Not just snot: Local inflammatory profiles in patients with aspirin-exacerbated respiratory disease differ from patients with aspirin-tolerant chronic rhinosinusitis.

KEY POINTS: IL-5, CCL2, and CXCL8 in sinus mucous are higher in patients with AERD relative to aspirin-tolerant patients with CRS These mediators are pleiotropic, leading to widescale inflammatory processes contributing to AERD AERD is not only a T2 disease but heterogeneous: this may explain the refractory nature of AERD.

Local cytokine levels associate with SNOT-22 and UPSIT scores in chronic rhinosinusitis.

KEY POINTS: Elevated IL-5, IL-13, IL-33, and CCL2 correlate with lower UPSIT scores in CRS and AERD patients. Elevated IL-5, IL-13, TNF-α, CCL2, and CXCL-8 correlate with higher SNOT-22 scores in CRS and AERD patients.

Validation of a questionnaire assessing smell loss in an international aspirin-exacerbated respiratory disease population.

Background: Olfactory dysfunction (OD) and smell loss affects aspects of patients' everyday life and lowers their quality of life. OD questionnaires are considered one of the core-outcome measures in chronic rhinosinusitis, but many existing smell loss questionnaires contained pandemic-prohibitive questions on social gatherings or restaurant visits, were too culture specific or gender specific, or were overly long and cumbersome. Objective: We aimed to develop a new brief questionnaire to assess the impact and consequences of smell loss and its burden on daily life. This study validates this new, short, multicultural, dichotomized questionnaire in an international population that has aspirin-exacerbated disease (AERD). Methods: The Consequences of Smell Loss (COSL) questionnaire was developed and content validity was assessed by experts and patients at Brigham and Women's Hospital. The questionnaire, along with other validated quality-of-life surveys, was answered by 853 patients with AERD. We evaluated the factor structure, reliability, validity, and discriminative ability of the COSL questionnaire. Results: The final version of the COSL questionnaire consisted of 13 items divided into three subdomains (emotional distress, food and safety, and physical health) through factor analysis. The Cronbach α for internal consistency was 0.82. Convergent and discriminant validity with the 22-item Sinonasal Outcome Test (SNOT-22), Healthy Days Core Module-4, Patient Health Questionnaire-4, and a specific question on taste and smell were high (p < 0.0001 for all). The COSL questionnaire score was associated with SNOT-22 categories (p < 0.001) and was categorized as follows: normal, 0-1 points; very few consequences, 2-3 points; few, 4 points; moderate, 5-6 points; and severe, 7-13 points. Conclusion: The COSL questionnaire is a new, brief, valid, reliable tool that can effectively screen for a high burden of OD in patients with AERD and has the potential to be used in other patient populations with OD as well.

Cluster Analysis of Finnish Population-Based Adult-Onset Asthma Patients.

BACKGROUND: Phenotypes of adult asthma have been identified in previous studies but rarely in population-based settings. OBJECTIVE: To identify clusters of adult-onset asthma in a Finnish population-based study on subjects born before 1967. METHODS: We used population-based data from 1350 asthmatics with adult-onset asthma (Adult Asthma in Finland) from Finnish national registers. Twenty-eight covariates were selected based on literature. The number of covariates was reduced by using factor analysis before cluster analysis. RESULTS: Five clusters (CLU1-CLU5) were identified, 3 clusters with late-onset adult asthma (onset ≥40 years) and 2 clusters with onset at earlier adulthood (<40 years). Subjects in CLU1 (n = 666) had late-onset asthma and were nonobese, symptomatic, and predominantly female with few respiratory infections during childhood. CLU2 (n = 36) consisted of subjects who had earlier-onset asthma, were predominantly female, obese with allergic asthma, and had recurrent respiratory infections. Subjects in CLU3 (n = 75) were nonobese, older, and predominantly men with late-onset asthma, smoking history, comorbidities, severe asthma, least allergic diseases, low education, many siblings, and childhood in rural areas. CLU4 (n = 218) was a late-onset cluster consisting of obese females with comorbidities, asthma symptoms, and low education level. Subjects in CLU5 (n = 260) had earlier onset asthma, were nonobese, and predominantly allergic females. CONCLUSIONS: Our population-based adult-onset asthma clusters take into account several critical factors such as obesity and smoking, and identified clusters that partially overlap with clusters identified in clinical settings. Results give us a more profound understanding of adult-onset asthma phenotypes and support personalized management.

The effect of single kinetic oscillation stimulation treatment on nonallergic rhinitis.

