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1.
Am J Otolaryngol ; 45(2): 104185, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38104469

RESUMO

INTRODUCTION: There has been historical controversy regarding the extent of resection in the management of pleomorphic adenomas. This study aims to evaluate the extent of surgery and short-term postoperative outcomes of partial superficial parotidectomy (PSP) for the management of pleomorphic adenomas at a tertiary, high-volume center. METHODS: A retrospective chart review of patients who underwent PSP was performed. Variables included demographics, pre-operative facial nerve function, operative techniques, postoperative complications/facial nerve function, and recurrence. RESULTS: 151 adults who underwent PSP for pleomorphic adenoma from January 1st, 2000 to December 31st, 2022 were identified. Median age was 55 (IQR 40-66) years with females representing 74 % of the cohort. Median tumor size at presentation was 1.8 (IQR 1.3-2.3) cm. Baseline facial nerve function was excellent for most patients (House-Brackmann I, 99 %). Most patients underwent a superficial inferior parotidectomy (88 %). Modified Blair incision (70 %) was the most common incision. Intraoperatively, the facial nerve was identified in 149 (99 %) patients. The main trunk was identified in 126 (85 %) patients. No patient had tumor spillage. Only two patients required parotid bed reconstruction. The most common complication was ear numbness (60 %). Postoperatively, 114 patients were House-Brackmann grade I at both preoperative and postoperative assessment, 8 went from grade I to II, and 1 went from grade VI to II (Bell's palsy that resolved to grade II following surgery). Median follow-up was 1(IQR 1-5) month. CONCLUSION: PSP is efficacious in the management of pleomorphic adenomas with preservation of facial nerve function, and minimal post-operative complications. Future study is needed to assess long term recurrence risk.


Assuntos
Adenoma Pleomorfo , Neoplasias Parotídeas , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Glândula Parótida/cirurgia , Glândula Parótida/patologia , Adenoma Pleomorfo/cirurgia , Adenoma Pleomorfo/patologia , Neoplasias Parotídeas/cirurgia , Neoplasias Parotídeas/patologia , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/patologia , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia
2.
Am J Otolaryngol ; 44(2): 103806, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36842422

RESUMO

BACKGROUND: Parotidectomies have historically been performed on an inpatient basis despite being well-tolerated surgeries with minimal postoperative wound care and low rates of complications at high-volume institutions. Past studies have supported the safety of outpatient surgery for parotidectomy but have been limited to superficial parotidectomy and have not addressed the patient experience surrounding the surgical intervention such as pre-operative and post-operative care and communication. PURPOSE: This study assesses the impact of outpatient superficial, deep, and partial parotid surgery on various parameters including surgical safety, distance traveled for care, utilization of telehealth, and patient-initiated communication. MATERIALS AND METHODS: Retrospective study from January 2020 to October 2021. Patients undergoing superficial lobe, deep lobe, and partial parotidectomies for benign and malignant pathologies were divided into inpatient and outpatient cohorts. A multivariable model examined the relationship between admission status and surgical complications, adjusted for age, sex, and tumor size. RESULTS: 159 patients total, 94 outpatient and 65 inpatients. No statistical difference in rates of surgical complications with the exception of salivary leak. There was an increased rate of salivary leak reported in the inpatient group (OR 5.4, 95 % CI 1.6 to 18.0, p = 0.01). Mean patient travel distance of 354 miles one-way. Post-operatively, 76 % were evaluated via video visit. Following discharge, >55 % of patients initiated communication with the surgical team, which was not statistically different between the groups. CONCLUSIONS: Outpatient parotidectomy is safe and can be more convenient, but telehealth communication must be balanced with rigorous attention to patient education.


Assuntos
Neoplasias Parotídeas , Humanos , Neoplasias Parotídeas/cirurgia , Neoplasias Parotídeas/patologia , Pacientes Ambulatoriais , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/patologia , Glândulas Salivares/patologia , Glândula Parótida/cirurgia , Glândula Parótida/patologia
3.
Ann Surg Oncol ; 29(2): 780-786, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34825282

