Nasal and paranasal sinus mucosal melanoma: Long-term survival outcomes and prognostic factors.

OBJECTIVE: To determine prognostic factors and survival patterns for different treatment modalities for nasal cavity (NC) and paranasal sinus (PS) mucosal melanoma (MM). METHODS: Patients from 1973 to 2013 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier method and multivariable cox proportional hazard modeling were used for survival analyses. RESULTS: Of 928 cases of mucosal melanoma (NC = 632, PS = 302), increasing age (Hazard Ratio [HR]:1.05/year, p < 0.001), T4 tumors (HR: 1.81, p = 0.02), N1 status (HR: 6.61, p < 0.001), and PS disease (HR: 1.50, p < 0.001) were associated with worse survival. Median survival length was lower for PS versus NC (16 versus 26 months, p < 0.001). Surgery and surgery + radiation therapy (RT) improved survival over non-treatment or RT alone (p < 0.001). Adding RT to surgery did not yield a survival difference compared with surgery alone (p = 0.43). Five-year survival rates for surgery and surgery + RT were similar, at 27.7% and 25.1% (p = 0.43). CONCLUSION: Surgery increased survival significantly over RT alone. RT following surgical resection did not improve survival.

Predictive factors for prolonged operative time in head and neck patients undergoing free flap reconstruction.

PURPOSE: Defining the predictive factors associated with prolonged operative time may reduce post-operative complications, improve patient outcomes, and decrease cost of care. The aims of this study are to 1) analyze risk factors associated with prolonged operative time in head and neck free flap patients and 2) determine the impact of lengthier operative time on surgical outcomes. METHODS: This retrospective cohort study evaluated 282 head and neck free flap reconstruction patients between 2011 and 2013 at a tertiary care center. Perioperative factors investigated by multivariate analyses included gender, age, American Society of Anesthesiologists class, tumor subsite, stage, flap type, preoperative comorbidities, and perioperative hematocrit nadir. Association was explored between operative times and complications including flap take back, flap survival, transfusion requirement, flap site hematoma, and surgical site infection. RESULTS: Mean operative time was 418.2 ± 88.4 (185-670) minutes. Multivariate analyses identified that ASA class III (beta coefficient + 24.5, p = .043), stage IV tumors (+34.8, p = .013), fibular free flaps (-44.8, p = .033 for RFFF vs. FFF and - 67.7, p = .023 for ALT vs FFF) and COPD (+36.0, p = .041) were associated with prolonged operative time. History of CAD (-43.5, p = .010) was associated with shorter operative time. There was no statistically significant association between longer operative time and adverse flap outcomes or complications. CONCLUSION: As expected, patients who were medically complex, had advanced cancer, or underwent complex flap reconstruction had longer operative times. Surgical planning should pay special attention to certain co-morbidities such as COPD, and explore innovative ways to minimize operative time. Future research is needed to evaluate how these factors can help guide planning algorithms for head and neck patients.

Prognostic factors and survival for malignant conjunctival melanoma and squamous cell carcinoma over four decades.

PURPOSE: To determine the epidemiology and survival of primary conjunctival malignant neoplasms. METHODS: Retrospective analysis of primary malignant conjunctival neoplasms using Surveillance, Epidemiology, and End Results database from 1973 to 2012. RESULTS: Of 1661 cases, the most common neoplasms are squamous cell carcinoma (SCC) at 54.8% and melanoma at 38.8%. Mean diagnostic age for melanoma was 62.1 compared to 65.5 years for SCC (p = 0.002). 52.2% of melanoma are male versus 77.4% of SCC (p < 0.001). For SCC only age (HR: 1.09, 95% CI:1.04-1.14) is a predictor of survival. For melanoma, age (HR: 1.07, 95% CI: 1.05-1.10), male sex (HR: 2.04, 95% CI: 1.16-3.60), T4 tumors (HR: 3.38, 95% CI: 1.17-9.80) and N1 status (HR: 8.69, 95% CI: 2.75-27.42) are all survival predictors. The 5 and 10-year overall survival (OS) estimates are not significantly different between SCC and melanoma, with 70% and 50% respectively for SCC, and 71% and 50% respectively for melanoma. Median survival time is worse for blacks (52 months) compared to whites (118 months) and Asians/Native Americans/Pacific Islanders (145 months), however race was not found to be a significant prognostic factor in multivariate analysis. Five-year survival are similar between decades 1973-1982 (66.2%), 1983-1992 (69.2%), 1993-2002 (71.3%) and 2003-2012 (70.2%). CONCLUSION: Age at diagnosis is a determinant of survival for both conjunctival SCC and melanoma. Male sex, T4 and N1 staging are also important prognostic factors for melanoma. With respect to overall survival, SCC and melanoma did not differ significantly.

