Paragangliomas Arising From the Laryngeal Paraganglia: Thyroid and Laryngeal Paragangliomas With Radiology-Pathology Correlation.

Paragangliomas are neuroendocrine tumors that arise from the embryonic neural crest cells of the extra-adrenal chromaffin and non-chromaffin cellular system. Paragangliomas arising from the laryngeal paraganglia, which occur in the thyroid and larynx, are a rare subset of paragangliomas compared to the more common locations of the carotid body, vagale, jugular, and tympanic paragangliomas. The preoperative diagnosis of both thyroid and laryngeal paragangliomas may pose a challenge due to cytological, pathological, and imaging non-specificity that overlaps with many other neoplasms. These lesions may be associated with significant intraoperative bleeding and complicated excision with adherence to nearby structures, including the recurrent laryngeal nerve. This article discusses the imaging appearance, pathological features, clinical and operative considerations and manifestations, and management of head and neck paragangliomas, as seen in two patients at our institution.

Family support role in hospital rapid response teams: a scoping review.

OBJECTIVE: The objective of this review was to identify and understand the primary research investigating the family support role in hospital rapid response teams. INTRODUCTION: Individual studies have described the benefits of providing emotional and psychosocial support to family members of a person receiving emergency medical care from a rapid response team in a hospital setting. To the authors' knowledge, there are no studies that have identified and described these studies together. INCLUSION CRITERIA: All empirical qualitative and quantitative papers investigating a family support role delivered in a rapid response team in a hospital setting were included. METHODS: This review followed a published a priori protocol. The databases searched were MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane Library, and OpenGrey. The search strategy was not limited by publication date or by language. The title and abstract of all citations were reviewed by two authors independently to assess against the inclusion criteria. The full text of the studies meeting the inclusion criteria were retrieved and reviewed by two authors independently. Data from eligible studies were extracted by two authors separately using a predetermined data extraction form and summarized in tabular and narrative format. RESULTS: After a full-text review of 110 studies, six studies met all inclusion criteria. The studies were set in four countries. All rapid response teams were set in hospital locations. Charted data demonstrated that the family support role had been investigated predominantly by qualitative study designs from the perspective of staff delivering the support. One study reported health outcomes of family members who received family support. In all studies, the family support role was part of a resuscitation rapid response team. Family support was provided at all stages of the resuscitation procedure. The family support role was not consistently defined, with the activities of the family support person reported differently between studies. Twenty-five varying support activities were described, such as attending to the family members'comfort needs, explaining the process of resuscitation, and providing guidance to the family member. In all studies, the family support role was available to support the family witnessing the resuscitation. The family support role was delivered by professionals from varying disciplines, including social workers, nurses, health care workers, and health care chaplains. CONCLUSIONS: Family support roles are varied and are carried out by health professionals of diverse backgrounds, highlighting the importance of considering the support and training needs of the person performing the role. Future research using evaluation methods is recommended to deepen the understanding about the family support role in hospital-based rapid response teams.

Enhanced Recovery After Surgery Nutrition Protocol for Major Head and Neck Cancer Surgery.

OBJECTIVE: To determine whether an enhanced recovery after surgery (ERAS) nutrition protocol is reasonably possible among our head and neck cancer (HNC) population with respect to system feasibility and patient compliance. Second, we aim to identify improvements in patient outcomes as a result. METHODS: Preexperimental research design among patients undergoing major HNC surgery after implementation of the ERAS nutrition protocol from July 2018 to July 2019 as quality improvement (QI). Preoperative clinical nutritional assessment and laboratory values were completed the same day as informed surgical consent in the clinic. Protocol focus was patient consumption of nutritional supplements perioperatively, monitored by our outpatient dietitian. Early postoperative enteral nutrition was initiated with monitoring of nutritional laboratory values. To support our model, we provide preliminary analysis of HNC patient outcomes after implementation of the ERAS nutritional protocol. RESULTS: Twenty-five patients were enrolled. Preoperatively, 40% of patients were malnourished, and 100% complied with perioperative nutrition supplementation. Health care provider compliance obtaining preoperative laboratory values was 56%. There was a strong negative correlation between modified Nutrition-Related Index (mNRI) and number of complications (P = .01), specifically, fistula rate (P = .04) and unplanned reoperation (P = .04). Enrolled patient average length of stay was 7 ± 4.4 days. DISCUSSION: Our patients demonstrated compliance with implementation of an ERAS nutrition protocol likely facilitated by dietitian engagement. mNRI potentially reflects risk for head and neck surgery complications. IMPLICATIONS FOR PRACTICE: QI processes demand reassessment and modification to ensure efficient and targeted approaches to improving patient care.

