Salivary, lacrimal and nasal (SALANS) measure to assess side effects following radioactive iodine treatment: development, psychometric properties, and factor structure.

PURPOSE: This study aimed to develop and psychometrically evaluate a patient-reported outcome measure (PROM), SAlivary, LAcrimal, NaSal (SALANS), to document patients' symptoms after radioactive iodine (RAI) treatment for differentiated thyroid cancer (DTC). METHODS: We generated and iteratively revised SALANS items based on expert input, focus group discussions and feedback from cognitive testing (n = 17). We administered an initial SALANS measure with 39 items to patients diagnosed with DTC in the past two years (n = 105). Exploratory factor analysis (EFA) examined the factor structure of the SALANS items. We assessed the consistency reliability and related the total and subscale scores of the final SALANS to existing PROMs to assess validity. RESULTS: The final SALANS consisted of 33 items and six subscales (sialadenitis, taste, xerostomia, dry eyes, epiphora, and nasal) with six factors extracted by EFA. The six subscales demonstrated good internal reliability (α range = 0.87-0.92). The SALANS total score showed good convergent validity with the Xerostomia Inventory (r = 0.86) and good discriminant validity with a measure of spirituality (r = - 0.05). The mean SALANS total score was significantly higher (d = 0.5, p < 0.04) among patients who had RAI compared to those who did not have RAI. CONCLUSION: Preliminary evidence suggests that SALANS is a novel and reliable PROM to assess the type and frequency all symptoms experienced after RAI treatment for DTC. Future work is needed to further validate and develop the scale.

Needle in the Haystack: Wire Bristle Foreign Body Presenting Deep Within the Tongue Base.

OBJECTIVES: To report a case of ingested wire bristle embedded within the extrinsic musculature of the tongue requiring a transcervical approach for removal and to provide a revised algorithm for the management of ingested wire bristles. METHODS: The clinical record of 1 patient who ingested a grill brush wire bristle was reviewed. A literature review was also conducted to refine a treatment algorithm for managing ingested wire bristles. RESULTS: We present a case of a 53-year-old male who accidentally ingested a grill brush wire bristle. After multiple unsuccessful endoscopic attempts at removal, the wire bristle migrated deep into the extrinsic musculature of the tongue, necessitating a transcervical approach for adequate visualization and retrieval. CONCLUSIONS: This is the first case reported of a wire bristle migrating deep into the tongue musculature that was successfully removed via a transcervical approach. Our proposed algorithm provides a comprehensive approach to the management of ingested wire bristles, specifically in cases where endoscopic retrieval is not feasible.

Citations and Author Characteristics in Open-Access and Subscription-Based Otolaryngology Journals.

OBJECTIVE: To describe the academic impact and author characteristics of open-access journals in otolaryngology. METHODS: Original articles from three open-access (OTO Open, Laryngoscope Investigative Otolaryngology, and World Journal of Otorhinolaryngology) and three conventional subscription-based otolaryngology specific journals (Otolaryngology - Head & Neck Surgery, The Laryngoscope, JAMA Otolaryngology - Head & Neck Surgery) were assessed. Publication dates of articles from January 2017 to July 2020 were included. Google Scholar and Web of Science citation counts were recorded. H-indexes of first and last authors were included according to Google Scholar and Web of Science and analyzed. RESULTS: This analysis included 3284 articles. Articles published in open-access otolaryngology-specific journals had significantly fewer citations on average (6.8) than articles published in subscription-based journals (12.4, p < 0.0001). The last authors of articles published in subscription-based journals had significantly higher h-indexes (23.50) compared with the last authors of articles published in open-access journals (19.53, p < 0.0001). The first authors of articles published in open-access journals had similar h-indexes (10.26) as the first authors of articles published in subscription-based journals (10.33). CONCLUSIONS: Articles published in open-access journals in otolaryngology were cited significantly less than those published in subscription-based journals. The h-index of the last authors was significantly lower in open-access journals; however, the h-index of the first authors was similar between open-access and subscription-based journals. As measured by citations, open-access publications do not yet appear to have the impact of subscription-based publications. LEVEL OF EVIDENCE: NA Laryngoscope, 133:79-82, 2023.

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.

Looking under the hood of "the Cadillac of cancers:" radioactive iodine-related craniofacial side effects among patients with thyroid cancer.