RESUMO

INTRODUCTION: The effect of neoadjuvant systemic therapies (NST) on technical aspects of operation for resectable stage III melanoma is unknown. Prospective capture of the estimated and actual degree of difficulty of therapeutic lymphadenectomy at presentation and after NST may inform the relative merits of NST versus surgery followed by adjuvant therapy. METHODS: We designed surgeon survey tools to capture key impressions at baseline prior to NST and postoperatively. We conducted a sub-study within a multi-institutional clinical trial for high-risk operable stage III melanoma (NeoACTIVATE, NCT03554083) which enrolls clinically node-positive patients to 12 weeks of combinatorial NST determined by BRAF status. Survey data were analyzed. RESULTS: Surveys were completed for 24 of 25 patients (96%). Affected nodal basins were cervical (3, 13%) axillary (9, 38%), inguinal ± pelvic (14, 58%); 2 (8%) involved ≥ 2 basins. Baseline estimates included largest affected node size (median/range 4/1.4-11 cm), number of involved nodes (median/range 3/1-10) and tumor fixation (present in 12, 50%). At operation, actual degree of difficulty increased from the baseline estimate in 4 (17%) and decreased in 6 (25%). Surgery was less difficult, average, or more difficult versus usual operation in 4, 9, and 11 cases (17%, 38%, 46%), respectively. CONCLUSIONS: Although many operations were judged to be more difficult than the usual therapeutic lymphadenectomy, operation following NST was more often perceived as easier than more difficult versus baseline impression. Engaging surgical oncologists to perform similar structured assessments across clinical trials will permit cross-study analysis of the effect of NSTs on the technical conduct of lymphadenectomy.


Assuntos
Melanoma , Neoplasias Cutâneas , Cirurgiões , Humanos , Excisão de Linfonodo , Melanoma/tratamento farmacológico , Melanoma/cirurgia , Terapia Neoadjuvante , Estadiamento de Neoplasias , Estudos Prospectivos , Neoplasias Cutâneas/tratamento farmacológico , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia
4.
Dermatol Surg ; 48(2): 157-161, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-34889209

RESUMO

BACKGROUND: Limited data exist on sentinel lymph node biopsy (SLNB) for cutaneous squamous cell carcinoma (cSCC) of the head and neck. OBJECTIVE: To review the results of SLNB for patients with cSCC of the head and neck at the authors' institution. MATERIALS AND METHODS: A retrospective review was completed for patients who underwent SLNB for cSCC of the head and neck over 19 years. Patient demographics, immune status, tumor stage, total patients with positive SLNB, local recurrence, nodal recurrence, in-transit metastasis, and disease-specific death were recorded. RESULTS: Sixty patients underwent lymphoscintigraphy, and an SLN was identified in 58 patients. The mean follow-up was 3.2 years (range, 15 days-16 years). Four patients (6.9%) had a positive SLNB. All were Brigham and Women's Hospital (BWH) stage T2b tumors. Three of these patients were immunosuppressed, 3 patients underwent neck dissection, and 2 patients received adjuvant radiation. None developed local or regional recurrence. Of the 53 patients with a negative SLNB, there were 4 local recurrences, 2 in-transit metastases, and no nodal recurrences. CONCLUSION: Immunosuppressed patients with tumors BWH stage T2b or greater may be a reasonable cohort to focus future prospective studies on the utility of SLNB in cSCC of the head and neck.


Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Cutâneas , Adulto , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Linfonodos/patologia , Estudos Prospectivos , Recidiva , Estudos Retrospectivos , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Carcinoma de Células Escamosas de Cabeça e Pescoço/cirurgia
5.
Am J Otolaryngol ; 43(1): 103194, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-34509079

RESUMO

PURPOSE: Determine rates of intra-parotid and neck nodal metastasis, identify risk factors for recurrence, and report outcomes in patients with primary high-grade parotid malignancy who undergo total parotidectomy and neck dissection. MATERIALS & METHODS: Retrospective review of patients undergoing total parotidectomy and neck dissection for high-grade parotid malignancy between 2005 and 2015. The presence and number of parotid lymph nodes, superficial and deep, as well as cervical lymph nodes involved with metastatic disease were assessed. Risk factors associated with metastatic spread to the parotid deep lobe were identified and recurrence rates reported. RESULTS: 75 patients with median follow-up time of 47 months. 35 patients (46.7%) had parotid lymph node metastasis. Seven patients (9.3%) had deep lobe nodal metastasis without metastasis to the superficial lobe nodes. Nine patients (12%) had positive intra-parotid nodes without positive cervical nodes. Cervical nodal disease was identified in 49.3% patients (37/75). Local, parotid-bed recurrence rate was 5.3% (4/75). Regional lymph node recurrence rate was also 5.3% (4/75). Rate of distant metastasis was 30.6% (23/75). The overall disease free survival rate for all patients at 2 and 5 years were 71% and 60% respectively. CONCLUSION: Parotid lymph node metastasis occurred at a similar rate to cervical lymph node metastasis (46.7% and 49.3%, respectively). Deep lobe parotid nodal metastasis occurred in nearly a quarter of patients and can occur without superficial parotid nodal metastasis. Rate of recurrence in the parotid bed, which may represent local or regional recurrence, was similar to regional cervical lymph node recurrence. Total parotidectomy and neck dissection should be considered high-grade parotid malignancy regardless of clinical nodal status.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Esvaziamento Cervical , Glândula Parótida/cirurgia , Neoplasias Parotídeas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Linfonodos/patologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Pescoço , Recidiva Local de Neoplasia/epidemiologia , Estadiamento de Neoplasias , Glândula Parótida/patologia , Neoplasias Parotídeas/mortalidade , Neoplasias Parotídeas/patologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
6.
J Oral Pathol Med ; 49(9): 857-864, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32449549