Quality-Adjusted Life Years and Disability-Adjusted Life Years Are Better With Concurrent Chemoradiation Therapy Than Induction Chemotherapy Followed by Chemoradiation Therapy in Nasopharyngeal Carcinoma.

Introduction As traditional measures such as overall survival (OS) or disease-free survival (DFS) alone do not give a holistic view of the outcomes of a treatment paradigm, we determine to add the evidence of quality-adjusted life year (QALY) and disability-adjusted life year (DALY) to the outcomes of the nasopharyngeal carcinoma patients (NCP) treated with definitive chemoradiation therapy (chemoRT) with or without induction chemotherapy (induction chemo). Methods This is a retrospective analysis of 85 NCPs treated at an academic state institution. The OS estimated by the Kaplan-Meier method and the multivariate Cox regression model determined the co-variables associated with the OS. The relationship between QALYs gained and DALYs saved were calculated from age of the disease onset, duration of the disease, quality of life (QoL) and disability weights. Results Of the 85 eligible NCPs of this cohort, the disease frequency distribution per the World Health Organization (WHO) classification was 41.2% for Type-I, 42.4% for Type-II, and 16.5% for Type-III. The median follow-up (24 months). The five-year OS of patients treated with concurrent chemoRT vs. induction chemo followed by concurrent chemoRT was 54.7 vs. 14.8% for WHO Type I, 60.1 vs. 58.3% for WHO Type II, and 83.3 vs. 50.0% for WHO Type III (p=0.029). The average DALYs saved with concurrent chemoRT were 12.2 years vs. 5 years for induction chemo followed by concurrent chemoRT. The average QALYs gained with concurrent chemoRT were 6.9 years vs. 3.1 years for induction chemo followed by concurrent chemoRT. Conclusion Patients treated with concurrent chemoRT had an increased QoL when compared to induction chemo followed by concurrent chemoRT. The average DALYs saved were higher in the patients treated with concurrent chemoRT than treated with induction chemo followed by concurrent chemoRT.

The family support role in hospital rapid response teams: a scoping review protocol.

OBJECTIVE: The objective of this review is to identify and understand how a family support role has been delivered in rapid response teams in hospital settings. INTRODUCTION: A family support role in a hospital rapid response team is a designated position that is responsible for supporting the family members of people being medically attended to during a hospital rapid response. Support may include the provision of guidance to the family regarding a hospital procedure, support whilst witnessing the rapid response, or assisting the family to process their emotional response. This review will assist in identifying the ways in which the family support role is delivered in rapid response teams within a hospital environment. INCLUSION CRITERIA: Family support must be delivered by a person who has a designated family support role within a rapid response team in a hospital setting. Studies will not be limited to geographical location, gender, or culture. Studies are not limited to year of publication or methodological design. METHODS: Databases will include MEDLINE (Ovid), Embase (Ovid), CINAHL, and Cochrane. Gray literature will be searched with predetermined search criteria. Two independent authors will be used to screen articles and perform data extraction on a predetermined data extraction form. A narrative Summary of Findings is planned, alongside a presentation of the data in diagrammatic or tabular form.

Radiation Therapy Impact on Lymph Node Yield in Patients With Laryngeal Squamous Cell Carcinoma.

