The current state of autonomous suturing: a systematic review.

BACKGROUND: Robotic technology is an important tool in surgical innovation, with robots increasingly being used in the clinical setting. Robots can be used to enhance accuracy, perform remote actions, or to automate tasks. One such surgical task is suturing, a repetitive, fundamental component of surgery that can be tedious and time consuming. Suturing is a promising automation target because of its ubiquity, repetitive nature, and defined constraints. This systematic review examines research to date on autonomous suturing. METHODS: A systematic review of the literature focused on autonomous suturing was conducted in accordance with PRISMA guidelines. RESULTS: 6850 articles were identified by searching PubMed, Embase, Compendex, and Inspec. Duplicates and non-English articles were removed. 4389 articles were screened and 4305 were excluded. Of the 84 remaining, 43 articles did not meet criteria, leaving 41 articles for final review. Among these, 34 (81%) were published after 2014. 31 (76%) were published in an engineering journal9 in a robotics journal, and 1 in a medical journal. The great majority of articles (33, 80%) did not have a specific clinical specialty focus, whereas 6 (15%) were focused on applications in MIS/laparoscopic surgery and 2 (5%) on applications in ophthalmology. Several suturing subtasks were identified, including knot tying, suture passing/needle insertion, needle passing, needle and suture grasping, needle tracking/kinesthesia, suture thread detection, suture needle shape production, instrument assignment, and suture accuracy. 14 articles were considered multi-component because they referred to several previously mentioned subtasks. CONCLUSION: In this systematic review exploring research to date on autonomous suturing, 41 articles demonstrated significant progress in robotic suturing. This summary revealed significant heterogeneity of work, with authors focused on different aspects of suturing and a multitude of engineering problems. The review demonstrates increasing academic and commercial interest in surgical automation, with significant technological advances toward feasibility.

Free flap jaw reconstruction with dental implantation: A single-institution experience.

BACKGROUND: We sought to review our institution's experience with dental implant placement in free flap jaw reconstruction to determine factors impacting restoration of dental occlusion. METHODS: Exactly 48 patients underwent free flap jaw reconstruction with or without dental restoration from 2017 to 2022. Primary outcome was achievement of restored dental occlusion after jaw free flap reconstruction. RESULTS: A total of 48 patients with a mean age of 59.8 ± 16.4 years underwent jaw reconstruction from 2017 to 2022. Ten patients (20.8%) received osteointegrated dental implants. Two patients received a temporary dental prosthesis, 12 ± 4 months after initial reconstruction. Three patients received a final prosthesis, with a mean time to final prosthesis of 17.7 ± 12.4 months. Five patients did not receive any prosthesis despite placement of implants. CONCLUSION: A minority of patients received dental implant placement with free flap jaw reconstruction and only a small subset of these received a definitive dental prosthesis.

Transoral Surgery in HPV-Positive Oropharyngeal Carcinoma: Oncologic Outcomes in the Veterans Affairs System.

OBJECTIVES: Most transoral robotic surgery (TORS) literature for HPV-positive oropharyngeal squamous cell carcinoma (HPV-OPC) derives from high-volume tertiary-care centers. This study aims to describe long-term recurrence and survival outcomes among Veterans Health Administration patients. MATERIALS AND METHODS: Using the US Veterans Affairs database, we identified patients with HPV-OPC treated with TORS between January 2010 and December 2016. Patients were stratified in risk categories: low (0-1 metastatic nodes, negative margins), intermediate (close margins, 2-4 metastatic nodes, lymphovascular or perineural invasion, pT3-pT4 tumor), or high (positive margins, extranodal extension (ENE), and/or ≥5 metastatic nodes). Primary outcomes included overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS). RESULTS: The cohort included 161 patients of which 29 (18%) were low-risk, 45 (28%) intermediate-risk, and 87 (54%) high-risk. ENE was present in 41% of node-positive cases and 24% had positive margins. Median follow-up was 5.6 years (95% CI, 3.0-9.3). The 5-year DSS for low, intermediate, and high-risk groups were: 100%, 90.0% (95% CI, 75.4-96.1%), and 88.7% (95% CI, 78.3-94.2%). Pathologic features associated with poor DSS on univariable analysis included pT3-T4 tumors (HR 3.81, 95% CI, 1.31-11; p = 0.01), ≥5 metastatic nodes (HR 3.41, 95% CI, 1.20-11; p = 0.02), and ENE (HR 3.53, 95% CI, 1.06-12; p = 0.04). Higher 5-year cumulative incidences of recurrence were observed in more advanced tumors (pT3-T4, 33% [95% CI, 14-54%] versus pT1-T2, 13% [95% CI, 8-19%]; p = 0.01). CONCLUSIONS: In this nationwide study, patients with HPV-OPC treated with TORS followed by adjuvant therapy at Veterans Affairs Medical Centers demonstrated favorable survival outcomes comparable to those reported in high-volume academic centers and clinical trials. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:207-214, 2024.