PURPOSE: Despite having a generally favorable prognosis, differentiated thyroid cancer is known to have a significant, long-term impact on the quality of life of survivors. We wished to investigate short- and long-term effects among thyroid cancer survivors following radioactive iodine therapy. METHODS: We conducted eight focus groups (N = 47) to understand patients' experiences of short- and long-term effects after radioactive iodine treatment and the impact these treatment-related side effects had on patients' quality of life. We elicited responses regarding experiences with side effects following radioactive iodine treatment, particularly salivary, lacrimal, and nasal symptoms. We transcribed audiotapes and conducted qualitative analyses to identify codes and themes. RESULTS: We identified eight broad themes from the qualitative analyses. Themes reflecting physical symptoms included dry mouth, salivary gland dysfunction, altered taste, eye symptoms such as tearing or dryness, and epistaxis. Psychosocial themes included lack of knowledge and preparation for treatment, regret of treatment, and distress that thyroid cancer is labeled as a "good cancer." CONCLUSIONS: Thyroid cancer survivors reported a wide range of radioactive iodine treatment-related effects and psychosocial concerns that appear to reduce quality of life. The psychosocial concerns reported by participants underscore the significant unmet information and support needs prior to and following RAI treatment among individuals diagnosed with thyroid cancer. IMPLICATIONS FOR CANCER SURVIVORS: Future research is needed to help both patients and physicians understand the effect of radioactive iodine on quality of life, and to better assess the benefits versus the risks of radioactive iodine therapy.

Management of Adult Inpatient Otolaryngologic Consultations During the COVID-19 Pandemic: A Proposed Tier-Based Triage System.

The coronavirus disease 2019 (COVID-19) pandemic has placed tremendous strain on health care systems, leading to unprecedented challenges and obstacles in the delivery of patient care. Otolaryngologists are frequently called on for inpatient consultations for an array of pathologies, ranging from chronic benign conditions to acutely life-threatening processes. Professional otolaryngologic societies across the world have proposed limiting patient care to time-sensitive and urgent matters; however, limited literature is available to describe how this transient change in philosophy may translate to clinical practice. Here we present a structured algorithm that allows for rapid triage of otolaryngologic consults during the ongoing pandemic, in efforts to minimize infectious spread and protect clinicians while preserving high-quality patient care. Considerations for managing these consults are presented, with a commentary on practical and ethical considerations.

Prescription and Usage Pattern of Opioids after Thyroid and Parathyroid Surgery.

OBJECTIVE: We seek to characterize the prescribing patterns of opioids, opioid consumption, and pain severity after thyroid and parathyroid surgery. We also aim to determine if a relationship exists between preoperative medication use and postoperative pain or opioid consumption. STUDY DESIGN: Case series with chart review. SETTING: Academic university hospital. SUBJECTS AND METHODS: Medical records of 237 adult patients undergoing thyroid and parathyroid surgery were included. Clinicopathologic data were collected, including pain scores, preoperative medications, and inpatient pain medications. RESULTS: The mean maximum pain score was 5.74 and varied by surgery type (range, 0-10). Mean pain score decreased to 2.61 upon discharge (0-8) and to 0.51 at the first postoperative visit. Patients with a length of stay exceeding 1 day had significantly higher maximum pain scores than those with a length of stay of 0 or 1 day (8 vs 5.58, P < .001). Morphine milligram equivalents while in the hospital averaged 25.4 per day and were significantly influenced by preoperative opioid use (0-202). Acetaminophen/oxycodone was the most commonly prescribed opioid. The mean number of pills prescribed postoperatively was 43.1 (0-120). CONCLUSION: In our population, patients are discharged with opioid prescriptions that may be in excess of their requirements following thyroid and parathyroid surgery. Preoperative opioid use was associated with higher postoperative pain score and, on multivariate analysis, greater inpatient opioid consumption. Further investigation is warranted to ensure that we are prescribing opioids appropriately following thyroid and parathyroid surgery.

Expanding primary cells from mucoepidermoid and other salivary gland neoplasms for genetic and chemosensitivity testing.

Restricted availability of cell and animal models is a rate-limiting step for investigation of salivary gland neoplasm pathophysiology and therapeutic response. Conditionally reprogrammed cell (CRC) technology enables establishment of primary epithelial cell cultures from patient material. This study tested a translational workflow for acquisition, expansion and testing of CRC-derived primary cultures of salivary gland neoplasms from patients presenting to an academic surgical practice. Results showed that cultured cells were sufficient for epithelial cell-specific transcriptome characterization to detect candidate therapeutic pathways and fusion genes, and for screening for cancer risk-associated single nucleotide polymorphisms (SNPs) and driver gene mutations through exome sequencing. Focused study of primary cultures of a low-grade mucoepidermoid carcinoma demonstrated amphiregulin-mechanistic target of rapamycin-protein kinase B (AKT; AKT1) pathway activation, identified through bioinformatics and subsequently confirmed as present in primary tissue and preserved through different secondary 2D and 3D culture media and xenografts. Candidate therapeutic testing showed that the allosteric AKT inhibitor MK2206 reproducibly inhibited cell survival across different culture formats. By contrast, the cells appeared resistant to the adenosine triphosphate competitive AKT inhibitor GSK690693. Procedures employed here illustrate an approach for reproducibly obtaining material for pathophysiological studies of salivary gland neoplasms, and other less common epithelial cancer types, that can be executed without compromising pathological examination of patient specimens. The approach permits combined genetic and cell-based physiological and therapeutic investigations in addition to more traditional pathologic studies, and can be used to build sustainable bio-banks for future inquiries.This article has an associated First Person interview with the first author of the paper.

