CT predictors of sub-centimeter occult lymph node metastases in oral cavity squamous cell carcinoma: A case-control study.

BACKGROUND: For patients with oral cavity squamous cell carcinoma (OCSCC) without evidence of nodal metastasis (cN0) on pre-operative evaluation, there are no clear guidelines who should undergo elective neck dissection (END) versus clinical surveillance. OBJECTIVE: To identify CT imaging characteristics of sub-centimeter lymph nodes that would help predict the likelihood of nodal metastases on pathology. METHODS: Retrospective review of cN0 OCSCC patients at a tertiary academic medical center was performed. Inclusion criteria included elective neck dissection, pre-operative CT imaging and presence of metastatic disease within lymph nodes. Control group consisted of patients without nodal metastases on pathology. CT features that were evaluated included asymmetric size, disrupted fatty hilum, asymmetric number, presence of cortical nodule, cortical nodule size, and round/oval shape. We evaluated the associations between CT LN features and the presence of metastases using multi-level mixed-effects logistic regression models. Model evaluation was performed using 5-fold cross-validation. The positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: 26 patients in each study and control groups were included. Three-level mixed-effects logistic regression models indicated round/oval shape (OR = 1.39, p = .01), asymmetric number (OR = 7.20, p = .005), and disrupted fatty hilum (OR = 3.31, p = .04) to be independently predictive in a 3-variable model with sensitivity = 38.0%, specificity = 92.0%, and PPV = 93.8%. CONCLUSIONS: In cN0 OCSCC patients undergoing END, round/oval shape, asymmetric number, and disrupted fatty hilum of lymph nodes on pre-operative CT imaging are novel and highly predictive of occult nodal disease.

Reducing Surgical Risks for Otoplasty.

Prominauris is a common auricular deformity most often due to underdevelopment of the antihelical fold or overdevelopment of the conchal bowl. Significant psychosocial distress may result from prominent ears, leading to the development of a variety of surgical techniques over the years. A thorough understanding of the anatomy of both the normal and prominent ear is crucial for accurate analysis and surgical correction of the deformity. The procedure is well-tolerated and careful preoperative evaluation and adherence to meticulous cartilage-sparing techniques will lead to good results and low complication rates.

Predictors of Health Care Utilization Following Major Head and Neck Oncologic Surgery in Older Patients.

OBJECTIVE: To identify patient factors in older patients associated with making posttreatment visits in the first year after major head and neck oncologic surgery. STUDY DESIGN: Retrospective cohort study. SETTING: Academic institution. METHODS: Patients aged ≥60 years who underwent a neck dissection with or without a free flap reconstruction were retrospectively analyzed. Data collected included patient demographics, comorbidities, social variables, perioperative course, and clinical visits. RESULTS: Within a 1-year postoperative period, the 181 patients in our cohort had a mean ± SD 6.37 ± 3.6 postoperative clinic visits; 70% attended at least 4 visits. Multivariable regression analysis showed a significant association with distance closer to the hospital (P = .013): for every 10-mile increase in distance, the number of visits decreased by 0.15 (SE = 0.06). Additionally, receiving adjuvant radiation therapy (P = .0096) demonstrated significant associations: when compared with no adjuvant therapy, radiation therapy had on average 1.5 (SE = 0.56) more visits, and chemoradiation had 0.04 (SE = 0.73) more visits. CONCLUSION: Older patients who undergo major head and neck oncology surgery are more likely to attend posttreatment visits in the 1 year following surgery if they are discharged home rather than to a skilled nursing facility, live closer to the hospital, and undergo adjuvant radiation therapy.

Pediatric Mandible Fractures: Mechanism, Pattern of Injury, Fracture Characteristics, and Management by Age.

Background: Development of the craniofacial skeleton and different mechanisms of injury warrant different treatment paradigms for younger children versus those at skeletal maturity. Objective: To characterize the mechanism, fracture patterns, and management of mandible fractures across the pediatric age spectrum. Methods: A 10-year retrospective review of <18-year-old children with mandible fractures at a level 1 trauma center. Characteristics were compared by age subgroup analysis. Results: Of 220 patients meeting inclusion criteria, motor vehicle collision (n = 53, 40.8%), falls (n = 48, 36.9%), and assault (n = 19, 14.6%) were the most common mechanisms with more falls in younger children and more injury by assault in teenagers. Condylar fractures were most common in the 0- to <9-year-old children (n = 27, 38.4%); angle/ramus fractures (56, 62.6%) were most common in 15- to <18-year-old children (p < 0.001). Nonsurgical management was associated with younger age (p < 0.001). Fourteen of 125 patients (8.0%) undergoing surgical intervention experienced complications. Being uninsured was associated with shorter median (interquartile range) follow-up of 5.6 (1.4-10.7) weeks, compared with private [11.9 (4.3-49.0) weeks] and public insurance [11.7 (3.7-218.0) weeks] (p < 0.001). Conclusion: The mechanism, fracture sites, and treatment differed by age with the youngest frequently managed nonoperatively and teenagers treated with adult algorithms. Complications were rare overall within 6-12 weeks after injury, with or without surgical management.