BACKGROUND: A lymph node yield (LNY) over 20 is considered a quality metric for lateral neck dissection to ensure an oncologic representative sample. Anecdotally, however, LNY in patients undergoing neck dissection after radiation therapy (RT) is lower due to atrophy and fibrosis. OBJECTIVE: To determine whether preoperative RT decreases LNY in patients with laryngeal cancers undergoing surgery. METHODS: Medical record database was queried for patients presenting between 2006 and 2015 with laryngeal cancer. Tabulation was made for location (glottic/supraglottic), stage, and side for the total number of lymph nodes between primary surgery and RT (salvage surgery) groups. Descriptive analysis and a paired Student t test were used for statistical analysis. RESULTS: Fifty-nine patients were included in the study for a total of 98 neck dissections. Twenty-six (44%) patients had primary surgery, and 33 (56%) patients had salvage surgery. The mean left and right total LNY in the salvage surgery group was 27.6 and 29.5, respectively, and 32.2 and 33.7 for the primary surgery group. A difference of 4.5 (left) and 4.3 (right) in LNY between the salvage surgery and primary surgery group was found. A Student t test showed no statistically significant difference in LNY between both groups when analyzed per site (glottic and supraglottic), side, and stage (III-IV). CONCLUSION: Although patients with prior RT had a lower mean of LNY, our results did not demonstrate a statistically significant difference. Further studies with a larger number of patients are recommended.

The role of intravenous acetaminophen in post-operative pain control in head and neck cancer patients.

OBJECTIVE: This study investigated the role of intravenous acetaminophen for alleviation of postoperative pain after surgical resection of head and neck cancers. METHODS: A single-center study was conducted, which investigated a prospective group of 48 participants who underwent surgery between April 2016 and May 2017 and postoperatively received scheduled IV acetaminophen (1 g every 6 hours for 4 doses) plus the standard opioid PCA and breakthrough narcotics. These were compared to a similar retrospective cohort of 51 patients who had surgery between January 2014 to March 2015 and only received an opioid patient controlled analgesia (PCA) pump and breakthrough narcotics. Outcome measures included averaged pain scores, total amount of narcotics received (in morphine equivalents), and number of PCA attempts measured in 8-hour intervals over the first 24 hours, as well as duration of PCA and length of stay. Statistical measures included descriptive analysis and gamma regression analysis. RESULTS: The acetaminophen group achieved equally low pain scores (0.8 ± 1.2 vs. 1.0 ± 1.3, P = .408) with significantly less total narcotics in the first 8 hours after surgery (13.5 ± 13.3 vs. 22.5 ± 21.5 MEs, P = .014). This group had a significantly decreased length of stay (7.8 ± 4.6 vs. 10.6 ± 7.6 days, P = .03). CONCLUSION: This study demonstrates that intravenous acetaminophen may play a role in reducing the total narcotic requirement in the first 8 hours after surgery and contribute to a decreased length of stay and potentially decrease cost to the patient and hospital overall. Future research should be aimed at comparing these groups in a randomized control study/setting. LEVEL OF EVIDENCE: 3.

Frailty as a Predictor of Postoperative Outcomes among Patients with Head and Neck Cancer.

OBJECTIVES: To understand measures of frailty among preoperative patients and explain how these can predict perioperative outcomes among patients with head and neck cancer. STUDY DESIGN: Retrospective cross-sectional case series with chart review. SETTING: Academic tertiary medical center. SUBJECTS AND METHODS: A retrospective review was performed of patients presenting to an academic hospital following a surgical procedure for a head and neck cancer diagnosis. Charts were queried for preoperative medical diagnoses to calculate 2 frailty scores: the American College of Surgeons National Surgical Quality Improvement Program modified frailty index and the Johns Hopkins Adjusted Clinical Groups frailty index. The American Society of Anesthesiologists classification system was also analyzed as a predictor. Primary outcomes were mortality, 30-day readmission, and length of stay. Perioperative complications and discharge disposition were also evaluated. RESULTS: A total of 410 charts were queried between January 2014 and December 2017. Mortality was 11%; mean ± SD length of stay was 7.4 ± 5.5 days; and the readmission rate was 17%. The modified frailty index score significantly increased the odds of mortality (odds ratio = 1.475, P = .012) and readmission (odds ratio = 1.472, P = .004), the length of stay (relative risk = 1.136, P = .001), and the number of perioperative complications. The American Society of Anesthesiologists classification was also significantly associated with poor outcomes, including readmission, length of stay, and perioperative complications. The Adjusted Clinical Groups index was not a significant predictor of outcomes in this study population. CONCLUSIONS: This study demonstrated a significant increase in poor perioperative outcomes and mortality among patients with head and neck cancer and increased frailty, as measured by the modified frailty index.