Simulation-based workshop for emergency preparedness in otolaryngology.

Objectives: This study aimed to evaluate the outcomes of a hands-on simulation-based course with emphasis on procedural techniques, clinical reasoning, and communication skills developed to improve junior Otolaryngology - Head and Neck Surgery (OHNS) residents' preparedness in managing otolaryngologic emergencies. Methods: Junior OHNS residents and faculty from residency programs in California, Nevada, and Arizona participated in this workshop in 2020 and 2021. The stations featured airway management techniques, ultrasound-guided needle aspiration, nasoseptal hematoma evacuation, and facial fracture repair using various models and cadavers. Participants completed a pre-workshop survey, post-workshop survey, and 2-month follow-up survey that assessed resident anxiety and confidence in three OHNS emergency situations across knowledge, manual skills, and teamwork using a 5-point Likert scale. Results: Pre-workshop surveys reported the least anxiety and most confidence in teamwork, but the most anxiety and least confidence in technical skills and knowledge related to foreign body retrieval and airway management. Immediately post-workshop participants reported significant reductions in anxiety and increases in confidence, largest in the manual skills domain, in foreign body retrieval (anxiety: -0.99, confidence: +0.95, p < .01) and airway management stations (anxiety: -0.68, confidence: +1.07, p < .01). Data collected for the epistaxis station showed decreasing confidence and increasing anxiety following the workshop. Conclusion: Our findings demonstrate the effectiveness of a workshop in preparing junior residents in potentially lifesaving otolaryngologic techniques that residents will encounter. Optimizing use of simulation centered training can inform the future of residency education, improving confidence and decreasing anxiety in residents responsible for the safety of patients. Level of Evidence: III.

Race and sex demographics in the surgical management of facial nerve palsy.

Objective: Facial palsy affects patients of all backgrounds, yet no existing studies describe differences in its treatment patterns between demographic groups. Methods: We used the National Surgical Quality Improvement Project database to investigate whether race and sex disparities exist in facial reanimation surgery. Patients were identified using CPT codes corresponding to facial-nerve procedures. Results: Seven hundred sixty-one patients met criteria; 681 self-identified as White (89.5%), 51 as Black (6.7%), 43 as Hispanic (5.6%), 23 as Asian (3.0%), and 5 patients as other (0.61%). White patients were more than twice as likely to undergo brow ptosis repair than Non-White patients (OR 2.49, 95% CI 1.16-6.15, p = .03). After controlling for malignancy, men had longer operative times than women (480.2 vs. 413.9 min, p = .04) and higher likelihood of free tissue transfer (OR 4.1, 95% CI 1.9-9.8), fascial free tissue transfer (OR 10.7, 95% CI 2.1-195), and ectropion repair (OR 1.8, 95% CI 1.2-2.8). Conclusion: Most patients undergoing facial reanimation surgery in the United States are White. Men have longer operative times and a higher likelihood of undergoing free fascial grafts and cutaneous and fascial free tissue transfer than women regardless of malignancy status. Level of Evidence: 2c.

Intraoperative molecular imaging: 3rd biennial clinical trials update.