Traumatic Optic Neuropathy Management: A Survey Assessment of Current Practice Patterns.

INTRODUCTION: The treatment of traumatic optic neuropathy (TON) is highly controversial with a lack of substantiated evidence to support the use of corticosteroids or surgical decompression of the optic nerve. The aim of the study was to determine if there was a general consensus in the management of TON despite controversy in the literature. METHODS: An anonymous survey of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the North American Neuro-Ophthalmology Society regarding their practice patterns in the management of patients with TON was performed. RESULTS: The majority of 165 respondents indicated that they treated TON with corticosteroids (60%) while a significant minority (23%) performed surgical interventions (P < 0.0001). Subgroup analysis comparing rates of treatment with steroids among oculoplastic surgeons and neuro-ophthalmologists (67% vs. 47%) was not significant (Fisher's Exact test [FET], P =0.11) while results did suggest that a higher proportion of oculoplastic surgeons (33%) than neuro-ophthalmologists (11%) recommended surgical intervention (FET, P =0.004). In cases where visual acuity exhibited a downward trend treatment with steroids was the most commonly employed management. In general, neuro-ophthalmologists trended toward observation over treatment in TON patients with stable visual acuity while oculoplastic surgeons favored treatment with corticosteroids. CONCLUSIONS: In spite of the lack of class I evidence supporting intervention of TON, the majority of respondents were inclined to offer corticosteroid treatment to patients whose visual acuity showed progressive decline following injury.

The digital doctor: telemedicine in facial plastic surgery.

PURPOSE OF REVIEW: In the setting of the COVID-19 global pandemic, the demand for and use of telemedicine has surged in facial plastic and reconstructive surgery. This review aims to objectively review and summarize the existing evidence for the use of telemedicine within facial plastic surgery. RECENT FINDINGS: Telemedicine has been successfully implemented among subsets of facial plastic surgery patients, with high patient and provider satisfaction. Although the technology to facilitate telemedicine exists and preliminary studies demonstrate promise, multiple technological, financial, and medical barriers may persist in the postpandemic era. SUMMARY: Telemedicine will likely continue to grow and expand within facial plastic surgery moving forward, and we should continue to critically evaluate patient selection, access to care, and strategies for effective implementation to enhance current clinical practices.

Telemedicine, Patient Satisfaction, and Chronic Rhinosinusitis Care in the Era of COVID-19.

BACKGROUND: Telemedicine has become increasingly popular in the care of rhinologic patients during the COVID-19 pandemic. This change in practice patterns may place patients at risk of a perceived lower-quality exchange with their healthcare provider, which may in turn impact satisfaction. OBJECTIVE: This study compares patient satisfaction scores between in-person clinic visits and telemedicine video visits in patients with chronic rhinosinusitis (CRS). METHODS: Sixty-nine patients with CRS presenting to an academic rhinology clinic between March to April 2020 were retrospectively divided into video visits (VV) and clinic visits (CV) groups based on mandated state quarantine orders on March 19. Patient demographics, disease severity measures, and Patient Satisfaction Questionnaire-18 (PSQ-18) scores were collected and analyzed. Chi square test and Fisher's exact test were performed. RESULTS: There were no significant differences in age (p = 0.81), gender (p = 0.55), CRS phenotype (p = 0.16), and disease severity measures (Sinonasal Outcomes Test-22 (SNOT-22) (p = 0.92); Lund-Mackay score (p = 0.96)) between the video and clinic visit groups. There were no significant differences in PSQ-18 total scores (VV PSQ-18 mean score = 78.1, CV PSQ-18 mean score = 78.4; p = 0.67) or the following subdomain scores between the two groups: general satisfaction (p = 0.73), technical quality (p = 0.62), interpersonal manner (p = 0.41), communication (p = 0.31), financial aspects (p = 0.89), time spent with doctor (p = 0.88), and accessibility and convenience (p = 0.47). CONCLUSION: Patient satisfaction with telemedicine in the COVID-19 pandemic parallels that of traditional in-person visits. Video visits can serve as a viable alternative to clinic visits, while still maintaining high satisfaction.

Neoadjuvant PD-1 Immune Checkpoint Blockade Reverses Functional Immunodominance among Tumor Antigen-Specific T Cells.