Safety and efficacy of hypofractionated stereotactic body reirradiation in head and neck cancer: Long-term follow-up of a large series.

BACKGROUND: The purpose of this study was to report long-term outcomes for a large cohort of patients with head and neck squamous cell carcinoma (HNSCC) who underwent stereotactic body radiotherapy (SBRT) reirradiation. METHODS: From 2002 to 2011, 85 patients with previously irradiated HNSCC were treated with SBRT to 94 lesions. Some underwent surgery (29%), and many were treated with induction, concurrent, and/or adjuvant chemotherapy or biologic therapy (70%). RESULTS: Reirradiation occurred at a median interval from initial radiotherapy (RT) of 32 months. Median follow-up for survivors was 17.3 months. Two-year Kaplan-Meier estimates of overall survival (OS) and locoregional control for patients and lesions treated with curative intent were 24% and 28%, respectively. Interval from initial RT to SBRT of 2 years or more was associated with improved OS (p = .019). Five patients had grade 3 or higher late toxicity (5.9%). CONCLUSION: SBRT reirradiation results in limited toxicity. Further research is needed to refine optimal roles for SBRT and intensity-modulated radiotherapy (IMRT) reirradiation.

Patterns of cervical lymph node metastases in primary and recurrent papillary thyroid cancer.

The incidence of thyroid cancer is rising in the United States with papillary thyroid cancer (PTC) being the most common type. We performed a retrospective study of 49 patients with PTC who underwent 57 lateral neck dissections (NDs). The extent of NDs varied, but 29 of 57 (51%) consisted of levels II-V. Twelve of 57 (21%) NDs consisted of levels I-V. Twelve of 57 (21%) NDs consisted of levels II-IV. One of 57 (1.8%) necks involved only levels I-IV. One of 57(1.8%) necks involved only levels I-V. One of 57(1.8%) necks involved only levels III-V. Two (3.5%) double-level (III-IV) neck surgeries were also performed. Metastatic PTC adenopathy was confirmed pathologically in 2%-level-I, 45%-level-II, 57%-level-III, 60%-level-IV, and 22%-level-V necks. Level-V was positive in 21% of primary and 24% of recurrent groups (P = 0.76). Comparing primary and recurrent disease, there was no difference in nodal distribution or frequency for levels I, II, III, and V. Level-IV was more common in the recurrent cases (P = 0.05). Based on the pathologic distribution of nodes, dissection should routinely include levels II-IV and extend to level-V in primary and recurrent cases. Our data does not suggest routine dissection of level-I.

Hypopharyngeal diverticulum formation following anterior discectomy and fusion: case series.

Pharyngoesophageal diverticulum is a rare complication following anterior cervical discectomy and fusion (ACDF). Dysphagia is a well-documented complication associated with ACDF. It may result postoperatively from a variety of etiologies, including hardware displacement, pharyngeal edema, or vocal fold paresis. One rare cause of persistent dysphagia is the formation of a hypopharyngeal diverticulum, reported in the literature in 9 previous cases. Such diverticula after ACDF surgery may have pathogenesis that is distinct from that of typical Zenker diverticula. We report 3 new cases of hypopharyngeal diverticula in patients who underwent revision ACDFs. Variables assessed included age, sex, level of fusion, ACDF-related complications, and diverticulum management. Two patients underwent successful open surgical diverticulectomy and cricopharyngeal myotomy. In the third case, the patient had a small diverticulum close to the surgical hardware and minimal symptoms and was managed conservatively. Our cases, combined with the 9 previous cases, demonstrate commonalities, particularly with regard to the risk of revision spinal surgery and infection and subsequent hypopharyngeal diverticula development. Hypopharyngeal diverticulum can occur as a complication of ACDF and should be considered in patients with persistent dysphagia after surgery. In this patient population, open resection and cricopharyngeal myotomy are recommended.

Decreased risk of squamous cell carcinoma of the head and neck in users of nonsteroidal anti-inflammatory drugs.