Significance: This third biennial intraoperative molecular imaging (IMI) conference shows how optical contrast agents have been applied to develop clinically significant endpoints that improve precision cancer surgery. Aim: National and international experts on IMI presented ongoing clinical trials in cancer surgery and preclinical work. Previously known dyes (with broader applications), new dyes, novel nonfluorescence-based imaging techniques, pediatric dyes, and normal tissue dyes were discussed. Approach: Principal investigators presenting at the Perelman School of Medicine Abramson Cancer Center's third clinical trials update on IMI were selected to discuss their clinical trials and endpoints. Results: Dyes that are FDA-approved or currently under clinical investigation in phase 1, 2, and 3 trials were discussed. Sections on how to move benchwork research to the bedside were also included. There was also a dedicated section for pediatric dyes and nonfluorescence-based dyes that have been newly developed. Conclusions: IMI is a valuable adjunct in precision cancer surgery and has broad applications in multiple subspecialties. It has been reliably used to alter the surgical course of patients and in clinical decision making. There remain gaps in the utilization of IMI in certain subspecialties and potential for developing newer and improved dyes and imaging techniques.

Carbon Dioxide Laser Sequestrectomy for Osteoradionecrosis: A Case Series.

Objective: To demonstrate a new approach to sequestrectomy using a carbon dioxide (CO2) laser for a clinic-based technique. Background: Osteoradionecrosis (ORN) of the jaw is a debilitating complication of radiotherapy for head and neck malignancies. Often refractory to medical therapy, surgical intervention for early staged disease with curettage and mechanical bone removal has mixed success, making this disease extremely difficult to treat. Therefore, new approaches to treat ORN of the jaw is needed. Methods: We describe five cases of early-to-intermediate-staged ORN illustrating a novel clinic-based sequestrectomy technique using a CO2 laser. Results: The exposed bone lesions involved the mandibular fixed gingiva, maxillary fixed gingiva, and hard palate. None of the patients had diabetes. Four patients required a total of two laser treatments and one patient needed only one treatment. All five patients demonstrated an excellent response with complete resolution of their ORN-related pain and complete mucosal coverage of the exposed bone with durable results (follow-up range, 7-19 months). Conclusions: This small series demonstrates encouraging results for CO2 laser sequestrectomy for ORN. This novel office-based intervention merits further study in larger prospective series and exploration in other disease populations, such as medication-related osteonecrosis of the jaws.

Identification of Degenerated Murine Facial Nerves With Fluorescence Labeling After Transection Injury.

OBJECTIVE: Delayed peripheral nerve repair is complicated by nerve degeneration and atrophy that can prevent identification. We use a murine facial nerve transection model to demonstrate the efficacy of ALM-488 (bevonescein) in labeling degenerated facial nerves with quantitative image analysis and qualitative survey data. STUDY DESIGN: Prospective cohort study. SETTING: Laboratory. METHODS: Ten wild-type mice underwent transection of the lower facial nerve division with subsequent degeneration. Either 9 (n = 5 mice) or 12 (n = 5 mice) weeks later, mice underwent intravenous infusion of ALM-488 with in vivo real-time fluorescence imaging (FL) of the facial nerve. Using ImageJ, the mean gray value of each nerve segment under white light reflectance (WLR) and FL was compared to that of adjacent soft tissue to calculate the signal-to-background ratio (SBR). A survey was distributed to evaluate the perceived utility of ALM-488 in surgeon identification of degenerated nerves. RESULTS: The mean SBR of degenerated nerves was 1.08 (standard deviation [SD]: 0.07) under WLR and 2.11 (SD: 0.31) under FL (p < 0.001). In mice with degenerated nerves, survey participants identified on average 3.01 (SD: 1.84) nerve branches under WLR and 5.73 (SD: 1.88) under FL (p < 0.0001). Under FL, 47 of 48 survey responses correctly identified isolated, degenerated nerves; in contrast, only 12 responses identified degenerated nerves under WLR (p < 0.0001). CONCLUSION: Preoperative intravenous infusion of ALM-488 with FL improves the identification of degenerated facial nerves. ALM-488 also improves surgeon confidence in nerve identification, particularly in degenerated nerve branches that are not visible with WLR.