RESUMO

BACKGROUND: Buccal squamous cell carcinoma (SCC) is a locoregionally aggressive malignancy, representing a small subset of oral cancers in North America. We investigated the prognostic value of several clinicopathologic factors in a cohort of patients diagnosed with buccal SCC. METHODS: Between years 1992 and 2017, 52 patients were diagnosed with conventional buccal SCC. Archival surgical pathology material was retrospectively reviewed for reportable findings according to the latest reporting guidelines published by the College of American Pathologists. Clinical data were obtained through chart review. RESULTS: The majority of patients were of older age, current or past smokers, and without specific gender predilection. Most presented at a clinically advanced stage and were treated with surgery alone, or surgery followed by adjuvant radiotherapy. The tumor recurred in about 40% of patients, and almost half of the patients died from the disease by the end of the follow-up period. The worst pattern of invasion (WPOI) was associated with greater depth of invasion (DOI) (P = .031) and perineural invasion (P < .001). In univariate analyses, older age (P = .004), positive nodal status (P = .047), lymphovascular invasion (P = .012), perineural invasion (P = .05), and WPOI-5 (P = .015) were adverse predictors of 5-year overall survival (OS). In multivariate analysis, older age (P = .011), WPOI-5 (P < .001), and perineural invasion (P = .001) remained statistically significant independent prognosticators of worse 5-year OS. CONCLUSIONS: Older age, WPOI-5, and perineural invasion are significant prognosticators of worse OS. WPOI is associated with DOI, a finding which may have important implications for the pathogenesis and biologic behavior of the disease.


Assuntos
Carcinoma de Células Escamosas , Neoplasias Bucais , Idoso , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/terapia , Humanos , Neoplasias Bucais/patologia , Neoplasias Bucais/cirurgia , Invasividade Neoplásica/patologia , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Estudos Retrospectivos
7.
Am J Otolaryngol ; 41(6): 102642, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32682193

RESUMO

PURPOSE: To compare recurrent pleomorphic adenoma tumor burden as detected on magnetic resonance and computerized tomography imaging with postoperative histopathology. MATERIALS AND METHODS: 44 patients were identified at a tertiary medical center between 2000 and 2015. Patients were included if they had viewable preoperative imaging and a postoperative diagnosis of recurrent pleomorphic adenoma. Primary outcomes were differences in the number and size of lesions detected on imaging and pathology. RESULTS: The size in greatest dimension between pathology and imaging was not significant on aggregate MRI + CT (p = 0.78), MRI (p = 0.41), or CT (p = 0.69). There were more lesions found on pathology compared to both aggregate MRI + CT (p = 0.003) and CT alone (p = 0.014). The number of lesions between MRI and pathology failed to reach significance (p = 0.06). On univariate analysis, the interval between imaging and pathology (recurrent surgery) did not significantly affect the number of lesions detected (p = 0.18). On multivariable analysis, CT as the primary imaging modality and >1 recurrence was independently associated with greater inaccuracy with respect to number of lesions detected (p = 0.006; p = 0.008). CONCLUSION: The size of the largest lesion on pathology can be accurately determined with imaging. Compared to MRI, CT scans significantly underpredict the number of lesions found on pathology. MRI should be prioritized unless contraindications exist. These findings will help guide imaging choice, preoperative planning, and patient counseling.


