volume included lack of personal protective equipment (PPE) (35%) and lack of rapid COVID-19 testing (86%). CONCLUSIONS: The COVID-19 pandemic has caused a reduction in HNC care. Rapid COVID-19 testing and correlation with infectious potential remain paramount to resuming the care of patients with head and neck cancer. Cloud-based platforms to share practice patterns will be essential as the pandemic evolves.


Assuntos
Infecções por Coronavirus/epidemiologia , Neoplasias de Cabeça e Pescoço/cirurgia , Microcirurgia/métodos , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Padrões de Prática Médica/organização & administração , Oncologia Cirúrgica/organização & administração , COVID-19 , Teste para COVID-19 , Técnicas de Laboratório Clínico , Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/prevenção & controle , Bases de Dados Factuais , Feminino , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Masculino , Oncologia/organização & administração , Segurança do Paciente/estatística & dados numéricos , Pneumonia Viral/prevenção & controle , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Sociedades Médicas , Inquéritos e Questionários , Estados Unidos
19.
Head Neck ; 42(10): 3031-3040, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32652771

RESUMO

BACKGROUND: Diabetes mellitus (DM) is a risk factor for surgical complications and a common comorbidity in the setting of head and neck (H&N) cancer. Our objective was to determine if DM is associated with increased rates of H&N cancer surgery complications. METHODS: We conducted a search of Pubmed, Embase, and the national clinical trials database focusing on H&N cancer surgery or free flap reconstruction and diabetes. Two reviewers screened studies by title/abstract and then full text. We then collected data using a pre-made template. Meta-analysis was performed using Revman 5.3. RESULTS: Of the 272 results from Pubmed and 559 from Embase, we selected 16 studies for inclusion. Meta-analysis revealed DM was associated with increased rates of flap failure (risk ratio [RR] = 1.83 95% confidence interval [CI], 1.18-2.85; P = .007) and local complications (RR = 1.87 95% CI, 1.24-2.80; P < .00001). CONCLUSION: Although DM is associated with increased risk of flap failure and local H&N cancer surgery complications, further research is required to optimize care in this population.


Assuntos
Diabetes Mellitus , Retalhos de Tecido Biológico , Neoplasias de Cabeça e Pescoço , Procedimentos de Cirurgia Plástica , Diabetes Mellitus/epidemiologia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco
20.
Expert Rev Mol Diagn ; 19(1): 63-70, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30575409

RESUMO

Introduction: The majority of squamous cell carcinoma (SCC) of the oropharynx, one of the sites within the head and neck region, is now associated with high-risk human papillomavirus (HPV) in North America. Several modalities are available to determine the HPV status, however, the understanding of each assay in its application and limitations is essential for accurate interpretation and appropriate utilization of results in management of these patients. Areas covered: This expert review will cover the role of HPV in head and neck squamous cell carcinoma (HNSCC), indications for HPV testing, HPV detection methods in tumors, saliva and serum, and exploiting HPV status as a prognostic biomarker of clinical outcome in HNSCC. Expert commentary: The HPV status is the most significant diagnostic and prognostic biomarker in HNSCC, specifically in the oropharynx. Research underway is currently delineating the role of HPV and p16 testing in non-oropharyngeal sites. While the feasibility of non-invasive serum and saliva testing for HPV detection has been established, the clinical application of these assays is still evolving.


Assuntos
Biomarcadores Tumorais/análise , Carcinoma de Células Escamosas/diagnóstico , Neoplasias de Cabeça e Pescoço/diagnóstico , Testes de DNA para Papilomavírus Humano/métodos , Alphapapillomavirus/genética , Alphapapillomavirus/patogenicidade , Carcinoma de Células Escamosas/virologia , Neoplasias de Cabeça e Pescoço/virologia , Humanos
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