Transoral Laser Microsurgery With Neck Dissection Versus Radiotherapy for T2N0 Supraglottic Cancer.

OBJECTIVES: To compare overall survival outcomes associated with transoral laser microsurgery (TLM) with neck dissection versus definitive radiotherapy in the management of T2N0 supraglottic squamous cell carcinoma. METHODS: Data were extracted from the National Cancer Database concerning patients with cT2N0M0 supraglottic cancer treated with either TLM and neck dissection with minimum lymph node yield of 10 or definitive radiotherapy. Predictors of overall survival were assessed via Cox proportional hazards regression. RESULTS: Seventy-six cT2N0 supraglottic squamous cell carcinoma patients who underwent TLM with neck dissection (+/- adjuvant therapy) versus 991 patients who underwent radiotherapy. TLM was associated with an overall survival benefit (OR = 0.574; 95% CI 0.383-0.860) compared with radiotherapy. There was no difference in survival between TLM patients receiving adjuvant treatment and those receiving definitive radiotherapy. CONCLUSIONS: An up-front, TLM-based surgical approach to cT2N0 supraglottic cancer may offer an overall survival benefit compared with definitive radiotherapy, and should receive more frequent consideration as a primary approach to this disease process. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:601-606, 2023.

Narrow-field supracricoid partial laryngectomy: Procedure development and initial clinical experiences.

OBJECTIVES: To evaluate the feasibility of narrow-field supracricoid partial laryngectomy with cricohyoidoepiglottopexy (NF-SCPL-CHEP). METHODS: Between 2019 and 2020, five patients with glottic cancers underwent NF-SCPL-CHEP. The mean durations of surgical drains, tracheostomy canula, and nasogastric tube use were evaluated. Length of stay following NF-SCPL-CHEP was compared with that of our open SCPL historical controls. A case summary is provided for the first patients, with detailed information about postoperative management and function. RESULTS: All five patients achieved uneventful postoperative recoveries without major complications. The average time for surgical drains, tracheostomy canula, and nasogastric tube use were 2, 15, and 46 days, respectively. The mean overall hospitalization period was 36 days for NF-SCPL-CHEP patients. The mean period of hospitalization based on our early experiences between 1997 and 2005 with classical open SCPL was 72 days. All patients were fully functional and local recurrences or distant metastases were not encountered during a mean observation period of 39 months. CONCLUSIONS: NF-SCPL-CHEP with 6 cm cervical access appeared technically feasible and oncologically sound in this initial clinical experience. An extra 2 cm incision, which enabled lateral neck dissection, was not felt to detract from the overall minimally invasive basis of NF-SCPL-CHEP. The clinical results were encouraging with limited complications and predictable postoperative recovery. The length of stay for patients undergoing NF-SCPL was half that of open SCPL historical controls. Less damages to local circulation may associate with the positive influences. Further study with a large patient sample across multiple institutions are needed to carefully evaluate long-term functional and oncological outcomes.

Surgical ergonomics: Assessment of surgeon posture and impact of training device during otolaryngology procedures.

Objective: To identify factors associated with cervical-thoracic spine posture in otolaryngology surgeries and evaluate the efficacy of a commercially available posture-training device in enhancing surgeon ergonomics. Methods: Over 3 months, neck and spine posture from individuals performing otolaryngology surgeries was recorded using UpRight Go 2™. Average baseline posture was first recorded and biofeedback was later introduced to attempt to correct posture. The proportion of time spent in upright/neutral cervical-thoracic spine posture was correlated with surgeon and procedure characteristics and compared to proportion of upright posture time after biofeedback intervention. Results: The proportion of upright operating time was significantly different between procedure subtypes and surgical approaches with best performance in rhinology procedures and worst performance in head and neck surgeries (90% vs. 62%; both p < .001). Female gender, shorter stature, and use of sitting stools were associated with greater proportion of surgery spent upright (all p < .05). Loupes use was associated with less time in upright posture (p < .001). With biofeedback intervention, 8 of 10 subjects demonstrated an average of 5% improvement in operating upright, with most improvement found when performing laryngology procedures (7%) and least improvement in head and neck procedures (2%). Conclusions: While surgeon posture varies across otolaryngology surgeries, sitting and minimizing the use of loupes may help promote a more ergonomic operating environment and improve surgeon posture. Although the efficacy of biofeedback intervention from a commercially available posture-training device differs among otolaryngologists, exploration of alternative interventions and incorporation of an ergonomics curriculum is warranted to address postural issues experienced by many surgeons. Level of Evidence: 3.

