Management of double carotid blowout with definitive repair after temporizing stent graft placement.

Carotid blowout syndrome is a life-threatening complication for patients with head and neck cancer. Temporizing stent graft procedures improve short-term survival and can be the definitive treatment for various reasons, including a poor oncologic prognosis, unsuitability for definitive reconstruction, or a lack of operative options. A second carotid blowout will often be fatal. Preventing such events requires multidisciplinary strategic planning because of a hostile reoperative field. We have described a case of a 44-year-old man with a history of laryngeal cancer who had experienced a carotid blowout. Treated with a stent graft, the patient had experienced a second event 6 weeks later. Treatment involved excision and suture ligation with rotational muscle flap coverage.

Operative management of symptomatic, metachronous carotid body tumors involving the skull base and its neurological sequelae.

A 44-year-old morbidly obese woman with a history of right carotid body tumor (CBT) resection presented with a symptomatic, nonfunctional, left Shamblin-III CBT. Abutment of the skull base precluded distal internal carotid artery control for arterial reconstruction, favoring parent vessel sacrifice after an asymptomatic provocative test. She underwent CBT resection with anticipated sacrifice of cranial nerves X and XII and the common carotid artery and its branches, developing baroreceptor failure syndrome and sequelae of cranial nerve sacrifice. When facing a symptomatic, metachronous CBT abutting the skull base, upfront operative intervention with adjuvant radiation for residual tumor optimizes curative resection.

Chronic opioid use after laryngeal cancer treatment.

BACKGROUND: Survivors of head and neck cancer may be at increased risk for chronic opioid use and questions remain about risk factors. METHODS: Retrospective study of patients with laryngeal cancer prescribed opioids utilizing the Truven Health Marketscan database. Patients had laryngeal cancer, underwent treatment, filled an opioid prescription, and were enrolled in this private insurance plan 1 year prior to and after treatment. RESULTS: In this study, 7484 patients were included; 17.2% developed chronic opioid use, defined as consecutive opioid fills at least 90 days after treatment cessation. Early opioid use (OR = 3.607, 95% CI [3.125-4.163]), tobacco use (OR = 1.28, 95% CI [1.117-1.467]), median morphine milligram equivalent (MME; OR = 1.001, 95% CI [1.000-1.0001]), and radiation alone (OR = 1.435, 95% CI [1.199-1.717]) were predictive of chronic opioid use. CONCLUSIONS: Nearly one in five patients prescribed opioids during treatment developed chronic use. Providers should discuss the risk of chronic opioid use, set expectations for opioid weaning, and consider adjunct pain regimens to develop effective pain management strategies.

Chronic Opioid Use after Laryngeal Cancer Treatment: A VA Study.

OBJECTIVE: To investigate opioid utilization in veterans undergoing laryngeal cancer treatment and describe the risk of chronic use after treatment cessation. STUDY DESIGN: A retrospective cohort study. SETTING: A single Veterans Health Administration site. SUBJECTS AND METHODS: Veterans with newly diagnosed and treated laryngeal cancer with attributable opioid use from 2005 to 2015. Milligram morphine equivalents (MMEs) were calculated from 90 days prior to diagnosis for up to 1 year. Adjuvant pain medications filled 30 days prior to and up to a year from the date of diagnosis were assessed. RESULTS: Of 74 veterans with biopsy-proven laryngeal carcinoma, 73 (98.6%) were male and 71 (96%) were white. Forty-three (58%) patients were stage 0/I/II; 31 (42%) were III/IV. Eleven (14.9%) were treated with surgery alone, 35 (47.3%) with radiation alone, and 28 (38%) with multimodal therapy. Twenty-four (32.4%) patients had preexisting opioid use prior to cancer diagnosis. Patients who used opioids more than 30 days prior to date of diagnosis were found to be 10 times more likely to have persistent opioid use at 90 days (P = .0024) and 8 times more likely to have chronic use at 360 days (P = .0041). Maximum MMEs within 1 year of diagnosis were significantly associated with chronic use at 90 days (P = .00045) and chronic use at 360 days (P = .0006). CONCLUSION: Preexisting opioid use and maximum MMEs are strongly associated with chronic opioid use among veterans treated for laryngeal carcinoma independent of stage and treatment type.

