Oncological outcomes post transoral robotic surgery (TORS) for HPV-associated oropharyngeal squamous cell carcinoma, a single-centre retrospective Australian study.

We present a cohort review of TORS resection for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) and its associated oncological outcomes spanning a 10-year period. A retrospective case series review was performed of patients undergoing primary surgical treatment for HPV-associated OPSCC through the St. Vincent's Head and Neck Cancer service from 2011 to 2022. The primary outcomes were to investigate complete resection of the primary tumour, rates of recurrence, and survival analysis. Secondary outcomes included complications, rates of adjuvant therapy, sites of recurrence and rates of percutaneous endoscopic gastrostomy (PEG). 184 patients underwent TORS-based therapy with neck dissection, and guideline-directed adjuvant therapy for HPV-associated OPSCC. Our median follow-up was 46 months. The positive margin rate on final histopathology analysis was 10.9%. Adjuvant therapy was indicated in 85 patients (46%). The local recurrence rate was 10.9% with the majority (80%) of patients recurring in the first 3 years since treatment. The disease-specific survival at 3 years was 98.6% and at 5 years was 94.4%. The 3-year and 5-year OS for the cohort was 96.7% and 92.5%, respectively. The presence of extranodal extension and positive margins were associated with increased risk of recurrence, whereas adjuvant therapy was found to be a protective factor for both overall recurrence and survival. Major complications occurred in 12 patients (6.5%), resulting in one death. This study has demonstrated that primary surgical therapy for HPV-associated OPSCC is a safe and effective treatment modality with low local recurrence and complication rates, and overall survival benefits.

Virtual otolaryngologic management of sleep apnea patients: Lessons learned from COVID-19 pandemic.

OBJECTIVE: To discuss the virtual management options and strategies learned during the COVID-19 pandemic for treatment of patients with sleep complaints and sleep disordered breathing presenting to the otolaryngologist. METHODS/RESULTS: The addition of a virtual evaluation can be beneficial in assessing the patient presenting to the otolaryngologist with sleep complaints. With the implementation of telemedicine, validated subjective assessment tools, and a limited physical exam, patients can be triaged for the need for treatment implementation, further evaluation or testing, and counseled regarding various management options.In this article, we discuss the lessons learned from the authors' collective experience on how to effectively use telemedicine as a tool in the management repertoire for patients with sleep disorders. CONCLUSION: The otolaryngologist will commonly see patients with sleep complaints, particularly patients diagnosed with obstructive sleep apnea not able to tolerate conservative therapies. These patients are well suited for virtual evaluation utilizing telemedicine. The technology and workflows which have been developed during the COVID-19 pandemic can be carried forward for select patients to improve access and efficiency of care.Level of evidence: 5.

Altered presentation of oropharyngeal cancer, a 6-year review.

BACKGROUND: Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) continues to increase in incidence. Patients are younger, non-smokers and most commonly present with a neck mass often with no other symptoms. This altered presentation compared with non-HPV OPSCC may not be recognized by medical practitioners, leading to delayed diagnosis. METHODS: Patients with histopathological confirmation of OPSCC and known HPV and/or P16 status who presented to our institution between 2012-2017 inclusive were included in the study. Demographic data, tumour characteristics and presenting symptoms were retrospectivxely obtained from both electronic- and paper-based records. Descriptive statistics were used to report demographic data and the two sample t-test and Fisher's exact test were used to compare groups based on HPV status. Time to diagnosis was also reported. RESULTS: A total of 184 patients were included in the study. The majority of patients were male (85.4%) and HPV + (85.3%). The tonsillar complex (53.8%) and tongue base (42.4%) were the most common primary sites. HPV+ patients were less likely to smoke (17.8%) and they commonly presented with a neck mass (39.5% alone or with other symptoms 61.2%). Time to diagnosis in the HPV+ group was longer (15 weeks). CONCLUSION: Our review has highlighted the altered presentation of OPSCC due to the increased incidence of HPV infection. We showed a delayed time to diagnosis in HPV+ OPSCC compared with non-HPV disease. This confirms the importance of focusing our efforts on educating medical practitioners and creating further awareness to facilitate early detection and treatment.

Acinic cell carcinoma of the salivary gland in the adult and paediatric population: a survival analysis.

BACKGROUND: Acinic cell carcinoma (AcCC) is a rare malignant neoplasm of the salivary glands and generally considered to be a low-grade tumour. Surgical treatment is often curative, but a more aggressive high-grade variant has been associated with poorer survival and propensity for distant metastasis. No standard treatment guidelines exist and the approach to treatment is varied in the published series. The aim of this study is to present the experience of three major hospitals in Sydney, Australia, in treating AcCC of the salivary gland, with a focus on clinico-pathological features of disease and their associations with survival outcomes. METHODS: Adult and paediatric cases of AcCC of the salivary gland during the time period 1979-2018 were retrospectively included. Demographic, clinico-pathological, treatment and survival outcome data were extracted. Survival analysis was undertaken to assess the effect of clinical and pathological variables on overall and disease-free survival. RESULTS: Thirty-two cases were reviewed (29 adult and three paediatric). Thirty tumours (93.8%) were parotid gland primary tumours. Mean overall and disease-free survival was 17.0 ± 0.7 and 16.0 ± 0.9 years, respectively. Features associated with poorer survival were cT staging >1, presence of preoperative clinical facial nerve deficit and local recurrence. Positive margins were associated with recurrence. CONCLUSION: These data suggest that disease-free and overall survival in AcCC of the salivary gland is excellent with surgery as the first-line treatment. Poor survival outcomes are uncommon and may be associated with locally advanced disease in the presence of other well-established high-risk features.