Assuntos
Adenoma Pleomorfo/diagnóstico por imagem , Adenoma Pleomorfo/patologia , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/patologia , Glândula Parótida/diagnóstico por imagem , Glândula Parótida/patologia , Neoplasias Parotídeas/diagnóstico por imagem , Neoplasias Parotídeas/patologia , Carga Tumoral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X , Adulto Jovem
8.
Am J Otolaryngol ; 40(5): 729-734, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31303455

RESUMO

OBJECTIVES: To review swallowing, airway and speech outcomes following transoral robotic surgery (TORS) ±â€¯adjuvant therapy for human papillomavirus associated oropharyngeal squamous cell carcinoma (HPV[+]OPSCC). METHODS: Patients underwent TORS ± standard adjuvant therapy from 5/1/2007-5/31/2015. Clinical data were recorded and descriptive analysis was performed. RESULTS: 267 patients met criteria. All patients underwent surgery at Mayo, however, only 41/81 and 71/119 patients received RT and CRT at a Mayo Clinic site. A PEG was placed in 77 patients (3 prior to any treatment, 74 reactively during adjuvant therapy), with 3 PEG dependent and 3 partially PEG reliant at last follow-up. Tracheostomy was performed in 30 (11%) patients; 28 were decannulated. Swallow evaluations were completed for 20/81 undergoing RT and 50/119 undergoing CRT at a median of 3.8 and 7.6 months post-treatment, respectively. An unrestricted oral diet was reported by 5% following RT and 12% following CRT on the Functional Oral Intake Scale. HN-PSS normalcy of diet scores indicated a diet beyond soft chewable foods for 27% following RT and 46% following CRT. No restriction of place, food, or companion was reported for the HN-PSS for public eating in 13% after RT and 33% after CRT. Aspiration of thin liquid was present in 17% and 28% following RT and CRT, respectively. HN-PSS understandability of speech was "always understandable" in 60% and 63%, following RT and CRT, respectively. Hoarseness was reported in 56% and 45% following RT and CRT respectively. CONCLUSION: Long-term PEG and tracheostomy dependence in this cohort is low. However, these outcomes under-represent the decrement in patient speech and swallowing following TORS ± standard adjuvant therapy for HPV(+)OPSCC.


Assuntos
Carcinoma de Células Escamosas/cirurgia , Cirurgia Endoscópica por Orifício Natural/métodos , Neoplasias Orofaríngeas/cirurgia , Papillomaviridae/isolamento & purificação , Infecções por Papillomavirus/epidemiologia , Procedimentos Cirúrgicos Robóticos/métodos , Centros Médicos Acadêmicos , Adulto , Idoso , Institutos de Câncer , Carcinoma de Células Escamosas/epidemiologia , Carcinoma de Células Escamosas/patologia , Estudos de Coortes , Nutrição Enteral/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota , Boca , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Neoplasias Orofaríngeas/diagnóstico , Neoplasias Orofaríngeas/epidemiologia , Infecções por Papillomavirus/diagnóstico , Cuidados Pós-Operatórios/métodos , Prognóstico , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Estatísticas não Paramétricas , Traqueostomia/métodos , Resultado do Tratamento
10.
Histopathology ; 70(7): 1021-1029, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27926789

RESUMO

Understanding the structure and function of the oropharynx is paramount for providing excellent patient care. In clinical oncology, the oropharynx is generally divided into four distinct components: (i) the base of the tongue; (ii) the soft palate; (iii) the palatine tonsillar fossa; and (iv) the pharyngeal wall. The oropharyngeal mucosa is distinct from other mucosal surfaces in the body, as it is composed of a reticulated epithelium with a discontinuous basement membrane, also known as lymphoepithelium. This review describes the anatomy, histology, immunology and surgical resection of the oropharynx as they relate to oncological care.


Assuntos
Orofaringe/anatomia & histologia , Carcinoma de Células Escamosas/imunologia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Neoplasias de Cabeça e Pescoço/imunologia , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Neoplasias Orofaríngeas/imunologia , Neoplasias Orofaríngeas/patologia , Neoplasias Orofaríngeas/cirurgia , Orofaringe/imunologia , Orofaringe/cirurgia , Carcinoma de Células Escamosas de Cabeça e Pescoço
11.
Am J Otolaryngol ; 38(5): 537-541, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28662971

RESUMO

PURPOSE: The utility of sentinel lymph node biopsy in desmoplastic melanoma has been questioned due to multiple reports of a low rate of occult nodal metastasis in this variant of melanoma. We describe a single institution experience with management of desmoplastic melanoma of the head and neck and discuss the utility of sentinel lymph node biopsy. MATERIALS AND METHODS: A retrospective review was performed of 49 patients with desmoplastic melanoma of the head and neck at a tertiary care center from 1994 to 2014. RESULTS: Sentinel lymph node biopsy was performed in 15 patients. Only 1 (6.7%) of these patients was found to have a positive sentinel node. Of the 46 patients without evidence of neck disease at presentation, 3 (6.5%) were found to have occult nodal disease or developed neck recurrences. When looking at the entire cohort, there were a total of 16 recurrences in 14 patients (28.6%). The majority (85.7%) of recurrences were either local or distant metastasis with only 2 (14.3%) recurrences being in regional lymph node basins. The overall rates of local, regional, and distant recurrences were 14.2%, 4.1%, and 10.2% respectively. The mixed pathologic subtype was not associated with a higher rate of nodal metastasis. CONCLUSIONS: Desmoplastic melanoma has a low rate of occult nodal metastasis and a high propensity to recur locally or as a distant metastasis, regardless of regional node status. Our experience combined with the uncertain impact that sentinel node status has on survival raises the question of the utility of routine sentinel node biopsy in this specific variant of melanoma.