We evaluated the chemopreventive effect of nonsteroidal anti-inflammatory drug (NSAID) use in head and neck squamous cell carcinomas (HNSCC) by conducting a case-control study based on the administration of a standardized questionnaire to 71 incident HNSCC cases and same number of healthy controls. NSAID use was associated with a 75% reduction in risk of developing HNSCC. A significant risk reduction was noted in association with frequency of NSAID use. Restricting the analysis to aspirin users revealed a significant 90% reduction in risk of developing HNSCC. This study provides evidence for a significant reduction in the risk of developing HNSCC in users of NSAIDs, and specifically aspirin users.

Occupational injury in plastic surgeons.

BACKGROUND: Little research to date has investigated musculoskeletal injury in the surgical workforce. This study estimates the prevalence and functional impact of work-related injury in plastic surgeons and other surgical specialists. METHODS: A validated self-assessment of work-related injury was administered to surgeons at various professional conferences, over the telephone, and via email. Prevalence rates for each injury were tabulated, and a regression analysis was conducted to identify potential associations between demographic risk factors and self-reported injury. RESULTS: Of 500 surveys administered, 339 (67.8 percent) were returned. Musculoskeletal symptoms were observed in 81.5 percent of surveyed surgeons. Of 17 injuries of interest, the most prevalent conditions were muscle strain, vision changes, cervical pain, lumbar pain, and shoulder arthritis/bursitis. Carpal tunnel syndrome and epicondylitis were reported by 15.1 and 13.5 percent of respondents, respectively, more than three times general population prevalence rates. Years in practice were associated with carpal tunnel syndrome. Microscope usage of 3 hours or more per week was associated with cervical and thoracic pain. Hand surgeons appeared to be more prone to thumb arthritis than other specialties. CONCLUSIONS: Self-reported injury is more prevalent in surgery than in previously described, labor-intensive populations. Sampled surgeons appear younger than the general surgery workforce, and as a result, this study may underestimate the prevalence of occupational injury, particularly carpal tunnel syndrome. This study underscores the need for a formal, multicenter assessment of occupational injury in surgeons.

Fractionated stereotactic radiosurgery for reirradiation of head-and-neck cancer.

PURPOSE: Stereotactic radiosurgery (SRS) is an appealing treatment option after previous radiotherapy because of its precision, conformality, and reduced treatment duration. We report our experience with reirradiation using fractionated SRS for head-and-neck cancer. METHODS AND MATERIALS: From 2002 to 2008, 65 patients received SRS to the oropharynx (n = 13), hypopharynx (n = 8), nasopharynx (n = 7), paranasal sinus (n = 7), neck (n = 7), and other sites (n = 23). Thirty-eight patients were treated definitively and 27 patients with metastatic disease and/or untreated local disease were treated palliatively. Nine patients underwent complete macroscopic resection before SRS. Thirty-three patients received concurrent chemoradiation. The median initial radiation dose was 67 Gy, and the median reirradiation SRS dose was 30 Gy (21-35 Gy) in 2-5 fractions. RESULTS: Median follow-up for surviving patients was 16 months. Fifty-six patients were evaluable for response: 30 (54%) had complete, 15 (27%) had partial, and 11 (20%) had no response. Median overall survival (OS) for all patients was 12 months. For definitively treated patients, the 2-year OS and locoregional control (LRC) rates were 41% and 30%, respectively. Multivariate analysis demonstrated that higher total dose, surgical resection, and nasopharynx site were significantly associated with improved LRC; surgical resection and nonsquamous histology were associated with improved OS. Seven patients (11%) experienced severe reirradiation-related toxicity, including one treatment-attributed death. CONCLUSION: SRS reirradiation for head-and-neck cancer is feasible. This study demonstrates encouraging response rates with acceptable toxicity. Fractionated SRS reirradiation with concurrent chemotherapy in select patients warrants further study.

Adopting the operating microscope in thyroid surgery: safety, efficiency, and ergonomics.

BACKGROUND: Our aim was to assess the safety and efficiency of operating microscope use by surgeons in thyroid surgery to reduce static neck flexion. METHODS: A retrospective case review comparing thyroidectomies performed using an operating microscope to those using surgical loupes was done. Operative times and incidence of complications were compared between total thyroidectomy procedures done with either microscope or loupes. RESULTS: The use of microscope in 51 thyroidectomies (including 20 for malignancy with central compartment node dissection [CND] and 9 for substernal goiter [SG]) was compared with 65 cases (15 with CND and 11 with SG) done previously using loupes. Surgical times using the microscope were longer (p = .0001), but the increase was significant only in the subset of patients who underwent thyroidectomy with CND. There was no difference in complications between the groups. CONCLUSION: The use of an operating microscope during thyroidectomy is safe with modest increases in surgical time.