Awake vs Sedated Tracheostomies: A Review and Comparison at a Single Institution.

OBJECTIVE: The literature surrounding awake tracheostomies is sparse, particularly comparing awake tracheostomy patients to that of the sedated tracheostomy population. This study sought to compare tracheostomy patient demographics, indications, and outcomes of the 2 populations. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care center. MATERIALS AND METHODS: All tracheostomies performed at our tertiary academic medical institution between January 2013 through November 2015 were reviewed. The data collected included demographics, comorbidity, anticoagulation, and outcomes. RESULTS: A total of 978 tracheostomies performed during this period met inclusion criteria, with 78 (8.0%) on awake patients. Most awake procedures were performed by otolaryngology (97.4%). Male sex predominated (73.1% awake vs 57.8% sedated). Forty-four patients (56.4%) were smokers in the awake group vs 326 of 900 (36.2%) in the sedated group. Malignancy was the primary indication for awake tracheostomy (68/78, 87.1%). One patient (1.3%) had significant postoperative bleeding compared to 26 of 900 (2.9%) of the sedated tracheostomy patients ( P = .406). Only 9 (11.4%) were ever decannulated. Thirty-one (39.2%) patients ultimately underwent total laryngectomy, 3 could not be decannulated secondary to anatomical causes (stenosis or vocal fold paralysis), and 19 were lost to follow-up after discharge. There were 12 of 78 (15.4%) overall deaths in the awake cohort, with 215 of 900 (23.9%) in the sedated cohort ( P = .088). CONCLUSION: Despite all the differences between the 2 patient populations, the urgent awake tracheostomy appears to be safe and its complications do not appear significantly different from the sedated population.

Ceruminous Adenoid Cystic Carcinoma of External Auditory Canal.

An adenoid cystic carcinoma (AdCC) of the ceruminous glands is very rare; its diagnosis is most often challenging, and simple biopsies may be misleading. Our paper describes a case of a circumferential mass of the left ear canal that was initially reported as a basal cell carcinoma on biopsies in the clinic and on frozen sections intraoperatively. The final pathology was an AdCC of the ceruminous glands of the external auditory canal. Our case reflects the difficulty in the diagnosis of an AdCC of the ceruminous gland and the importance of keeping broad differential diagnoses in mind when counseling patients with masses in the ear canals until final pathology is obtained.

Prognostic indicators and survival in salvage surgery for laryngeal cancer.

BACKGROUND: Perineural invasion (PNI) and lymphovascular invasion (LVI) are known to be poor prognostic indicators in primary surgery. The purpose of this study was to determine their impact on survival in the setting of salvage laryngectomy. METHODS: We conducted a retrospective review of patients who underwent salvage laryngectomy between 2006 and 2014. RESULTS: Seventy-eight patients were included in this study; PNI was diagnosed in 48 patients (61.54%) and LVI in 25 patients (32.05%). Median overall survival was 32 months; PNI was associated with decreased survival; and the unadjusted hazard ratio (HR) was 2.69 (P = .006). Cases of LVI trended toward a decreased survival; with an unadjusted HR of 1.74 (P = .076). On multivariate analysis, PNI, LVI, or both conferred decreased survival compared to having neither (P = .01). Extracapsular spread and nodal metastases significantly impacted survival, and positive margins trended toward significance. CONCLUSION: The presence of PNI, LVI, nodal disease, and extracapsular spread significantly affected survival in this cohort of patients with laryngeal cancer.

Outpatient versus observation/inpatient parotidectomy: patient factors and perioperative complications.