Objective: Kinetic oscillation stimulation (KOS) is a new treatment method for nonallergic rhinitis (NAR), usually delivered twice with a 2- to 4-week interval, and thought to stabilize autonomous dysregulation in the nasal mucosa. We aimed to assess the long-term (1 year) results following one KOS treatment amongst patients with NAR. Methods: KOS was administered through a latex balloon placed in the patient's nasal cavity. The balloon is connected to a device that fills the balloon with air pulses, thus vibrating the balloon for 10 min per side. Outcomes were evaluated through patient-reported outcome measures (Sino-Nasal Outcome Test 22 [SNOT-22], Total Nasal Symptom Score [TNSS], Nasal Obstruction Symptom Evaluation [NOSE], and 15D) and measures of patency (rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow [PNIF], and clinical inferior turbinate size). Pre-treatment actions were repeated at 1, 3, 6, and 12 months. Results: In all 49 patients, we found significant improvement in the SNOT-22, NOSE, and TNSS scores. At 12 months, SNOT-22 improved from 44 to 34, NOSE from 60 to 45, TNSS from 8 to 7, and PNIF from 80 to 100 L/min (p < .005 for all). We observed no major complications. Conclusion: One KOS treatment appears to provide NAR patients with a subjective symptom improvement for at least 1 year, thus possibly decreasing the need for invasive treatment methods. Level of Evidence: III.

Frontal Sinus Balloon Sinuplasty-Patient Satisfaction and Factors Predicting Reoperation.

Objective: To explore predictive factors of postoperative outcome of frontal sinus balloon dilation. Study Design: Retrospective questionnaire study. Setting: Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Finland. Methods: We reviewed electronic records of all patients who underwent frontal sinus balloon dilatation (successful or attempted) in our clinic from 2008 to 2019. We documented patient characteristics, preoperative imaging results, intraoperative factors, possible complications, and reoperations. Those who underwent frontal sinus balloon sinuplasty were sent a questionnaire regarding their current symptoms and long-term satisfaction with surgery. Results: In total, 258 operations (404 frontal sinuses) were reviewed, with a technical success rate of 93.6% (n = 378). The revision rate was 15.7% (n = 38). Previous sinonasal surgery predicted a higher revision rate (p = .004, odds ratio [OR] = 3.03, 95% confidence interval [CI] 1.40-6.56). Patients with hybrid surgery had significantly fewer reoperations compared to the balloon only group (p = .002, OR = 0.33, 95% CI 0.16-0.67). The response rate of the questionnaire was 64.5% (n = 156), of which 88.5% (n = 138) reported a long-term benefit from the balloon sinuplasty. Patient satisfaction was higher (p = .02, OR = 8.26, 95% CI 1.06-64.24) among patients using nasal corticosteroids. Conclusion: Technical success rate and patient satisfaction after frontal sinus balloon sinuplasty are high. Balloon sinuplasty seems insufficient in reoperations. A hybrid approach appears to result in fewer reoperations than a balloon only approach.

Long-Term Follow-Up After Maxillary Sinus Balloon Sinuplasty and ESS.

OBJECTIVES: The aim of this controlled follow-up study was to compare the need for revision surgery, long-term efficacy, and satisfaction in chronic rhinosinusitis patients who had undergone maxillary sinus operation with either balloon sinuplasty or traditional endoscopic sinus surgery (ESS) technique. METHODS: Thirty-nine ESS patients and 36 balloon patients of our previously described cohort, who had been primarily operated in 2008 to 2010, were contacted by phone. Symptoms, satisfaction, and need for revision surgery were asked. In addition, we collected data of patients who had undergone primary maxillary sinus balloon sinuplasty in the Helsinki University Hospital during the years 2005 to 2019. As a control group, we collected data of patients who had undergone primary maxillary sinus ESS at 3 Finnish University Hospitals, and 1 Central Hospital in years 2005, 2008, and 2011. RESULTS: Altogether, 77 balloon patients and 82 ESS patients were included. The mean follow-up time was 5.3 years in balloon group and 9.8 years in ESS group. Revision surgery was performed on 17 balloon patients and 6 ESS patients. In the survival analysis, the balloon sinuplasty associated significantly with a higher risk of revision surgery compared to ESS. According to the phone interviews, 82% of ESS patients and 75% of balloon patients were very satisfied with the primary operation. CONCLUSION: Although the patient groups expressed equal satisfaction and change in symptoms after the operations, the need for revision surgery was higher after balloon sinuplasty than after ESS. This should be emphasized when counselling patients regarding surgical options.