PURPOSE: Surgical resection of primary tumor with regional lymphadenectomy remains the treatment of choice for patients with advanced human papillomavirus-negative head and neck squamous cell carcinoma. However, even when pathologic disease-free margins can be achieved, locoregional and/or distant disease relapse remains high. Perioperative immunotherapy may improve outcomes, but mechanistic data supporting the use of neoadjuvant or adjuvant treatment clinically are sparse. EXPERIMENTAL DESIGN: Two syngeneic models of oral cavity carcinoma with defined T-cell antigens were treated with programmed death receptor 1 (PD-1) mAb before or after surgical resection of primary tumors, and antigen-specific T-cell responses were explored with functional and in vivo challenge assays. RESULTS: We demonstrated that functional immunodominance developed among T cells targeting multiple independent tumor antigens. T cells specific for subdominant antigens expressed greater levels of PD-1. Neoadjuvant, but not adjuvant, PD-1 immune checkpoint blockade broke immunodominance and induced T-cell responses to dominant and subdominant antigens. Using tumors lacking the immunodominant antigen as a model of antigen escape, neoadjuvant PD-1 immune checkpoint blockade induced effector T-cell immunity against tumor cells lacking immunodominant but retaining subdominant antigen. When combined with complete surgical excision, neoadjuvant PD-1 immune checkpoint blockade led to formation of immunologic memory capable of preventing engraftment of tumors lacking the immunodominant but retaining subdominant antigen. CONCLUSIONS: Together, these results implicate PD-1 expression by T cells in the mechanism of functional immunodominance among independent T-cell clones within a progressing tumor and support the use of neoadjuvant PD-1 immune checkpoint blockade in patients with surgically resectable carcinomas.

Contemporary management of frontal sinus fractures.

PURPOSE OF REVIEW: Frontal sinus fracture management is evolving. This article will highlight recent literature and provide an evidence-based algorithm in the contemporary management of frontal sinus fractures. RECENT FINDINGS: The role of transnasal endoscopic treatment of frontal sinus fractures has expanded to include fracture reduction and posterior table reconstruction. Evidence continues to support the safety of nonoperative management in select frontal sinus outflow tract fractures. SUMMARY: The management of frontal sinus fractures with frontal sinus outflow tract injury continues to evolve with a trend toward observation and minimally invasive approaches. Restoration of the frontal sinus outflow tracts with transnasal endoscopic techniques is being used increasingly in the acute and delayed setting. For severe fractures, the role of conservative treatment paradigms requires further research.

Radiologic and clinical characteristics of vertebral fractures in multiple myeloma.

BACKGROUND CONTEXT: Nearly 80% of patients with newly diagnosed multiple myeloma (MM) have bony lesions on magnetic resonance imaging (MRI). These lesions may progress to debilitating vertebral fractures. No studies have quantitatively characterized these fractures or identified predictors of fracture burden and severity. PURPOSE: The purpose of this study was to characterize the clinical and radiologic features of these fractures and to identify independent predictors of fracture burden and severity. STUDY DESIGN/SETTING: A consecutive retrospective chart review was conducted from January 2007 to December 2013 at a single tertiary-care institution. PATIENT SAMPLE: Patients with diagnoses of both MM and vertebral fracture were included in this study. Those with a history of non-MM vertebral fracture were excluded. OUTCOME MEASURES: The primary outcome measure was height loss of the fractured vertebral body, whereas secondary outcome measures included number of fractures and morphology. METHODS: Data were collected at fracture presentation. Radiologic data were obtained from T1-weighted MRI. Anterior, middle, and posterior vertebral body height losses were recorded, and a Genant grading was made. Multivariable Poisson and logistic regression were performed to identify predictors of fracture burden and severity. RESULTS: Among 50 patients presenting with vertebral fracture, 124 fractures were observed. The majority (76%) of these patients did not have a previous MM diagnosis. The most common presenting symptom was back pain (84%), followed by neurologic (54%) and constitutional (50%) symptoms. The mean anterior, middle, and posterior height losses of the fractured vertebral body were 30%, 37%, and 16%, respectively. Twenty percent of fractures were Genant Grade 1 (mild), whereas 32% and 48% were grades 2 (moderate) and 3 (severe). Fifty-five percent of fractures were biconcave, whereas 32% and 13% were wedge and crush fractures. Lower body mass index and albumin and increased myeloma protein, light chains, and creatinine predicted an increased number of fractures at presentation. Increased ß2-microglobulin and creatinine predicted more severe vertebral fractures. CONCLUSIONS: In the present study, 124 fractures were observed among 50 patients. These fractures were generally severe, biconcave, and in the thoracic spine. Laboratory signs of advanced MM predict greater fracture burden and severity. In the future, monitoring of these predictors may raise suspicion for an MM-associated vertebral fracture.