Human papillomavirus: the fundamentals of HPV for oral health care providers.

Human papillomavirus (HPV) has become widely known as the causative agent of cervical cancer and some oropharyngeal cancers. The development of HPV vaccines has further piqued public interest. As a result, dentists will have increasing numbers of patients who will inquire about oral HPV infection and its prevention by means of vaccination. Dental professionals must be informed. This review provides an overview of HPV, its association with HIV and oropharyngeal cancer, and information on HPV vaccinations.

Human papillomavirus: the fundamentals of HPV for oral health care providers.

Human papillomavirus (HPV) has become widely known as the causative agent of cervical cancer and some oropharyngeal cancers. The development of HPV vaccines has further piqued public interest. As a result, dentists will have increasing numbers of patients who will inquire about oral HPV infection and its prevention by means of vaccination. Dental professionals must be informed.This review provides an overview of HPV, its association with HIV and oropharyngeal cancer and information on HPVvaccinations.

Developing positive relationships with voices: a preliminary Grounded Theory.

BACKGROUND: Research has been exploring the phenomenon of 'voice hearing' within a relational framework. To date, studies have paid limited attention to voice hearers who view the experience positively. MATERIAL: Semi-structured interviews were conducted with five mental health service users and seven non-service users who had had positive experiences of hearing voices. Interview transcripts were analyzed using Grounded Theory. CONCLUSIONS: The preliminary theory suggests that the moderation of fear and control may impact on relationships with voices. Actively engaging with voices to understand their subjective meaning may be beneficial. Promoting a positive self-concept and connecting with communities who value and accept voice-hearing experiences may be particularly important.

Human papillomavirus-active head and neck cancer and ethnic health disparities.

OBJECTIVES/HYPOTHESIS: Mortality for black males with head and neck squamous cell carcinoma (HNSCC) is twice that of white males or females. Human papillomavirus (HPV)-active HNSCC, defined by the concurrent presence of high-risk type HPV DNA and host cell p16(INK4a) expression, is associated with decreased mortality. We hypothesized that prevalence of this HPV-active disease class would be lower in black HNSCC patients compared to white patients. STUDY DESIGN: Multi-institutional retrospective cohort analysis. METHODS: Real-time polymerase chain reaction was used to evaluate for high-risk HPV DNA presence. Immunohistochemistry for p16(INK4a) protein was used as a surrogate marker for HPV oncoprotein activity. Patients were classified as HPV-negative (HPV DNA-negative, p16(INK4a) low), HPV-inactive (HPV DNA-positive, p16(INK4a) low), and HPV-active (HPV DNA-positive, p16(INK4a) high). Overall survival and recurrence rates were compared by Fisher exact test and Kaplan-Meier analysis. RESULTS: There were 140 patients with HNSCC who met inclusion criteria. Self-reported ethnicity was white (115), black (25), and other (0). Amplifiable DNA was recovered from 102/140 patients. The presence of HPV DNA and the level of p16(INK4a) expression were determined, and the results were used to classify these patients as HPV-negative (44), HPV-inactive (33), and HPV-active (25). Patients with HPV-active HNSCC had improved overall 5-year survival (59.7%) compared to HPV-negative and HPV-inactive patients (16.9%) (P = .003). Black patients were less likely to have HPV-active disease (0%) compared to white patients (21%) (P = .017). CONCLUSIONS: The favorable HPV-active disease class is less common in black than in white patients with HNSCC, which appears to partially explain observed ethnic health disparities.