Real-Life Experience of Biologic Treatment for Asthma on Chronic Rhinosinusitis: A Finnish Cohort.

INTRODUCTION: Biologics are used in the treatment of severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). The purpose of this retrospective study was to evaluate the effects of biologics initiated for asthma on coexistent CRS and the influence of comorbid factors, including aspirin-exacerbated respiratory disease (AERD) and secretory otitis media (SOM). METHODS: A review of electronic health records (2009-2020) at a Finnish tertiary center was conducted to identify CRS patients treated with biologics for their asthma. We identified the type of biologic and treatment response, by comparing nasal polyp score (NPS), sinonasal outcome test (SNOT)-22, need for oral corticosteroids (OCS) and antibiotics, frequency of visits, and endoscopic sinus surgeries (ESS) pretreatment and during treatment. RESULTS: 55 patients were treated with anti-immunoglobulin E (IgE) (n = 18) or anti-interleukin-5/5-receptor (IL-5/5R) (n = 37) biologics. Treatment lasted for an average of 4.1 years. Seventy-five percent (n = 41) had CRSwNP and 25% (n = 14) had CRSsNP. Of all patients, 24% (n = 13) had comorbid AERD and 22% (n = 12) had SOM. Biologic therapy reduced the need for OCS courses (anti-IgE, n = 17, p = 0.03; anti-IL-5/5R, n = 35, p = 0.01) and for daily OCS in anti-IL-5/5R (n = 35, p = 0.001) but not in anti-IgE patients (n = 16, p = 0.07). Biologics also improved NPS by 0.5 point (n = 32, p = 0.009) and SNOT-22 by 14 points (n = 7, p = 0.02) in CRSwNP patients. The overall discontinuation rate was 37.7% (n = 20) and was independent of type of biologic. CONCLUSION: Treatment with anti-IgE and/or anti-IL-5/5R biologics reduced the overall need for OCS medication in individuals with asthma and concomitant CRS, but despite this, the discontinuation rate was high.

Loss of smell in patients with aspirin-exacerbated respiratory disease impacts mental health and quality of life.

BACKGROUND: The impact of anosmia on quality-of-life (QoL) for patients with aspirin-exacerbated respiratory disease (AERD) is poorly understood. We aimed to investigate how the severity of smell loss and olfactory dysfunction (OD) in patients with AERD affects their QoL, mental health and physical well-being. METHODS: Five validated QoL questionnaires (Sinonasal Outcome Test-22, Asthma Control Test, Healthy Days Core Module-4, Short Form-36 and Patient Health Questionnaire-4) and two newly developed questionnaires assessing severity and consequences of OD were electronically sent to all 2913 patients in the Brigham and Women's Hospital AERD registry. Responses were received from 853 participants for analysis. RESULTS: Overall, 85% of participants reported a present diminished sense of smell and/or taste, and 30% categorized their OD severity was, "as bad as it can be." There were significant relationships between the severity of self-reported OD and both psychological distress and general health scores, even after adjusting for asthma control. Additionally, incidence rates for physically and mentally unhealthy days in the prior month were higher for patients with moderate or severe OD than for normosmic patients. Patients with diminished smell responded that they could not identify spoiled food (86%), did not enjoy food (71%), felt unsafe (63%) and had encountered dangerous situations (51%) as consequences of their OD. CONCLUSIONS: Anosmia and hyposmia severely impact the physical, emotional and mental health of AERD patients, and lead to safety concerns in their daily lives. The importance of olfaction and the relevance of OD to patients' QoL should be acknowledged and evaluated by clinicians caring for these patients.

Effect of alar nasal valve stent on nasal breathing.

PURPOSE: Lateral nasal wall insufficiency has previously been a surgical challenge. In 2018, the Alar Nasal Valve Stent (Medtronic) was taken into use at Helsinki University Hospital. The alar cartilages are repositioned and locked into position with the Alar Nasal Valve Stent on the mucosa. The stent gives support and widens the alar valve while cartilages scar into their new position presumably facilitating breathing after removal of the stent. The aim of this prospective, observational study was to investigate whether the Alar Nasal Valve Stent has an effect on nasal breathing in patients with lateral nasal wall insufficiency. MATERIALS AND METHODS: Symptom questionnaires (Sino-Nasal Outcome Test-22, Nasal Obstruction Symptom Evaluation, five-step symptom score) were analyzed preoperatively and at 3, 6, and 12 months postoperatively. Acoustic rhinometry, rhinomanometry, and peak nasal inspiratory flow were analyzed preoperatively and 3 months postoperatively. The patients performed a stress ergometry preoperatively and 3 months postoperatively, with their noses being photographed and filmed. RESULTS: In a series of 18 patients, a significant positive difference was seen in subjective symptom scores preoperatively versus postoperatively. The difference remained stable throughout the follow-up. No difference in objective symptom measurements was observed. CONCLUSIONS: Patients suffering from lateral nasal wall insufficiency experience a significant subjective improvement in nasal breathing after Alar Nasal Valve Stent surgery.