Assuntos
Neoplasias de Cabeça e Pescoço/patologia , Melanoma/patologia , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Masculino , Melanoma/mortalidade , Melanoma/terapia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/terapia , Taxa de Sobrevida , Melanoma Maligno Cutâneo
12.
Am J Otolaryngol ; 36(6): 820-2, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26545479

RESUMO

PURPOSE: Radial forearm free flaps (RFFFs) and fibular osteocutaneous flaps (FOFs) are mainstays of head and neck reconstruction. Removal of the donor tissue often leaves a soft tissue defect requiring a split thickness skin graft (STSG) for coverage. The purpose of this study is to evaluate the potential to reduce the morbidity of removal of the STSG from a second site. MATERIALS AND METHODS: We report a series of 9 patients who had the STSG taken from the free flap donor skin paddle as an alternative to removal from the standard distant sight. RESULTS: 9/9 (100%) flaps were successfully transferred with no primary or secondary loss of the flap. 8/9 (89%) of STSGs were successfully harvested from the donor skin paddle. Postoperative complications included infection and partial STSG loss (2/9, 22%). CONCLUSIONS: This study demonstrates the feasibility and reduced morbidity associated with removal of the STSG from the donor flap skin paddle in addition to the placement of a de-epithelialized free flap in head and neck reconstruction patients. Given this research, which supports the previously published research on this topic, this technique could be considered in an effort to reduce morbidity in patients undergoing head and neck reconstruction using the RFFF and FOF.


Assuntos
Retalhos de Tecido Biológico/transplante , Transplante de Pele/métodos , Sítio Doador de Transplante , Adolescente , Adulto , Idoso , Criança , Feminino , Fíbula/cirurgia , Antebraço/cirurgia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos , Adulto Jovem
13.
Neurosurg Focus ; 37(4): E16, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25270135

RESUMO

OBJECT: Swallowing dysfunction is common following transoral (TO) odontoidectomy. Preliminary experience with newer endoscopic transnasal (TN) approaches suggests that dysphagia may be reduced with this alternative. However, the reasons for this are unclear. The authors hypothesized that the TN approach results in less disruption of the pharyngeal plexus and anatomical structures associated with swallowing. The authors investigate the histological and gross surgical anatomical relationship between pharyngeal plexus innervation of the upper aerodigestive tract and the surgical approaches used (TN and TO). They also review the TN literature to evaluate swallowing outcomes following this approach. METHODS: Seven cadaveric specimens were used for histological (n = 3) and gross anatomical (n = 4) examination of the pharyngeal plexus with the TO and TN surgical approaches. Particular attention was given to identifying the location of cranial nerves (CNs) IX and X and the sympathetic chain and their contributions to the pharyngeal plexus. S100 staining was performed to assess for the presence of neural tissue in proximity to the midline, and fiber density counts were performed within 1 cm of midline. The relationship between the pharyngeal plexus, clivus, and upper cervical spine (C1-3) was defined. RESULTS: Histological analysis revealed the presence of pharyngeal plexus fibers in the midline and a significant reduction in paramedian fiber density from C-2 to the lower clivus (p < 0.001). None of these paramedian fibers, however, could be visualized with gross inspection or layer-by-layer dissection. Laterally based primary pharyngeal plexus nerves were identified by tracing their origins from CNs IX and X and the sympathetic chain at the skull base and following them to the pharyngeal musculature. In addition, the authors found 15 studies presenting 52 patients undergoing TN odontoidectomy. Of these patients, only 48 had been swallowing preoperatively. When looking only at this population, 83% (40 of 48) were swallowing by Day 3 and 92% (44 of 48) were swallowing by Day 7. CONCLUSIONS: Despite the midline approach, both TO and TN approaches may injure a portion of the pharyngeal plexus. By limiting the TN incision to above the palatal plane, the surgeon avoids the high-density neural plexus found in the oropharyngeal wall and limits injury to oropharyngeal musculature involved in swallowing. This may explain the decreased incidence of postoperative dysphagia seen in TN approaches. However, further clinical investigation is warranted.