Preoperative laboratory data are associated with complications and surgical site infection in composite head and neck surgical resections.

OBJECTIVES: 1) Describe normal/abnormal preoperative laboratory testing incidence in head and neck (H&N) composite resections and 2) determine complication, surgical site infection (SSI), and transfusion predictors by laboratory test. METHODS: The 2006 to 2013 NSQIP databases were queried for H&N composite resections. Laboratory data was categorized within, under, or above the normal reference range according to NSQIP definitions. Overall complications and SSI were analyzed with multivariable logistic regression analysis. RESULTS: From 2006 to 2013, there were 1193H&N composite resections, of which 1135 (95.1%) underwent ≥1 preoperative laboratory test. Complete blood counts were obtained in 92.3%, basic metabolic panels in 90.7%, coagulation studies in 56.2%, and liver function tests (LFTs) in 52.6%. Low sodium was found in 11.5%, increasing complication odds by 2.30 (p = 0.005). High AST comprised 10.0% and increased complication odds (OR = 2.93, p = 0.012). Additionally, 9.2% had a high white blood cell (WBC) count and 3.5% had high platelets, increasing complications by 1.92 (p = 0.030) and 3.13 (p = 0.015), respectively. BUN, creatinine, total bilirubin, albumin, alkaline phosphatase, INR, PT, and aPTT abnormal values did not affect postoperative complications. Increased SSI odds were appreciated with low sodium (OR: 2.83, p = 0.002), high AST (OR: 6.85, p < 0.001), and high alkaline phosphatase (OR: 5.46, p = 0.007). Importantly, INR had no effect on transfusion rates. High PT, aPTT, or low platelets did not change transfusion odds. CONCLUSION: Inflammatory markers are associated with complications but not SSI. High LFTs and low sodium are associated with complications and SSI. Coagulopathies did not increase transfusion rates. These findings identify laboratory studies to focus on during H&N resection preoperative assessments.

Repair of complex pharyngocutaneous fistula using a staged temporoparietal fascial flap.

INTRODUCTION: PCF is the most common major complication after salvage total laryngectomy (TL), especially for previously irradiated patients with laryngeal or hypopharyngeal cancer. METHODS/RESULTS: A 65-year-old woman presented with recurrent bilateral supraglottic SCC requiring salvage TL 5.5years after initial T1N0M0 epiglottic SCC resection. Her post-operative course was complicated by PCF development one month post-operatively and surgical fistula closure was delayed for adjuvant chemoradiotherapy. The fistula persisted despite local wound therapy, several primary closures, pectoralis flap reconstruction with multiple revisions, and extensive hyperbaric oxygen treatments. Given her prior history, she underwent a staged right temporoparietal fascial flap reconstruction for persistent complex fistula, with second-stage flap takedown and complete inset of the TPFF skin island into the PCF. CONCLUSION: This case demonstrates the utility of staged TPFF in complex PCF repair, with minimal morbidity, especially in a patient with prior irradiation and flap use that complicates tissue availability.

Adjuvant radiotherapy mitigates impact of perineural invasion on oncologic outcomes in early-stage oral cavity squamous cell carcinoma. A multi-institutional analysis of 557 patients.