Effects of social distancing on the incidence of Bell's palsy and sudden sensorineural hearing loss.

BACKGROUND: The aetiology of idiopathic facial nerve palsy (Bell's palsy, BP) and sudden sensorineural hearing loss (SSNHL) are not known. It has been proposed that common respiratory tract viruses play a part in the pathophysiology of these diseases. OBJECTIVES: The incidence of many infectious diseases decreased during the lockdown of the society that took place during the COVID-19 pandemic. We investigated a possible change in the incidence of BP and SSNHL during the lock-down. MATERIAL AND METHODS: We searched the patient records for all BP and SSNHL cases between 1 Jan 2017 - 31 Aug 2020 at the hospital district of Helsinki and Uusimaa that covers a population of about 1.2 million. RESULTS: The mean monthly incidence on BP decreased during the COVID-19 pandemic lock-down. No change in the SSNHL incidence was discovered. CONCLUSIONS AND SIGNIFICANCE: There is reason to speculate that one aetiologic reason for BP are transmittable respiratory tract pathogens.

One dose of preoperative, intravenous, prophylactic antibiotics significantly lowers postoperative infection rate in septoplasty-a study of 772 operations.

OBJECTIVES: Postoperative infection is the most common complication after septoplasty. Pre- or postoperative prophylactic antibiotics are commonly used, although no official guidelines exist. DESIGN: We retrospectively collected data on postoperative infections from 772 septoplasties performed in 2015, 2016 and 2018, and classified the infections according to surgical site infection (SSI) criteria by the Centers for Disease Control and Prevention (CDC). We evaluated the infections according to antibiotic use (preoperative or postoperative, both, or none) and accounted for patient and surgical confounding factors. We compared the results with three previous studies from our department to find out the trend in the occurrence of postoperative infections and in the use of antibiotics. RESULTS: Twenty-nine cases (3.8%) fulfilled CDC infection criteria. Any kind of antibiotic prophylaxis reduced the risk of SSI (p = .018). One dose of intravenous cefuroxime before incision was the most effective preventive measure (p = .045). We found no significant effect of postoperative antibiotics. However, postoperative antibiotics lowered the infection rate to 1.8% compared to 6.1% among those not treated with any antibiotics. The only other factor reducing the risk of SSI was local anaesthesia compared with general anaesthesia. CONCLUSION: Preoperative antibiotic prophylaxis effectively reduced postoperative infection rate after septoplasty.

Pathomechanisms of AERD-Recent Advances.

The pathomechanisms behind NSAID-exacerbated respiratory disease are complex and still largely unknown. They are presumed to involve genetic predisposition and environmental triggers that lead to dysregulation of fatty acid and lipid metabolism, altered cellular interactions involving transmetabolism, and continuous and chronic inflammation in the respiratory track. Here, we go through the recent advances on the topic and sum up the current understanding of the background of this illness that broadly effects the patients' lives.

Low-phase angle in body composition measurements correlates with prolonged hospital stay in head and neck cancer patients.

BACKGROUND: Bioelectrical impedance analysis (BIA) is a method for estimating body composition. Clinically the most important parameter is the phase angle (PA), which decreases with progressing malnutrition and is highly predictive for impaired survival and mortality. AIM: To evaluate the association of low PA with the complication rate and length of hospital stay. MATERIAL AND METHODS: A cohort of 61 head and neck cancer (HNC) patients underwent BIA prior to surgical treatment. Information on patient and tumour characteristics, treatment, and surgical complications were gathered from hospital records and correlated with BIA results. RESULTS: The median PA was 4.5 (range, 2.7-6.5), and, in 67% of the patients, it was lower than reference values. Low PA was associated with longer hospital stay (p = .002) in the whole cohort and in the patient group with radical neck dissections it correlated with a higher surgical complication rate (p = .014), but not with Clavien-Dindo scoring for surgical complications. CONCLUSIONS AND SIGNIFICANCE: BIA is a feasible instrument for analysing body composition that reflects nutritional status in cancer patients. Our results show that HNC patients have a low PA at diagnosis. Low PA is associated with a long hospital stay and an increase in the complication rate. BIA can be of clinical value in preoperative risk evaluation.