Assuntos
Deglutição/fisiologia , Endoscopia/métodos , Nariz/cirurgia , Processo Odontoide/cirurgia , Análise de Variância , Cadáver , Feminino , Nervo Glossofaríngeo/metabolismo , Nervo Glossofaríngeo/cirurgia , Humanos , Masculino , Proteínas S100/metabolismo
14.
Laryngoscope ; 2024 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-38963264

RESUMO

OBJECTIVE: The use of composite chondromucosal nasal septal flaps (ccNSF) has been demonstrated to be effective in cadaveric studies for the anterior skull base and the orbit. However, their application in the clinical setting remains unexplored. Our study aims to introduce a new method for treating palatal defects using ccNSF. Additionally, we studied the average NSF area and compared it to the average palate area. METHODS: We collected 108 CT scans from the medical records of patients without head and neck pathologies from a tertiary medical institution. We quantified the quadrangular (septal) cartilage and palate areas. Furthermore, we included a clinical case in which we used the ccNSF for the palatal defect reconstruction. This was to compare the mean area between the palate and the septal cartilage. RESULTS: The ccNSF covered the palatal defect without any significant complications for the first 9 months of follow-up. A total of 102 CT scans met the inclusion criteria and were measured. We found that the mean quadrangular cartilage had a length of 2.50 (±0.52) cm, a width of 2.28 (±0.51) cm, and an area of 5.43 (±1.68) cm2. The mean palate length was 2.73 (±0.44) cm, with a width of 3.13 (±0.34) cm, and area of 7.87 (±1.43) cm2. CONCLUSIONS: The ccNSF proved successful in palatal defect reconstruction, resulting in positive outcomes and no major complications until the 9-month follow-up. The ccNSF is a useful flap that avoids the use of free flap transfer and its associated morbidities. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

15.
Oral Oncol ; 152: 106809, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38621326

RESUMO

OBJECTIVES: Blood-based multi-cancer early detection (MCED) tests are now commercially available. However, there are currently no consensus guidelines available for head and neck cancer (HNC) providers to direct work up or surveillance for patients with a positive MCED test. We seek to describe cases of patients with positive MCED tests suggesting HNC and provide insights for their evaluation. METHODS: Retrospective chart review of patients referred to Otolaryngology with an MCED result suggesting HNC. Patients enrolled in prospective MCED clinical trials were excluded. Cancer diagnoses were confirmed via frozen-section pathology. RESULTS: Five patients were included (mean age: 69.2 years, range 50-87; 4 male) with MCED-identified-high-risk for HNC or lymphoma. Only patient was symptomatic. After physical exam and follow-up head and neck imaging, circulating tumor HPV DNA testing, two patients were diagnosed with p16 + oropharyngeal squamous cell carcinomas and underwent appropriate therapy. A third patient had no evidence of head and neck cancer but was diagnosed with sarcoma of the thigh. The remaining two patients had no evidence of malignancy after in-depth workup. CONCLUSIONS: In this retrospective study, 2 of 5 patients referred to Otolaryngology with a positive MCED result were diagnosed with HPV + oropharyngeal squamous cell carcinoma. We recommend that positive HNC MCED work up include thorough head and neck examination with flexible laryngoscopy and focused CT or MRI imaging. Given the potential for inaccurate MCED tissue of origin classification, PET/CT may be useful in specific situations. For a patient with no cancer identified, development of clear guidelines is warranted.


Assuntos
Detecção Precoce de Câncer , Neoplasias de Cabeça e Pescoço , Humanos , Masculino , Idoso , Pessoa de Meia-Idade , Feminino , Detecção Precoce de Câncer/métodos , Neoplasias de Cabeça e Pescoço/diagnóstico , Neoplasias de Cabeça e Pescoço/cirurgia , Neoplasias de Cabeça e Pescoço/patologia , Idoso de 80 Anos ou mais , Estudos Retrospectivos , Encaminhamento e Consulta
16.
Med Sci Educ ; 34(3): 617-626, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38887403