Multi-spectral imaging analysis of HSPB1 expression in head and neck squamous cell carcinoma.

The objective of this study was to obtain more accurate quantitation of HSPB1 expression in HNSCC using a novel quantitative protein expression analysis system based on multispectral imaging. The study was a retrospective laboratory study of HNSCC patients treated at tertiary care academic medical center. Archival tissue samples from forty seven patients with HNSCC were subjected to immunohistochemistry using primary antibody to HSPB1. Seven of the patients had early stage cancers (TNM stage I/II) and forty patients had advanced stage cancers (TNM stage III/IV). HSPB1 expression was increased in advanced stage versus early stage cancers. Further investigation of HSPB1 as a potential biomarker for HNSCC is warranted.

Significance of HSPB1 expression in head and neck squamous cell carcinoma: a meta-analysis of published literatures.

OBJECTIVE: HSPB1 functions to prevent stress-induced cellular damage and has is elevated in multiple cancer types. The significance of HSPB1 in HNSCC remains controversial. We sought to perform a meta-analysis of HSPB1 expression to clarify previous findings. STUDY DESIGN: Meta-analysis of all published studies of HSPB1 in HNSCC patients using IHC techniques. METHODS: A literature review was performed on PubMed and Google Scholar search engines using terms HSP27, HSPB1, Heat Shock Proteins, Cancer, Head and Neck Squamous Cell Carcinoma. Additional studies were added by review of manuscript bibliographies. Means and standard deviations for continuous data were obtained for overall HSPB1 expression (in cancer, normal and dysplasia), nodal status and TNM stage. Chi-square and Cochran's Q test were used to test statistical significance. RESULTS: There were 77 studies identified in the context of HSPB1 and cancer in general. Of these, 7 studies (total patients n=347) met inclusion criteria and reported findings in HNSCC using IHC scoring techniques. For the mean difference in HSPB1 expression; cancer vs. normal, cancer vs. dysplasia, and dysplasia vs. normal all showed significance (p<0.0001) however the difference was not homogeneous across studies for cancer vs. dysplasia and normal. The difference was homogeneous for dysplasia vs. normal. There was no significant difference for HSPB1 expression by nodal status or stage. CONCLUSION: HSPB1 is elevated in HNSCC and may be a useful biomarker for this disease.

Primary combined small cell carcinoma of larynx with lateralized histologic components and corresponding side-specific neck nodal metastasis: report of a unique case and review of literature.

Combined small cell carcinoma (neuroendocrine) of the larynx has been rarely reported in the literature, and included in the current WHO classification. We hereby report an unusual case of combined carcinoma of the larynx; composed mainly of small cell neuroendocrine carcinoma nearly confined to the right side (mainly involving supraglottis extending to glottis) with synchronous minor in-situ and invasive squamous cell carcinoma component located on the left side of larynx (mainly glottis). Interestingly, this side-specific distribution of tumor was recapitulated in its metastatic nodal spread; so that right cervical lymph nodes showed only metastatic small cell carcinoma and left cervical lymph nodes only metastatic squamous cell carcinoma. To the best of our knowledge, the present case is the seventeenth reported case of a combined small cell carcinoma of larynx, second case in which individual tumor components were lateralized on either side of larynx, and the first case in which this side-specificity of tumor was reflected in its metastatic neck nodal spread. This report emphasizes the value of accurate pathologic diagnosis including diversity in differentiation and localization of laryngeal tumors, and underscores the need for thorough pathologic examination of bilateral laryngeal tumors. The pre-operative diagnostic yield of small cell carcinoma (pure or combined) can be enhanced by including deeper submucosal biopsies on laryngoscopy in all those cases in which the extent of disease on imaging is disproportionately larger than the apparent mucosal involvement on laryngoscopy. This approach can facilitate selection of neoadjuvant or palliative chemo-radiotherapy in large or unresectable tumors.