Different rhinologic diseases cause a similar multidimensional decrease in generic health-related quality of life.

BACKGROUND: Previous studies illustrated that chronic rhinosinusitis and allergic rhinitis represent individual and socioeconomic burdens to a patient. However, few studies exist on the health-related quality of life (HRQoL) amongst other rhinologic patients. Our study investigated the generic HRQoL in different rhinologic diseases. METHODOLOGY: Unselected adult rhinologic patients requiring special care at the Helsinki University Hospital were enrolled in this cross-sectional, questionnaire-based prospective study in February, May, August and November 2014. Patients were mailed a medical history questionnaire and a generic 15-dimension (15D) HRQoL questionnaire. Diagnostic data were collected from electronic patient records following outpatient visits. Patient HRQoL scores were compared to an age- and sex-standardised general population sample obtained from a large national health examination survey. RESULTS: This study consisted of 337 rhinologic patients (mean age 50.2 years, 50.4% men). The mean 15D score amongst rhinologic patients (0.865) was both statistically significant and clinically poorer than that amongst the general population (0.929). Rhinologic patients fared poorly on most dimensions of the 15D instrument, particularly on sleep, discomfort and symptoms, breathing and vitality. Patients with obstructive sleep apnoea (OSA) were particularly affected. Yet, comparing the five most common rhinologic diagnostic groups revealed no significant differences in the mean 15D scores. CONCLUSIONS: Rhinologic diseases, independent of the underlying cause, substantially and negatively affect patients' HRQoL. OSA decreases HRQoL in these patients, although patients without an OSA diagnosis still suffer from a clinically important impairment of HRQoL and poor quality sleep.

A Prospective Observational Study of Complications in 140 Sialendoscopies.

Objectives To evaluate the incidence and nature of complications associated with diagnostic and interventional sialendoscopies and to report intervention failures in a prospective setup. Study Design Prospective observational study. Setting Academic tertiary care university hospital. Subjects and Methods Patients who underwent diagnostic or interventional sialendoscopy between October 2015 and December 2016 were prospectively enrolled. Patient data, operation-related factors, treatment failures, and complications were recorded into a database and analyzed. Results A total of 140 sialendoscopies were attempted or performed on 118 patients; 67 (48%) were for a parotid gland and 73 (52%) for a submandibular gland. The sialendoscopy was interventional in 81 cases (58%), diagnostic in 56 (40%), and not possible to perform in 3 (2.1%). A total of 21 complications were registered for 21 sialendoscopies (15%) and 21 patients (18%). The most common complication was infection, in 9 cases (6.4%). Other observed complications were salivary duct perforation (4 cases), prolonged glandular swelling (3 cases), transient lingual nerve analgesia (2 cases), basket entrapment (2 cases), and transient weakness in the marginal branch of the facial nerve (1 case). All complications were related to interventional procedures or papilla dilatation. Failure to treat occurred in 21 (15%) sialendoscopies: sialendoscopy itself was unsuccessful in 3 cases, and an intended intervention failed in 18 cases. Conclusion Complications in sialendoscopy are usually related to interventional procedures. The complications are mainly minor and temporary but lead to additional follow-up visits, further treatments, and sometimes hospitalization. Sialendoscopic procedures are safe but not free of complications.

Presenting symptoms and clinical findings in HPV-positive and HPV-negative oropharyngeal cancer patients.

OBJECTIVES: Oropharyngeal squamous cell carcinoma (OPSCC) is divided in two different disease entities depending on HPV involvement. We investigated differences in presenting symptoms and clinical findings in patients with HPV-positive and -negative OPSCC tumors. METHODS: Altogether 118 consecutive patients diagnosed with primary OPSCC between 2012 and 2014 at the Helsinki University Hospital were included. HPV-status of the tumors was assessed by PCR detection of HPV DNA and immunostaining with p16-INK4a antibody. RESULTS: Fifty-one (47.7%) of the patients had HPV-positive and 56 (52.3%) HPV-negative tumors. Forty-nine (49/51, 96.1%) of the HPV+ tumors were also p16+ showing high concordance. The most common presenting symptom among HPV+/p16+ patients was a neck mass (53.1%), whereas any sort of pain in the head and neck area was more frequently related to the HPV-/p16- (60.0%) group. HPV+/p16+ tumors had a tendency to locate in the tonsillar complex and more likely had already spread into regional lymph nodes compared with HPV-/p16- tumors. Smoking and heavy alcohol consumption were significantly more common among HPV−/p16− patients but also rather common among HPV+/p16+ patients [corrected]. CONCLUSIONS: This analysis of symptoms and signs confirm that OPSCC can be dichotomized in two distinct disease entities as defined by HPV status.