OBJECTIVES: Understand the prognostic impact of perineural invasion (PNI) in early-stage oral cavity squamous cell carcinoma (OCSCC). Assess the influence of adjuvant radiotherapy on outcomes of patients with PNI-positive early-stage OCSCC. MATERIALS AND METHODS: Retrospective seven-institution cohort study including patients with pathologic T1-2 N0-1 OCSCC who underwent primary surgery with negative margins. Outcomes included disease-free survival (DFS) and locoregional control (LRC). Cox proportional hazards models were used to evaluate oncologic outcomes. Interaction terms were introduced to assess relationships between PNI and adjuvant radiotherapy. RESULTS: Among 557 patients (mean (SD) age 61.0 (13.9), 47.2% female, 66.6% pathologic T1, 93.5% pathologic N0), 93 had PNI-positive tumors, among which 87.1% underwent neck dissection and 39.6% received radiotherapy. On multivariable analysis, PNI was associated with lower DFS and LRC. Adjuvant radiotherapy was not associated with improved outcomes on multivariable analysis of the entire cohort. However, among patients with PNI-positive tumors, adjuvant radiotherapy significantly decreased hazard for DFS. CONCLUSION: Among patients with low-risk, early-stage OCSCC, PNI was associated with worse DFS and LRC. In patients with PNI-positive tumors, adjuvant radiotherapy lowered hazard for DFS on multivariable analysis. These data support using adjuvant radiotherapy for patients with early-stage OCSCC with PNI.

Submental Island Flap After Prior Contralateral Neck Dissection: A Case Series and Technical Considerations.

OBJECTIVES: The submental island flap is a dependable workhorse in head and neck reconstruction. However, the viability of this flap has not been established for oral cavity reconstruction when a contralateral neck dissection has already been performed in an earlier surgical setting. The aim of this study is to highlight technical considerations and outcomes of this approach with a small case series. METHODS: Three cases of oral cavity reconstruction with a submental island flap elevated in the context of a prior contralateral neck dissection are presented. RESULTS: In all cases, a doppler was used to identify the maintenance of the submental perforator in the neck opposite the previous neck dissection. In 2 cases, level IA was included within the dissection field of the previous neck dissection. Additionally, the old neck scar was included within the skin paddle of the submental island flap in 2 cases. In all cases, excellent healing of the flap was observed without partial or complete loss. CONCLUSIONS: The submental island flap appears to be a reliable reconstruction when a previous contralateral neck dissection has been performed, even when level IA was included in the prior dissection.

Insurance Status Effect on Laryngeal Cancer Survival: A Population Based Study.

OBJECTIVE: To analyze insurance status effect on overall survival (OS) and disease-specific survival (DSS) in laryngeal cancer. STUDY DESIGN: Cross-sectional population analysis. SETTING: Surveillance, Epidemiology, and End Results (SEER) database. PARTICIPANTS: Laryngeal cancer patients from 2007 to 2016. MAIN OUTCOME MEASURES: Kaplan-Meier method with log-rank statistic analyzed OS and DSS by insurance status. Multivariable cox proportional hazard modeling generated survival prognostic factors. RESULTS: Of 19 667 laryngeal cancer cases, initial disease presentation was stage I: 7770 patients (39.5%), stage II: 3337 patients (17.0%), stage III: 3289 patients (16.7%), and stage IV: 5226 patients (26.6%). Patients had non-Medicaid insurance (15 523, 78.9%), had Medicaid (3306, 16.8%), or were uninsured (891, 4.5%). Mean and median OS for insured, Medicaid, and uninsured patients were 60.5, 49.6, and 56.6 and 74.0, 40.0, and 65.0 months, respectively. Following multivariable analysis, OS for insured, Medicaid, and uninsured patients was stage I: 87.9, 82.8, and 88.4 (P < .001), stage II: 79.1, 75.1, and 78.3 (P = .12), stage III: 68.7, 66.1, and 72.1 (P = .11), and stage IV: 57.1, 51.7, and 50.3 (P < .001) months. DSS mean survival times were 77.0, 65.8, and 67.7 months (P < .001) for insured, Medicaid, and uninsured patients. Age (HR: 1.02/year, P < .001) and black (HR: 1.15, P = .001) compared to white race predicted worse survival. Compared to insured status, Medicaid insurance carried a death hazard ratio of 1.40 (P < .001) and uninsured status had a death hazard ratio of 1.40 (P < .001). CONCLUSION: Insured laryngeal cancer patients had prolonged OS and DSS compared to Medicaid and uninsured patients. Medicaid patients had equivalent survival outcomes to uninsured patients. LEVEL OF EVIDENCE: 2c.

Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVE: To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting. STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary center. METHODS: A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS. RESULTS: A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus-associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC. CONCLUSIONS: Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.

YAP1 maintains active chromatin state in head and neck squamous cell carcinomas that promotes tumorigenesis through cooperation with BRD4.