2D-DIGE proteomic characterization of head and neck squamous cell carcinoma.

OBJECTIVE: Identify proteins that are differentially expressed between head and neck squamous cell cancer (HNSCC) and patient-matched normal adjacent tissue, and validate findings in a separate patient cohort. STUDY DESIGN: Cross-sectional study of surgical specimens. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: Laser capture microdissection and two-dimensional difference gel electrophoresis were used previously to establish proteomic profiles for tumor and normal adjacent tissue from 14 patients. Here, significance analysis of microarray was used to rank candidate biomarkers. Spots meeting statistical and biological criteria of significance were analyzed by liquid chromatography and tandem mass spectrometry to obtain protein identifications. The expression pattern of the highest-ranked candidate biomarker (cornulin) was validated in a larger, independent patient cohort (n = 68) by immunohistochemical staining of a tissue microarray. RESULTS: Of 732 spots, 117 (15.9%) met criteria for significance. Identities were obtained for 39 spots, representing 17 different proteins. Four proteins were novel in the context of HNSCC: glutathione synthetase, which was upregulated; and cornulin (squamous epithelial heat shock protein 53), guanylate binding protein 6, and heat shock 70 kDa protein 5 (glucose-regulated protein, 78 kDa), which were downregulated. Cornulin functions in the stress response in normal squamous epithelium, and reduced expression has been proposed as a marker of susceptibility to laryngopharyngeal reflux and other stressors. Loss of cornulin expression was confirmed in an independent HNSCC patient cohort (P < 0.001). CONCLUSIONS: Downregulation of cornulin is a prominent feature of the molecular signature of HNSCC identified by comparative proteomics. Cornulin may represent a link between HNSCC and other pathologies arising in stratified squamous epithelium.

Quantitative analysis of syndecan-1 expression in dysplasia and squamous cell carcinoma of the oral cavity.

INTRODUCTION: Decreased expression of syndecan-1 has been reported in dysplasia and squamous cell carcinoma (SCCA) of the oral cavity and appears to correlate with decreasing histological differentiation and poor clinical outcome. Assays of syndecan-1 expression to date have utilized manual microscopic analysis with qualitative grading of immunohistochemical staining intensity, which may introduce observer bias. We evaluated syndecan-1 expression in dysplasia and squamous cell carcinoma (SCCA) of the oral cavity, using a novel automated cellular imaging system that incorporates both staining intensity as well as the percentage of positively stained cells to yield a quantitative value for syndecan-1 expression. MATERIALS AND METHODS: We performed a quantitative immunohistochemical analysis of syndecan-1 expression using an automated cellular image analysis system. We analyzed specimens from cases of mild dysplasia (N = 55), moderate dysplasia (N = 38), severe dysplasia (N = 25), carcinoma in situ (CIS) (N = 43), and SCCA of the oral cavity (N = 45), using normal mucosal epithelium (N = 21) as a positive control. The SCCA specimens were further subdivided by degree of differentiation. We retrospectively reviewed patient charts to identify tumor stage at diagnosis, recurrence, and disease-specific survival. RESULTS: Syndecan-1 expression was significantly greater in normal controls than in specimens of mild, moderate, or severe dysplasia, CIS, or invasive SCCA (P < .05). Syndecan-1 expression did not differ significantly among specimens of mild, moderate, or severe dysplasia, CIS or SCCA. There was no significant difference in syndecan-1 expression between specimens from patients with no evidence of disease at 3 years follow-up and patients with local, regional, or distant recurrence. CONCLUSIONS: Syndecan-1 expression does not appear to be useful as a marker of differentiation or as a prognostic indicator in dysplasia and SCCA of the oral cavity. The search for a suitable and reliable marker of biological aggressiveness is ongoing.

Classification and management of rhinosinusitis and its complications.

A stepwise evaluation of patients who have CRS allows a management approach that is tailored to each individual patient and to the specific type of disease.