Bioelectrical impedance analysis of head and neck cancer patients at presentation.

CONCLUSION: Finnish head and neck cancer (HNC) patients show signs of severe malnutrition already at presentation, measured by bioelectric impedance analysis (BIA). BIA may be a practical method to detect malnutrition, analyze body composition, and to identify high-risk patients in this population. OBJECTIVES: BIA is a validated method for evaluating body composition and detecting malnutrition. Low phase angle (PA) is associated with increased mortality and morbidity. Vector analysis (BIVA) provides a qualitative measure for hydration and cell mass, independent of body size. This study describes BIA results in Finnish HNC patients at presentation. METHODS: Forty-one newly-diagnosed HNC patients at the Helsinki University Hospital were included. BIA measures (resistance, reactance, PA, fat-free mass index [FFMI], and fat mass index [FMI]), body mass index (BMI), and Charlson Comorbidity Index (CCI) were determined. RESULTS: The majority of patients were men (78%), with a normal average BMI of 25.2. Low FFMI was seen in 44% of women and 28% of men. The PA (median = 4.6; IQ range = 4-5) was lower than the reference values in 76% (n = 31) of cases. In BIVA, only 13 (32%) of the patients were within normal range and 15 (37%) were plotted in the quadrant indicating malnutrition.

Immunohistochemical Staining of Histological Fragments Derived from Salivary Gland Tumour Fine-Needle Biopsy Aspirates.

OBJECTIVES: The aim of this study was to describe a method for analysing histological fragments derived from fine- needle aspirate biopsy (FNAB) of salivary gland tumours (SGTs), and to evaluate the use of immunohistochemistry (IHC) on them. STUDY DESIGN: We reviewed all 509 FNAB pathology reports taken from SGTs at Helsinki University Hospital, Finland, between 1999 and 2009. In 51% of the cases (n = 209) "histo-fragments" had been obtained and 31 had been further analysed by IHC. Of these, 25 (81%) were available for review. We evaluated the benefit of IHC by relating its added value to the preoperative cytological diagnosis and its accuracy compared with the postoperative histological diagnosis. RESULTS: Most of the samples analysed by IHC were assigned a malignant diagnosis, with 12 different types of malignancy represented. IHC was advantageous in 76% of the cases. In the 108 studies using IHC in this series, antibodies to 36 different antigens were used. CONCLUSION: Analysis of histo-fragments in FNABs using IHC can be valuable in specific differential diagnostics and raises diagnostic accuracy in SGTs.

Association of BMI-1 and p16 as prognostic factors for head and neck carcinomas.

CONCLUSIONS: BMI-1 is an upstream repressor of tumor suppressor p16 and their inverse expression patterns have been linked with patient survival in OPSCC. In this material only p16 remained a relevant prognostic marker in OPSCC. OBJECTIVES: HNSCC tumors carry variable phenotypes and clinical outcomes depending on their anatomical location. In OPSCC, expression of tumor suppressor p16 is used as a surrogate marker of HPV infection and has prognostic value. There are no good prognostic biomarkers for HNSCC tumors of other anatomical locations. AIM: To study the expression patterns of p16 and BMI-1 in not only oropharyngeal but also oral, hypopharyngeal, and laryngeal squamous cell carcinomas and to clarify their putative connections with clinical parameters, survival, and each other. METHOD: Hospital records on 130 patients (59 OPSCC, 18 OSCC, 20 HPSCC, and 33 LSCC) diagnosed between 1997-2008 at the Helsinki University Hospital, Finland, were reviewed. BMI-1 and p16 expressions were studied by immunohistochemistry. RESULTS: Sixty-eight per cent of OPSCC expressed p16 and expression correlated with lower age, lower T- and higher N-category, and with improved OS and DFS. BMI-1 expression was most prevalent in OPSCC and LSCC, but had no clinical correlations. No correlation between p16 and BMI-1 expression was found.