Analysis of The Cancer Genome Atlas and other published data of head and neck squamous cell carcinoma (HNSCC) reveals somatic alterations of the Hippo-YAP pathway in approximately 50% of HNSCC. Better strategies to target the YAP1 transcriptional complex are sought. Here, we show that FAT1, an upstream inhibitor of YAP1, is mutated either by missense or by truncating mutation in 29% of HNSCC. Comprehensive proteomic and drug-screening studies across pan-cancer models confirm that FAT1-mutant HNSCC exhibits selective and higher sensitivity to BRD4 inhibition by JQ1. Epigenomic analysis reveals an active chromatin state in FAT1-mutant HNSCC cells that is driven by the YAP/TAZ transcriptional complex through recruitment of BRD4 to deposit active histone marks, thereby maintaining an oncogenic transcriptional state. This study reveals a detailed cooperative mechanism between YAP1 and BRD4 in HNSCC and suggests a specific therapeutic opportunity for the treatment of this subset of head and neck cancer patients.

One institution's experience with self-audit of opioid prescribing practices for common cervical procedures.

BACKGROUND: We aim to audit our institution's opioid prescribing practices after common cervical procedures. METHODS: Retrospective cohort study from one medical center. Reviewed records from 2016-2019 for 472 patients who underwent one of several common cervical procedures. Data collected on demographics, perioperative details, in-hospital pain medication use, and opioids prescribed at discharge. Multivariable logistic regression was run. RESULTS: In hospital, median daily milligram morphine equivalents (MME) was 4 (IQR 0-15). Median MME prescribed at discharge was 112.5 MME (IQR 75-150). 3/472 patients received NSAIDs. Predictors of decreased discharge MME were age 70 and older (OR 0.33, p = 0.037) and more recent year (compared to 2016, OR 0.23 [p = 0.031] for 2017, OR 0.13 [p = 0.001] for 2018, and OR 0.070 [p < 0.001] for 2019). CONCLUSIONS: MME prescribed at discharge was 28 times the daily in-hospital MME. Only 3/472 patients received postoperative NSAIDs. Self-auditing of opioid prescribing practices identifies actionable items for change.

Opioid Usage and Prescribing Predictors Following Transoral Robotic Surgery for Oropharyngeal Cancer.

OBJECTIVE/HYPOTHESIS: Pain management following transoral robotic surgery (TORS) varies widely. We aim to quantify opioid usage following TORS for oropharyngeal squamous cell carcinoma (OPSCC) and identify prescribing predictors. STUDY DESIGN: Retrospective cohort study. METHODS: A consecutive series of 138 patients undergoing TORS for OPSCC were reviewed from 2016 to 2019. Opioid usage (standardized to morphine milligram equivalents [MME]) was gathered for 12 months post-surgery via prescribing record cross-check with the Massachusetts Prescription Awareness Tool. RESULTS: Of 138 OPSCC TORS patients, 92.8% were human papillomavirus (HPV) positive. Adjuvant therapy included radiation (XRT;67.4%) and chemoradiation (cXRT;6.5%). Total MME usage from start of treatment averaged 1395.7 MMEs with 76.4% receiving three prescriptions or less. Categorical analysis showed age <65, male sex, overweight BMI, lower frailty, former smokers, HPV+, higher T stage, and BOT subsite to be associated with increased MMEs. Adjuvant therapy significantly increased MMEs (TORS+XRT:1646.2; TORS+cXRT:2385.0; TORS alone:554.7 [P < .001]) and 12-month opioid prescription totals (TORS+XRT:3.2; TORS+cXRT:5.5; TORS alone:1.6 [P < .001]). Adjuvant therapy increased time to taper (total MME in TORS alone versus TORS+XRT/cXRT: 0 to 3 months:428.2 versus 845.5, 4 to 6 months:46.8 versus 541.8, 7 to 9 months:12.4 versus 178.6, 10 to 12 months:11.0 versus 4.4,[P < .001]). Positive predictors of opioid prescribing at the 4- to 6-month and 4- to 12-month intervals included adjuvant therapy (odds ratio [OR]:5.56 and 4.51) and mFI-5 score ≥3 (OR:36.67 and 31.94). Following TORS at 6-, 9-, and 12-month, 15.7%, 6.6%, and 4.1% were still using opioids. CONCLUSIONS: In OPSCC treated with TORS, opioid use tapers faster for surgery alone versus with adjuvant therapy. Opioid prescribing risks include adjuvant therapy and higher frailty index. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1888-E1894, 2021.