Adjuvant Radiotherapy in Surgically Treated HPV-Positive Oropharyngeal Carcinoma with Adverse Pathological Features.

Purpose: HPV-positive oropharyngeal carcinoma (HPV-OPC) is increasingly treated with primary surgery. The National Comprehensive Cancer Network (NCCN) recommends adjuvant therapy for surgically treated HPV-OPC displaying adverse pathological features (AF). We evaluated adjuvant radiotherapy patterns and outcomes in surgically treated AF-positive HPV-OPC (AF-HPV-OPC). Methods: The National Cancer Database was interrogated for patients ≥ 18 years with early-stage HPV-OPC from 2010 to 2017 who underwent definitive resection. Patients that had an NCCN-defined AF indication for adjuvant radiotherapy were assessed, including positive surgical margins (PSM), extranodal extension (ENE), lymphovascular invasion, and level 4/5 cervical lymph nodes. Overall survival (OS) was evaluated using Cox proportional hazards models and Kaplan−Meier analysis in whole and propensity score matched (PM) cohorts. Results: Of 15,036 patients meeting inclusion criteria, 55.7% were positive for at least one AF. Presence of any AF was associated with worse OS (hazard ratio (HR) = 1.56, p < 0.001). In isolation, each AF was associated with worse OS. On PM analysis, insurance status, T2 category, Charlson-Deyo comorbidity score, ENE (HR = 1.81, p < 0.001), and PSM (HR = 1.58, p = 0.002) were associated with worse OS. Median 3-year OS was 92.0% among AF-HPV-OPC patients undergoing adjuvant radiotherapy and 84.2% for those who did not receive adjuvant radiotherapy (p < 0.001, n = 1678). The overall rate of patients with AF-HPV-OPC who did not receive adjuvant radiotherapy was 13% and increased from 10% in 2010 to 17% in 2017 (ptrend = 0.007). Conclusions: In patients with AF-HPV-OPC, adjuvant radiotherapy is associated with improved survival. In the era of de-escalation therapy for HPV-OPC, our findings demonstrate the persistent prognostic benefit of post-operative radiotherapy in the setting of commonly identified adverse features. Ongoing clinical trials will better elucidate optimized patient selection for de-escalated therapy.

Surgical wound classification in otolaryngology: A state-of-the-art review.

Objective: To describe the issues related to the assignment of surgical wound classification as it pertains to Otolaryngology-Head & Neck surgery, and to present a simple framework by which providers can assign wound classification. Data Sources: Literature review. Conclusion: Surgical wound classification in its current state is limited in its utility. It has recently been disregarded by major risk assessment models, likely due to inaccurate and inconsistent reporting by providers and operative staff. However, if data accuracy is improved, this metric may be useful to inform the risk of surgical site infection. In an era of quality-driven care and reimbursement, surgical wound classification may become an equally important indicator of quality.

Orbital floor reconstruction via autologous radial forearm free flap with palmaris longus tendon.

We describe reconstruction of the orbital floor following suprastructure maxillectomy for resection of maxillary squamous cell carcinoma utilizing an osteocutaneous radial forearm free flap and palmaris longus tendon.

Remote telesurgery in humans: a systematic review.