Quantification of DNA repair capacity in whole blood of patients with head and neck cancer and healthy donors by comet assay.

Comet assay has been used to estimate cancer risk by quantification of DNA damage and repair in response to mutagen challenge. Our goal was to adopt best practices for the alkaline comet assay to measure DNA repair capacity of white blood cells in whole blood of patients with squamous cell carcinoma of the head and neck (HNSCC). The results show that initial damage by 10 Gy of gamma radiation expressed as percent DNA in comet tail was higher in stimulated lymphocytes (61.1+/-11.8) compared to whole blood (43.0+/-12.1) but subsequent repair was similar with comet tail of approximately 20% at 15 min and 13% at 45 min after exposure. Exposure of whole blood embedded in agarose from 5 to 10 Gy gamma radiation was followed by an approximately 70% repair of the DNA damage within 45 min with a faster repair phase in the first 15 min. Variability of the measurement was lower within repeated measurements of the same person compared to measurement of different healthy individuals. The repair during first 15 min was slower (p=0.01) in ex-/non-smokers (41.0+/-2.1%) compared to smokers (50.3+/-2.7%). This phase of repair was also slower (p=0.02) in HNSCC patients (36.8+/-2.1%) compared to controls matched on age and smoking (46.4+/-3.0%). The results of this pilot study suggest that quantification of repair in whole blood following a gamma radiation challenge is feasible. Additional method optimization would be helpful to improve the assay for a large population screening.

Papillary and follicular variant of papillary carcinoma of the thyroid: Initial presentation and response to therapy.

INTRODUCTION: The 2 most common histologic variants of papillary carcinoma are pure papillary carcinoma (PTC) and follicular variant of papillary thyroid carcinoma (FVPTC). The purpose of this study is to compare the presentation and short-term response to therapy of these variants and to determine if FVPTC is a more aggressive form of thyroid cancer that warrants intensive therapy. METHODS: A retrospective chart review of patients treated for PTC and FVPTC between 1996 and 1999 was performed. Clinical variables were compared with the Wilcoxon Rank-Sum test or the Fischer's Exact Test. RESULTS: Of 160 patients with papillary thyroid carcinoma included, 114 (71%) had PTC and 46 (29%) had FVPTC. Mean follow-up was 38.6 months. FVPTC presented with larger tumors (median 1.5 cm vs 1.0 cm, P = 0.007) and higher tumor stage than PTC. PTC patients were more likely to present with local invasion and to have local recurrence (9.65% vs 0% for both variables). There were no significant differences in patient age, gender, vascular invasion, lymph node or distant metastases, surgical treatment, radioactive iodine therapy, remission, or mortality. CONCLUSION: FVPTC presented with larger original tumor size and higher tumor stage but a lower local invasion rate and recurrence rate than patients with PTC despite similar therapies. These data suggest that FVPTC and PTC carry similar prognoses in early stages and that FVPTC may have a reduced predilection for local invasion. Although further studies with longer follow-up are required, these results do not suggest that FVPTC warrants more aggressive therapy than PTC.

First bite syndrome: a complication of surgery involving the parapharyngeal space.

INTRODUCTION: First bite syndrome (FBS) is the development of pain in the parotid region after the first bite of each meal and can be seen after surgery of the parapharyngeal space. The cause is not clear but has been proposed to involve a loss of sympathetic nerve function to the parotid, causing a denervation supersensitivity of salivary gland myoepithelial cells. The purpose of this study was to review the records of 12 patients with FBS to determine any common features of the operations performed that would support this theory of parotid "sympathectomy" as an etiologic factor of FBS. METHODS: Retrospective review of 12 patients with FBS managed at two tertiary care centers. RESULTS: Twelve patients were diagnosed with FBS after surgery involving the parapharyngeal space. All patients had most of their parotid gland preserved. Six patients exhibited a postoperative Horner's syndrome, suggesting sympathetic chain interruption. The six patients without Horner's syndrome were found to have undergone external carotid artery ligation inferior to the parotid gland, suggesting an interruption of sympathetic innervation to the parotid gland itself. CONCLUSIONS: Preservation of parotid gland tissue and a loss of its sympathetic nerve supply, whether by disruption of the cervical sympathetic chain as evidenced by a Horner's syndrome or more selective denervation by ligation of the external carotid artery with its accompanying sympathetic nerve plexus, were common features of all patients. This series supports the concept of parotid "sympathectomy" as an etiologic factor in FBS.