Systematic review of laryngocele and pyolaryngocele management in the age of robotic surgery.

OBJECTIVE: A laryngocele is a space that develops as a result of pathological dilatation of the laryngeal saccule. However, the reported management of laryngoceles varies. We conducted a systematic review of the literature regarding the surgical management of laryngoceles and pyolaryngoceles, to understand the evolving nature of treatment for this rare condition. METHODS: We searched for publications in the PubMed, Cochrane Library, JBI Library of Systematic Reviews, and Ovid databases using the terms "laryngocele", "pyolaryngocele", and "laryngopyocele", and reviewed the identified articles. RESULTS: After removal of repeated studies and filtering for relevance and studies written in English, a total of 227 studies were included in this review. No meta-analyses or randomized controlled trials have been published. The identified studies have been summarized in 14 reviews conducted since 1946. The meta-analysis determined that endoscopy was the preferred approach for internal laryngoceles, while combined laryngoceles benefited from both internal and external surgical approaches. CONCLUSIONS: Laryngocele management has progressed since its initial description, from open surgery to an endoscopic approach, and more recently to a robotic-assisted surgical approach. The uptake of robotic surgery as a possible treatment modality over the last decade shows much promise for the treatment of these conditions.

Research Gaps in Wilderness Medicine.

INTRODUCTION: Wilderness medicine involves the treatment of individuals in remote, austere environments. Given the high potential for injuries as well as the unique treatment modalities required in wilderness medicine, evidence-based clinical practice guidelines are necessary to provide optimal care. In this study, we identify evidence gaps from low-quality recommendations in wilderness medicine clinical practice guidelines and identify new/ongoing research addressing them. METHODS: We included relevant clinical practice guidelines from the Wilderness Medical Society and obtained all 1C or 2C level recommendations. Patient/Problem/Population, intervention, comparison, outcome (PICO) questions were created to address each recommendation. Using 24 search strings, we extracted titles, clinical trial registry number, and recruitment status for 8899 articles. We categorized the articles by trial design to infer the effect they may have on future recommendations. RESULTS: Twelve clinical practice guidelines met inclusion criteria. From these we located 275 low-quality recommendations and used them to create 275 PICO questions. Thirty-three articles were relevant to the PICO questions. Heat-related illness had the highest number of relevant articles (n=9), but acute pain and altitude sickness had the most randomized clinical trials (n=6). CONCLUSION: Overall, few studies were being conducted to address research gaps in wilderness medicine. Heat-related illness had the most new or ongoing research, whereas no studies were being conducted to address gaps in eye injuries, basic wound management, or spine immobilization. Animals, cadavers, and mannequin research are useful in cases in which human evidence is difficult to obtain. Establishing research priorities is recommended for addressing research gaps identified by guideline panels.

Is the Right Research Being Conducted to Advance Knowledge about Breast Reconstruction? An Analysis of the Research Pipeline.

BACKGROUND: It has been estimated that up to 85 percent of research is of limited value or wasted, in part because of the wrong research questions being addressed. In this study, the authors identified research gaps for breast reconstruction using guideline recommendations based on low-quality or no evidence. The authors then evaluated whether research was currently being conducted to fill these gaps. METHODS: The authors extracted grade C and D options, which are based on limited evidence, from the American Society of Plastic Surgeon's clinical practice guideline for breast reconstruction. For each option, the authors created Participants, Intervention, Comparator, Outcome questions and search strings using a systematic process. Searches were conducted of ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform to locate new and ongoing studies. The authors also catalogued studies on breast reconstruction funded by the Plastic Surgery Foundation. RESULTS: Of the 10 research gaps, only six were being addressed by new and ongoing research. Timing of reconstruction (immediate or delayed) and use of acellular dermal matrix were most frequently studied. Preoperative referral of a plastic surgeon before mastectomy, complications associated with preoperative breast size, effects of hormone therapy on postoperative outcomes, and methods for detecting local recurrence after mastectomy were not being addressed by new research. Studies funded by the Plastic Surgery Foundation showed a similar pattern. CONCLUSIONS: Of the areas identified, some have received more attention than others. Gaps remain. The authors' results should spark interest in conducting research on these topics and, by so doing, strengthen the clinical practice guideline recommendations.

Hemostatic Options for Transoral Robotic Surgery of the Pharynx and Base of Tongue.

Surgery with transoral robotic surgery (TORS) offers significant advantages compared with traditional open surgical approaches and potentially minimizes the long-term side effects of organ preservation therapy with chemoradiation. Angled telescopes and wristed instruments allow visualization and access to areas of the pharynx that are difficult to reach with line-of-sight instrumentation. Although the application of TORS in head and neck surgery has expanded considerably, there are still only limited data available on the postoperative complications and their management. As further data become available, it is likely that further risk factors and treatment strategies will become available.

Transoral robotic sleep surgery: the obstructive sleep apnea-hypopnea syndrome.

Nocturnal upper airway collapse is often multi-level in nature but typically will involve some degree of obstruction at the level of the tongue-base. Several surgical procedures have been developed in recent years to address this area in patients resistant to continuous positive airway pressure. This article outlines a novel way to treat obstructive sleep apnea lingual obstruction using the da Vinci robotic surgical system. This technique offers significant potential advantages over other established approaches and it should be included in the surgical armamentarium of sleep surgeons.