BACKGROUND: Since the conception of robotic surgery, remote telesurgery has been a dream upon which incredible technological advances haven been built. Despite the considerable enthusiasm for, there have been few published studies of remote telesurgery on humans. METHODS: We performed a systematic review of the English literature (PubMed, EMbase, Inspec & Compendex and Web of Science) to report studies of remote telesurgery in humans. Keywords included telesurgery, remote surgery, long-distance surgery, and telerobotics. Subjects had to be human (live patients or cadavers). The operating surgeon had to be remote from the patient, separated by more than one kilometer. The article had to explicitly report the use of a long-distance telerobotic technique. Articles that focused on telepresence or tele-mentoring were excluded. RESULTS: The study included eight articles published from 2001 to 2020. One manuscript (1 subject) described remote surgery on a cadaver model, and the other seven were on live humans (72 subjects). Procedure types included percutaneous, endovascular, laparoscopic, and transoral. Communication methods varied, with the first report using a telephone line and the most recent studies using a 5G network. Six of the studies reported signal latency as a single value and it ranged from 28 ms to 280 ms. CONCLUSIONS: Few studies have described remote telesurgery in humans, and there is considerable variability in robotic and communication methods. Future efforts should work to improve reporting of signal latency and follow careful research methodology.

Open and endoscopic surgery improve survival for squamous and nonsquamous cell nasopharyngeal carcinomas: An NCDB cohort study.

BACKGROUND: Nasopharyngeal tumors (NPTs) are primarily treated with nonsurgical therapy. Recent studies have demonstrated endoscopic salvage surgery for NPT recurrences may improve survival relative to reirradiation. However, there are very limited data on open compared with endoscopic approaches for NPTs. We investigated whether endoscopic and open surgical approaches to the nasopharynx improve overall survival for all histologic subtypes of NPTs. METHODS: We performed a retrospective cohort study using the National Cancer Database (NCDB). All adult patients with NPTs from 2004 to 2016 without distant metastasis who underwent treatment with curative intent were included. We extracted clinical and treatment variables to assess our primary outcome of overall survival. RESULTS: On univariate analysis, patients undergoing endoscopic surgery, but not open surgery, had significantly improved overall survival relative to those undergoing nonsurgical treatment. Post hoc analysis demonstrated significantly improved overall survival for surgery in patients with minor salivary gland histology, but not squamous cell carcinoma (SCC) histology or by T or N classification. A Cox proportional hazards model was used for multivariate regression. After adjusting for covariates, both endoscopic and open approaches were associated with improved overall survival relative to nonsurgical treatment for all tumor types. A multivariate regression of SCC found that open surgery, but not endoscopic surgery, was significantly associated with improved overall survival. CONCLUSION: Both endoscopic and open surgical approaches are associated with improved overall survival of patients with NPT. These findings highlight important oncologic validity as endoscopic and robotic platforms to the nasopharynx become more widely adopted.

Hereditary oral squamous cell carcinoma associated with CDKN2A germline mutation: a case report.

BACKGROUND: Germline CDKN2A mutations are a well-known cause of familial atypical multiple mole melanoma (OMIM #155601) and melanoma-pancreatic cancer syndrome (OMIM #606719). Increased risk of head and neck squamous cell carcinoma (HNSCC), particularly oral squamous cell carcinoma (OSCC) in those with germline CDKN2A mutations, has been described. However, screening for HNSCC is not a routine practice in patients with CDKN2A germline mutations and these mutations are not a conventional test for HNSCC patients without obvious risk factors. CASE PRESENTATION: We describe a female with no smoking history who developed oral squamous cell carcinoma at age 39 and had a complex clinical course of recurrent multifocal squamous cell carcinoma (SCC) and carcinoma in situ of the oral cavity and oropharynx. Detailed family history demonstrated that her mother was diagnosed with OSCC and melanoma in her 40 s, and her maternal grandfather was diagnosed with metastatic melanoma in his 40 s. Genetic testing of the patient and her mother revealed CDKN2A c.301G>T mutation. She was referred to genetic counseling as well as to dermatology, gastroenterology, and neurology for cancer surveillance. She was treated with resections and has no evidence of disease 3 years after diagnosis. CONCLUSIONS: We report a family with a CDKN2A c.301 G>T mutation who also have significant history of OSCC, adding to the growing body of literature suggesting increased risk of HNSCC, particularly OSCC, in CDKN2A germline mutation carriers. It is important to consider CDKN2A mutation testing in familial HNSCC and young patients without obvious risk factors. Moreover, surveillance for HNSCC should be routine practice in those with a CDKN2A germline mutation.