The objective of this manuscript is to review a single institution's experience with superficial or total parotidectomy in outpatient and observation/inpatient groups. All patients who underwent superficial or total parotidectomy between 2009 and 2015 were identified. Patients were excluded if they had undergone concurrent surgery such as neck dissection, had prior radiation treatment or surgery at the operative site. Main outcomes were perioperative complications in both groups. 215 consecutive patients were included in the study, 116 (54%) patients in the inpatient group and 99 (46%) in the outpatient group. Aside from a higher observed rate of cardiac disease in the outpatient group (24.2 vs. 11.2%, p = 0.014) and larger mean body mass index (BMI) in the inpatient group (32.448 vs. 30.034, p = 0.017), there were no significant differences for age, sex or smoking status. Average operative time differed between groups with 2 h 42 min for inpatients and 2 h 18 min for outpatients (p < 0.001). There were 26 complications in the inpatient group (22.4%, including two hematomas) and 8 in the outpatient group (8.1%). The rate of seroma/sialocele formation was significantly higher in the inpatient group at 15.5% (n = 18) compared with the outpatient group at 3% (n = 3, p = 0.001). Our study shows that parotidectomy, superficial or total, was performed safely as an outpatient procedure without significant increase in complications when compared to patients observed for at least one night after surgery.

Otolaryngology consultation tracheostomies and complex patient population.

PURPOSE: To assess for the differences in patients undergoing tracheostomy by the otolaryngology consult service versus other specialties. MATERIALS AND METHODS: A series of 1035 tracheostomies performed at our institution from January 2013 through November 2015 was retrospectively reviewed. Patient-related factors that contribute to procedural difficulty were reviewed. RESULTS: 805 consecutive tracheostomies were included. Otolaryngology performed 176/805 (21.8%) tracheostomies as a consulting service. Morbidly obese patients were three times as likely to be referred to otolaryngology as other services (adjusted OR: 3.23; 95% CI: 2.21-4.72). Mean BMI was 36.38kg/m2 for Consults vs. 28.69kg/m2 for Others and morbidly obese patients had a mean BMI of 49.84kg/m2 vs. 42.68kg/m2 for Consults and Others respectively (p<0.001). Patients with upper airway compromise (8.5% of Consults vs. 1.6% for Others) had 5.5 times higher odds to be performed by otolaryngology (adjusted OR: 5.46; 95% CI: 2.24-13.28). Otolaryngology performed 81.8% of awake tracheostomies (n=9/11). There were significantly higher proportions of patients with diabetes, renal, pulmonary and cardiovascular disease in the Consults groups vs. Others (p<0.05). CONCLUSIONS: More complex tracheostomies are being referred to and performed by otolaryngology at our institution. Difficult and challenging tracheostomies seem to be the "standard" for otolaryngologists.

Correlation of Positron Emission Tomography/Computed Tomography Scan with Smoking, Tumor Size, Stage and Differentiation in Head and Neck Cancer Patients.

The goal of this study was to identify associations between positron emission tomography/computed tomography (PET/CT) maximum standardized uptake value (SUVmax) in patients presenting with head and neck squamous cell carcinoma (SCC) with tumor site, size, histologic differentiation, smoking, and diabetes. Charts of patients with oropharyngeal and laryngeal SCC who underwent 18F-fluorodeoxyglucose PET/CT scans were reviewed between May 2007 and August 2013. Statistical analyses included modeling log-transformed SUVmax values by tumor site, size, histologic differentiation, smoking status, and diabetes using unadjusted linear regressions. Differences were considered statistically significant for P< 0.05. A total of 111 patients (54 with oropharynx and 57 with larynx cancers) were included, 83 men and 28 women with an average age of 57.5 years old. There was a significantly higher pack-year smoking history (P = 0.005) in the larynx cancer group. While tumor T-stage was found to be significantly different (P < 0.0001), there was no difference in tumor size between the two groups: 3.16 cm and 3.58 cm in the oropharynx and larynx, respectively (P = 0.55). In the oropharynx cohort, SUVmax was associated with both tumor size (P = 0.0001) and stage (P < 0.0002). Interestingly, SUVmax differed by tumor differentiation in the larynx (P = 0.04) but not the oropharynx (P = 0.71). Finally, there was no significant difference in SUVmax relative to diabetes and smoking status. PET/CT SUVmax correlated with both tumor size and stage in oropharyngeal cancer patients, and it correlated only with tumor differentiation but not the size or stage in the larynx. There were no significant differences in SUVmax by diabetes or smoking status.