RESUMO

Objectives: To report implementation and outcomes associated with a novel paid Summer Undergraduate Research Education Program (SREP) over the first 2 years in an academic otolaryngology program recruiting students underrepresented in medicine (URiM). Methods: A 10-week program including a research bootcamp, curriculum, mentoring, and clinical shadowing was created. Grant funding to provide salary and support for transportation, conference attendance, and graduate school preparation or applications was procured. Primary objectives included (1) development of successful mentorship relationships; (2) increasing student-reported outcomes using pre- and post-program surveys to assess confidence, career planning, and overall satisfaction; (3) increasing exposure to medicine; (4) completion of an oral presentation; and (5) submission of a manuscript. Secondary objectives included abstract submission and completion of a graduate exam course or graduate school applications. Tertiary objectives included conference attendance and graduate school matriculation. Results: One hundred thirty-five total applications were reviewed (89 from year 1 and 46 from year 2). Twelve students were interviewed for 3 spots in year 1, while 11 students were interviewed for 6 spots in year 2 (median application score, 9.25 (range, 1-14); median interview score, 8.7 (range, 5.4-10); acceptance rate, 6.7% (9/135)). Students met all primary objectives. Mean program survey scores increased from 3.8 to 4.77 (p < 0.0001). Eight of nine students submitted an abstract to a national conference, with five of eight students accepted for a presentation. Two students were accepted into graduate school, while five others are on track for graduate school application. Conclusion: Identifying mentors, curriculum, and opportunities to meaningfully strengthen graduate school applications for URiM students through a clinically rigorous, financially supported, and research-focused summer program in an academic otolaryngology program is feasible and may be an effective means of increasing diversity in medicine and otolaryngology. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-024-02021-z.

17.
Nat Commun ; 15(1): 1430, 2024 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-38365756

RESUMO

Both targeted therapies and immunotherapies provide benefit in resected Stage III melanoma. We hypothesized that the combination of targeted and immunotherapy given prior to therapeutic lymph node dissection (TLND) would be tolerable and drive robust pathologic responses. In NeoACTIVATE (NCT03554083), a Phase II trial, patients with clinically evident resectable Stage III melanoma received either 12 weeks of neoadjuvant vemurafenib, cobimetinib, and atezolizumab (BRAF-mutated, Cohort A, n = 15), or cobimetinib and atezolizumab (BRAF-wild-type, Cohort B, n = 15) followed by TLND and 24 weeks of adjuvant atezolizumab. Here, we report outcomes from the neoadjuvant portion of the trial. Based on intent to treat analysis, pathologic response (≤50% viable tumor) and major pathologic response (complete or near-complete, ≤10% viable tumor) were observed in 86.7% and 66.7% of BRAF-mutated and 53.3% and 33.3% of BRAF-wild-type patients, respectively (primary outcome); these exceeded pre-specified benchmarks of 50% and 30% for major pathologic response. Grade 3 and higher toxicities, primarily dermatologic, occurred in 63% during neoadjuvant treatment (secondary outcome). No surgical delays nor progression to regional unresectability occurred (secondary outcome). Peripheral blood CD8 + TCM cell expansion associated with favorable pathologic responses (exploratory outcome).


Assuntos
Anticorpos Monoclonais Humanizados , Azetidinas , Melanoma , Piperidinas , Neoplasias Cutâneas , Humanos , Melanoma/tratamento farmacológico , Melanoma/etiologia , Vemurafenib/uso terapêutico , Terapia Neoadjuvante , Proteínas Proto-Oncogênicas B-raf/genética , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Cutâneas/tratamento farmacológico , Neoplasias Cutâneas/etiologia , Mutação
18.
Oral Oncol ; 149: 106675, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38211528

RESUMO

OBJECTIVES: Social determinants of health (SDOH) can influence access to cancer care, clinical trials, and oncologic outcomes. We investigated the association between SDOH, distance from treatment center, and treatment type with outcomes in human papillomavirus associated oropharyngeal squamous cell carcinoma [HPV(+)OPSCC] patients treated at a tertiary care center. STUDY DESIGN: Retrospective review. METHODS: HPV(+)OPSCC patients treated surgically from 2006 to 2021 were selected from our departmental Oropharyngeal Cancer RedCap database. Demographic data, treatment, and oncologic outcomes were extracted. Distance was calculated in miles between the centroid of each patient zip code and our hospital zip code (zipdistance). RESULTS: 874 patients (89 % male; mean age: 58 years) were identified. Most patients (96 %) reported Non-Hispanic White as their primary race. 204 patients (23 %) had a high-school degree or less, 217 patients (25 %) reported some college education or a 2-year degree, 153 patients (18 %) completed a four-year college degree, and 155 patients (18 %) had post-graduate degrees. Relative to those with a high-school degree, patients with higher levels of education were more likely to live further away from our institution (p < 0.0001). Patients who received adjuvant radiation therapy elsewhere lived, on average, 104 miles further away than patients receiving radiation at our institution (Estimate 104.3, 95 % CI 14.2-194.4, p-value = 0.02). In univariable Cox PH models, oncologic outcomes did not significantly differ by zipdistance. CONCLUSIONS: Education level-and access to resources-varied proportionally to a patient's distance from our center. Patients travelling further distances for surgical management of OPSCC were more likely to pursue adjuvant radiation therapy at an outside institution. Distance traveled was not associated with oncologic outcomes. Breaking down barriers to currently excluded populations may improve access to clinical trials and improve oncologic outcomes for diverse patient populations.


Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Infecções por Papillomavirus , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Papillomavirus Humano , Carcinoma de Células Escamosas/patologia , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/patologia , Determinantes Sociais da Saúde , Neoplasias Orofaríngeas/patologia , Estudos Retrospectivos , Neoplasias de Cabeça e Pescoço/complicações
19.
Ann Otol Rhinol Laryngol ; 132(2): 173-181, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35249359

RESUMO

BACKGROUND: Instruments to assess surgical skills have been validated for several key indicator procedures in otolaryngology. Selective neck dissection is a core procedure for which trainees must integrate knowledge of complex head and neck anatomy with technical surgical skills. An instrument for assessment of surgical performance in selective neck dissection has not been previously developed. The objective of the current study is to develop and validate an instrument for assessing surgical competency for level II-IV selective neck dissection. DESIGN: A Delphi working group comprised of 23 fellowship trained head and neck surgeons from 17 institutions was assembled. The modified Delphi method encompassed a 3-step process, including 2 anonymous voting rounds to successively refine individual items and establish levels of consensus. Thresholds for achieving strong consensus, at >80% agreement, were determined a priori. The resulting instrument was subsequently validated in a prospective cohort of 17 resident surgeons, spanning postgraduate year 1 to 5 training experience. Participants were asked to perform a level II-IV selective neck dissection on fresh-frozen cadaveric specimens. Performance was scored by 2 independent, blinded observers using the devised instrument and construct validity was assessed. RESULTS: Through the modified Delphi process a final list of 30 items, considered to be the most essential items for achieving the goals of a level II-IV selective neck dissection, was developed. Construct validity was supported by a positive association between instrument scores compared to both resident postgraduate year level and number of head and neck rotations completed. CONCLUSION: The development and validation of a novel instrument for assessment of surgical competency in level II-IV selective neck dissection, a key indicator case in otolaryngology, is described. This new instrument may be used to provide objective feedback on overall and task-specific competency to identify surgical deficiencies and offer granular feedback to enhance surgical training.


Assuntos
Internato e Residência , Otolaringologia , Humanos , Esvaziamento Cervical , Estudos Prospectivos , Otolaringologia/educação , Avaliação Educacional , Competência Clínica
20.
Oral Oncol ; 147: 106608, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37897858

RESUMO

GOAL: We performed a systematic review of the literature and meta-analysis to determine how radiographic sarcopenia assessment methods and the presence of pre-treatment sarcopenia impact oncologic outcomes in patients with oral cavity cancer. INTRODUCTION: Pre-treatment sarcopenia has been associated with poor outcomes in many different malignancies, including head and neck cancers. However, the impact sarcopenia has on outcomes for oral cavity cancer patients is not well understood. RESULTS: Twelve studies met our inclusion criteria, totaling 1007 patients. 359 (36%) of these patients were reported as sarcopenic. The most commonly utilized sarcopenia assessment methods were L3 skeletal muscle index (n = 5) and C3 skeletal muscle index to estimate L3 skeletal muscle index (n = 5). The majority of studies established their sarcopenia cutoffs as the lowest quartile skeletal muscle index in their patient cohorts. Five studies were included in our meta-analysis, totaling 251 sarcopenic and 537 non-sarcopenic patients. Compared to non-sarcopenic patients, sarcopenic patients were found to have significantly poorer overall survival (univariate: HR = 2.24, 95% CI: 1.71-2.93, I2 = 0%; multivariate: HR = 1.93, 95% CI: 1.47-2.52, I2 = 0%) and disease-free survival (univariate: HR = 2.10, 95% CI: 1.50-2.92, I2 = 0%; multivariate: HR = 1.79, 95% CI: 1.29-2.47, I2 = 10%). CONCLUSIONS: Over one-third of oral cavity cancer patients may present with sarcopenia. Pre-treatment sarcopenia is associated with significantly worse overall and disease-free survival.


Assuntos
Neoplasias de Cabeça e Pescoço , Neoplasias Bucais , Sarcopenia , Humanos , Sarcopenia/complicações , Prognóstico , Músculo Esquelético/patologia , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias Bucais/complicações , Neoplasias Bucais/terapia , Neoplasias Bucais/patologia , Estudos Retrospectivos
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