A Scoping Review of Ongoing Fluorescence-Guided Surgery Clinical Trials in Otolaryngology.

OBJECTIVE: Fluorescence-guided surgery (FGS) is a rapidly developing intraoperative technology, and many contrast agents are currently under investigation. We sought to provide a review of the current state of FGS clinical trials in Otolaryngology, emphasizing its oncologic applications. METHODS: According to the preferred reporting Items for systematic reviews and meta-analyses (PRISMA) workflow for scoping reviews, a clinical trial search was performed across multiple international clinical trials registries, searching for permutations of "fluorescence," "tumor," "surgery," and "nerve" to identify all relevant studies. Studies that were active, enrolling, or soon to be enrolling patients undergoing head and neck surgery were included. RESULTS: Nineteen studies were eligible for inclusion. Seventeen studies are focused on FGS for oncologic resection and lymph node detection. One study assesses peripheral nerve fluorescence, and one evaluates normal parathyroid function after thyroidectomy. Contrast agents under development are conjugated to fluorophores that excite in the 800 nm (indocyanine green), 410 nm (5-aminolevulinic acid), 700 nm (Cyanine 5.5), and 525 nm ranges (fluorescein derivatives). CONCLUSION: Presently, there are 19 ongoing trials investigating novel FGS contrast agents for their safety, efficacy, and utility in Otolaryngology-Head and Neck Surgery. These agents rely on unique fluorophores and absorption ranges in the near-infrared and visible light spectra. FGS studies are expanding within Otolaryngology-Head and Neck Surgery with profound implications in oncologic surgery, lymph node detection, and anatomic and functional assessment. Laryngoscope, 132:36-44, 2022.

Patterns of Failure After Definitive Treatment of T4a Larynx Cancer.

OBJECTIVE: Recurrence is known to predict laryngeal squamous cell cancer (LSCC) survival. Recurrence patterns in T4a LSCC are poorly characterized and represent a possible explanation for observed survival discrepancies by treatment rendered. STUDY DESIGN: Retrospective database review. SETTING: Veterans Affairs national database. METHODS: Patients with T4a LSCC between 2000 and 2017 were identified and stratified by treatment (chemoradiotherapy [CRT] vs total laryngectomy + neck dissection + adjuvant therapy [surgical]). Primary outcomes were locoregional and distant recurrence. Secondary outcomes of overall mortality, larynx cancer mortality, and noncancer mortality were evaluated in Cox and Fine-Gray models. RESULTS: A total of 1043 patients had comparable baseline demographics: 438 in the CRT group and 605 in the surgical group. Patients undergoing CRT had higher proportions of node positivity (64.6% vs 53.1%, P < .001). Locoregional and distant recurrence were less common in the surgical group (23.0% vs 37.2%, P < .001; 6.8% vs 13.3%, P < .001, respectively); however, distant metastatic rates did not differ within the N0 subgroup (P = .722). On multivariable regression, surgery demonstrated favorable locoregional recurrence (hazard ratio [HR], 0.49; 95% CI, 0.39-0.62; P < .001), distant recurrence (HR, 0.47; 95% CI, 0.31-0.71; P < .001), overall mortality (HR, 0.75; 95% CI, 0.64-0.87; P < .001), and larynx cancer mortality (HR, 0.69; 95% CI, 0.56-0.85; P < .001). CONCLUSION: T4a LSCC survival discrepancies between surgical and nonsurgical treatment are influenced by varying recurrence behaviors. Surgery was associated with superior disease control and improved survival. Beyond the known benefit in locoregional control with surgery, there may be a protective effect on distant recurrence that depends on regional disease burden.