Impact of surgical margins on local control in patients undergoing single-modality transoral robotic surgery for HPV-related oropharyngeal squamous cell carcinoma.

BACKGROUND: The impact of close surgical margins on oncologic outcomes in HPV-related oropharyngeal squamous cell carcinoma (HPV + OPSCC) is unclear. METHODS: Retrospective case series including patients undergoing single modality transoral robotic surgery (TORS) for HPV + OPSCC at three academic medical centers from 2010 to 2019. Outcomes were compared between patients with close surgical margins (<1 mm or requiring re-resection) and clear margins using the Kaplan-Meier method. RESULTS: Ninety-nine patients were included (median follow-up 21 months, range 6-121). Final margins were close in 22 (22.2%) patients, clear in 75 (75.8%), and positive in two (2.0%). Eight patients (8.1%) recurred, including two local recurrences (2.0%). Four patients died during the study period (4.0%). Local control (p = 0.470), disease-free survival (p = 0.513), and overall survival (p = 0.064) did not differ between patients with close and clear margins. CONCLUSIONS: Patients with close surgical margins after TORS for HPV + OPSCC without concurrent indications for adjuvant therapy may be considered for observation alone.

Neuromonitored Thyroid Surgery: Optimal Stimulation Based on Intraoperative EMG Response Features.

OBJECTIVES: To evaluate/compare normative electrophysiologic electromyography (EMG) response characteristics of recurrent laryngeal, vagus, and external branch of superior laryngeal nerve evoked with different stimulators used in neuromonitored thyroid surgery. STUDY DESIGN: Prospective crossover study METHODS: EMG responses obtained via endotracheal tube surface electrodes in 11 patients undergoing thyroid surgery were recorded when stimulated with four stimulators: two monopolar (Prass standard and ball tip), one bipolar, and one dissecting instrument. Normative mean EMG results including latency, amplitude, threshold, saturation currents, and distance-sensitivity were compared. RESULTS: The Prass standard stimulator had shorter latency time when nerve was not covered with fascia (P = .04). The bipolar, dissecting instrument, and ball tip demonstrated similar latency times with and without nerve fascia. Pooled mean latency increased significantly from 1.86 ms to 2.16 ms when comparing nerves without fascia and nerves with fascia (P < .05). The Prass standard monopolar stimulator had the lowest mean threshold at 0.40 mA, with the dissecting instrument having the highest threshold at 0.89 mA for dissected nerve. Pooled mean threshold and saturation increased from 0.6 mA to 1.7 mA (P < .0001) and 1.57 mA to 4.15 mA (P < .001) with fascia covering nerve, respectively. The mean depolarization rate was 100% for monopolar and bipolar electrodes and 81% for dissecting instrument at 1 mA. Only 9% of monopolar electrodes generated an EMG response when stimulated from 2 mm away. CONCLUSION: Monopolar stimulators are more sensitive for neural mapping, whereas bipolar instruments are more specific, thus reducing false positive stimulation. Dissecting instruments share many features of monopolar stimulators while being more specific, and thus are a viable alternative. LEVEL OF EVIDENCE: 2b Laryngoscope, 2020.

Intralaryngeal paraganglioma workup and discussion of surgical approach.

Laryngeal paragangliomas are an uncommon presentation of head and neck paragangliomas, with laryngeal paragangliomas along with a synchronous paraganglioma being exceptionally rare. We present two challenging cases of laryngeal paragangliomas with extralaryngeal extension, completely resected through a transcervical approach without endolaryngeal disruption, with one case having synchronous bilateral carotid body tumours. Both patients had excellent results with complete tumour resection and no resultant functional impact. The surgical approaches for large laryngeal paraganglioma are discussed with considerations for endolaryngeal, transcervical and combined approaches as well as decision-making when approaching these rare lesions in the setting of synchronous head and neck paragangliomas.

RUVBL1 is an amplified epigenetic factor promoting proliferation and inhibiting differentiation program in head and neck squamous cancers.