Noncontact diffuse optical assessment of blood flow changes in head and neck free tissue transfer flaps.

Knowledge of tissue blood flow (BF) changes after free tissue transfer may enable surgeons to predict the failure of flap thrombosis at an early stage. This study used our recently developed noncontact diffuse correlation spectroscopy to monitor dynamic BF changes in free flaps without getting in contact with the targeted tissue. Eight free flaps were elevated in patients with head and neck cancer; one of the flaps failed. Multiple BF measurements probing the transferred tissue were performed during and post the surgical operation. Postoperative BF values were normalized to the intraoperative baselines (assigning "1") for the calculation of relative BF change (rBF). The rBF changes over the seven successful flaps were 1.89 ± 0.15, 2.26 ± 0.13, and 2.43 ± 0.13 (mean ± standard error), respectively, on postoperative days 2, 4, and 7. These postoperative values were significantly higher than the intraoperative baseline values (p<0.001), indicating a gradual recovery of flap vascularity after the tissue transfer. By contrast, rBF changes observed from the unsuccessful flaps were 1.14 and 1.34, respectively, on postoperative days 2 and 4, indicating less flow recovery. Measurement of BF recovery after flap anastomosis holds the potential to act early to salvage ischemic flaps.

Cognitive task demands modulate the sensitivity of the human cochlea.

Recent studies lead to the conclusion that focused attention, through the activity of corticofugal and medial olivocochlear (MOC) efferent pathways, modulates activity at the most peripheral aspects of the auditory system within the cochlea. In two experiments, we investigated the effects of different intermodal attention manipulations on the response of outer hair cells (OHCs), and the control exerted by the MOC efferent system. The effect of the MOCs on OHC activity was characterized by measuring the amplitude and rapid adaptation time course of distortion product otoacoustic emissions (DPOAEs). In the first, DPOAE recordings were compared while participants were reading a book and counting the occurrence of the letter "a" (auditory-ignoring) and while counting either short- or long-duration eliciting tones (auditory-attending). In the second, DPOAEs were recorded while subjects watched muted movies with subtitles (auditory-ignoring/visual distraction) and were compared with DPOAEs recorded while subjects counted the same tones (auditory-attending) as in Experiment 1. In both Experiments 1 and 2, the absolute level of the averaged DPOAEs recorded during the auditory-ignoring condition was statistically higher than that recorded in the auditory-attending condition. Efferent-induced rapid adaptation was evident in all DPOAE contours, under all attention conditions, suggesting that two medial efferent processes act independently to determine rapid adaptation, which is unaffected by attention, and the overall DPOAE level, which is significantly affected by changes in the focus of attention.

State of the art treatment of nasal polyposis.

BACKGROUND: Nasal polyposis represents the end point of multiple inflammatory pathways and controversy continues as to the exact roles of medical and surgical approaches in the management of nasal polyposis. METHODS: A combination of both is often required to manage polyps adequately with surgery and intranasal steroids remaining the mainstay of therapy. RESULTS: Fortunately, new technological advances are making surgery safer and more efficient. In the postoperative period, debridement is effective in reducing the formation of adhesions, and topical medications may play a beneficial role in preventing polyp reformation. CONCLUSION: Additional investigations into the optimal perioperative medical management is needed to ensure optimal surgical outcomes.