Mutations in histone modifying enzymes and histone variants were identified in multiple cancers in The Cancer Genome Atlas (TCGA) studies. However, very little progress and understanding has been made in identifying the contribution of epigenetic factors in head and neck squamous cell carcinoma (HNSCC). Here, we report the identification of RUVBL1 (TIP49a), a component of the TIP60 histone modifying complex as being amplified and overexpressed in HNSCC. RUVBL1 plays a key role in incorporating histone variant H2AZ in chromatin thereby regulating transcription of key genes involved in differentiation, cancer cell proliferation and invasion. H2AZ is also overexpressed in HNSCC tumors thereby regulating RUVBL1/H2AZ dependent transcriptional programs. Patient data analysis of multiple cohorts including TCGA and single cell HNSCC data indicated RUVBL1 overexpression as a poor prognostic marker and predicts poor survival. In vitro experiments indicate a pro-proliferative role for RUVBL1/H2AZ in HNSCC cells. RUVBL1 inversely correlates with differentiation program and positively correlates with oncogenic programs, making it a key contributor to tumorigenesis and a vulnerable therapeutic target in HNSCC patients.

Preoperative anemia displays a dose-dependent effect on complications in head and neck oncologic surgery.

INTRODUCTION: Anemia's effect on head and neck surgical complications is unknown. METHODS: Head and neck cancer operations were acquired from the 2006 to 2013 American College of Surgeons National Surgical Quality Improvement Program databases. Anemia was defined as <39% or <36% hematocrit in men and women, respectively. Multivariable logistic regression analyses were performed. RESULTS: Major head and neck surgery patients had a 44.2% anemia incidence (n = 527 of 1193). Anemic patients had increased complication rates (27.1%) and mortality (2.1%) vs non-anemic patients at 19.8% (P = .003) and 0.5% (P = .009), respectively. There was a significant difference in morbidity odds with hematocrit >27% (odds ratio [OR] = 1.09) vs <27% (OR = 4.22). Complication odds were further increased with hematocrit between 24% and 27% (OR = 8.94). There were increased rates of wound dehiscence (6.6% vs 2.7%, P < .001), pneumonia (8.5% vs 4.7%, P = .006), and myocardial infarction (1.7% vs 0.3%, P = .01) in anemic vs non-anemic patients. CONCLUSION: Anemia was associated with increased morbidity at hematocrit <27%. An inverse dose-dependent effect of decreasing hematocrit was observed for overall morbidity.

Primary intraosseous mucoepidermoid carcinoma of the mandible: radiographic evolution and clinicopathological features.

Mucoepidermoid carcinoma (MEC) can be rarely found as a primarily intraosseous lesion and mistaken for other intraosseous or odontogenic pathology. A 65-year-old man had a poorly defined radiolucency distal to the left mandibular second molar root. Periapical radiographs demonstrated a minor radiolucency from 2.5 years prior. An oral and maxillofacial surgeon felt the radiolucency represented periodontal disease, extracting tooth #18. The differential diagnosis of mixed radiolucent/radio-opaque mandibular lesions includes: (1) fibro-osseous lesion, (2) odontogenic and non-odontogenic cyst, (3) infection and inflammatory lesion, or (4) benign or malignant neoplasm (odontogenic, non-odontogenic, or metastatic). Histological analysis revealed low-grade MEC. A composite resection was performed with a 1 cm margin from first molar to ascending ramus. A buccal fat pad advancement flap covered the defect with an iliac crest bone graft placed later for a resulting osseous defect. Careful examination and diagnostic work-up for odontogenic cysts should be provided as they may harbour malignant tumours.

Intraoperative cardiac arrest etiologies in head and neck surgery: A comprehensive review.

BACKGROUND: The etiologies of intraoperative cardiac arrest within otolaryngology are not well understood as they are rare events. METHODS: A comprehensive review of the etiologies and corresponding pathophysiologic neural mechanisms of intraoperative cardiac arrest in otolaryngologic surgery are examined. RESULTS: The occurrence of this rare complication has been described in a range of head and neck procedures, including but not limited to suspension laryngoscopy and oncologic resections in the neck, maxilla and thyroid. Three anatomically distinct pathways leading to intraoperative cardiac arrest are described: direct vagal stimulation, the trigeminocardiac reflex and the baroreceptor reflex. All three share the final common pathway of parasympathetic signaling to the sinoatrial node via the cardiac fibers of the vagus nerve. CONCLUSION: With a firm understanding of the mechanistic underpinning of this rare phenomenon, otolaryngologic surgeons can be better prepared for its occurrence.