Search

Assess the testing rates and prognostic significance of human papilloma virus (HPV) status in hypopharynx malignancies.Historical cohort study.National Cancer Database.Review of the National Cancer Database was conducted between 2010 and 2017 for squamous cell carcinomas (SCCs) of the hypopharynx. We investigated how often the tumors were tested for HPV and whether it was associated with survival outcomes.A total of 13,269 patients with hypopharynx malignancies were identified. Most cases were not tested for HPV status (n = 8702, 65.6%). Of those tested, 872 (19.1%) were positive for HPV and 3695 (80.9%) were negative. The proportion of nonoropharyngeal SCCs tested for HPV increased nearly every year during the study, with roughly one-third of cases (31.9%) being tested in 2017. In the facilities classified as high-testing centers of nonoropharyngeal SCCs of the head and neck, 18.7% of hypopharyngeal tumors were HPV positive. HPV-negative status was associated with worse survival on multivariable analysis. In propensity score-matched analysis controlling for all factors significant in multivariable regression, 2-year survival remained higher in the HPV-positive cohort (77.7% vs 63.1%,HPV-positive tumors constitute a sizable minority of hypopharynx tumors and are associated with improved survival. Expansion of HPV testing to hypopharynx malignancies may be warranted.

Venous congestion accounts for most microvascular free tissue flaps failures. Given the lack of consensus on the use of single versus dual venous outflow, the authors present our institutional experience with 1 versus 2 vein anastomoses in microvascular free flap for head and neck reconstruction. A retrospective chart review was performed on all patients undergoing free flaps for head and neck reconstruction at our institution between 2008 and 2020. The authors included patients who underwent anterolateral thigh, radial forearm free flap, or fibula free flaps. The authors classified patients based on the number of venous anastomoses used and compared complication rates. A total of 279 patients with a mean age of 55.11 years (standard deviation 19.31) were included. One hundred sixty-eight patients (60.2%) underwent fibula free flaps, 59 (21.1%) anterolateral thigh, and 52 (18.6%) radial forearm free flap. The majority of patients were American Society of Anesthesiologists classification III or higher (N = 158, 56.6%) and had history of radiation (N = 156, 55.9%). Most flaps were performed using a single venous anastomosis (83.8%). Univariate analysis of postoperative outcomes demonstrated no significant differences in overall complications (P = 0.788), flap failure (P = 1.0), return to the Operating Room (OR) (P = 1.0), hematoma (P = 0.225), length of hospital stay (P = 0.725), or venous congestion (P = 0.479). In our cohort, the rate of venous congestion was not statistically different between flaps with 1 and 2 venous anastomoses. Decision to perform a second venous anastomoses should be guided by anatomical location, vessel lie, flap size, and intraoperative visual assessment.

To describe patterns of primary surgical treatments in patients with T4b oral cavity squamous cell carcinoma (OCSCC).Historical cohort study.National Cancer Database.Review of the National Cancer Database between 2004 and 2017 for all T4b OCSCCs. Only patients with curative treatment methods were included in the survival analysis. Surgical and nonsurgical outcomes were compared by multivariable and propensity score matching analysis.A total of 1515 cases of T4b OCSCC were identified. A minority of patients (n = 363, 24.0%) underwent curative treatment; among these, 206 (56.7%) underwent primary surgery. Median length of follow-up was 24 months. The 90-day mortality of patients who underwent surgical treatment was 1.0%. The 2-year survival was higher for patients who underwent surgery + chemoradiotherapy (CRT) as compared with CRT (64.6% vs 45.2%,A minority of patients with T4b OCSCC undergo treatments with curative intent. A subset of patients underwent primary surgical treatment, which was associated with longer survival. The T4b classification might entail a heterogenous group, and further studies in revision of this classification might be justified.

To investigate the patterns of care and outcomes of treatment of early stage tonsil cancers, controlling for human papillomavirus (HPV) status.Historical cohort study.National Cancer Database (NCDB).Review of the NCDB between 2010 and 2017 for all T1-2N0M0 tonsillar squamous cell carcinoma (SCC). Demographics, clinical characteristics, HPV status, treatment regimens, and survival were analyzed.A total of 4720 patients were identified with early stage SCC of the tonsil. Most were tested for HPV (2759 [58.5%]). Among tested patients, 1758 (63.7%) were positive for HPV and 1001 (36.3%) were negative for HPV. HPV-positive patients had higher 3-year survival compared to HPV-negative patients (93.2% vs 77.8%,Surgical- or radiation-based treatment resulted in similar survival in early stage HPV-positive tonsil cancer. Surgical-based treatments were associated with longer survival in HPV-negative cancers. These findings should be further investigated in a randomized prospective trial.

BACKGROUND: We examine the prognostic implications of mid-course nodal response in oropharyngeal cancer (OPX) to radiation therapy. METHODS: In 44 patients with node-positive OPX undergoing concurrent chemoradiation, nodal volumes were measured on cone beam CTs from days 1, 10, 20, and 35. Nodal decrease (ND) was based on percent shrinkage from day 1. RESULTS: At a median follow-up of 17 months, the 2-year disease-free survival (DFS), locoregional control (LRC), distant metastasis-free survival (DMFS), and overall survival (OS) were 87%, 92%, 89%, and 92%, respectively. Patients with ND ≥43% at D20 had improved LRC (100% vs 78.4%, P = .03) compared to D20 ND

To investigate differences in epidemiology of oropharyngeal squamous cell carcinoma (OPSCC) with regards to human papillomavirus (HPV), race, and socioeconomic status (SES) using the National Cancer Database (NCDB).Population-based cohort study.Racial and socioeconomic disparities in survival of OPSCC have been previously acknowledged. However, the distribution of HPV-related cancers and its influence on survival in conjunction with race and SES remain unclear.All patients with OPSCC in the NCDB with known HPV status from 2010 to 2016 were included. Differences in presentation, HPV status, treatment, and outcomes were compared along racial and socioeconomic lines. Univariable and multivariable Cox regression survival analyses were performed.In total, 45,940 patients met criteria. Most were male (38,038, 82.8%), older than 60 years (23,456, 51.5%), and white (40,156, 87.4%), and lived in higher median income areas ($48,000, 28,587, 62.2%). Two-thirds were HPV positive (31,007, 67.5%). HPV-negative disease was significantly more common in lower SES ($38,000, 2937, 41.5%,Significant differences in HPV status exist between socioeconomic and racial groups, with HPV-negative disease more common among blacks and lower SES. When controlling for HPV status, race and SES still influence outcomes in oropharyngeal cancers.

BACKGROUND Virtual surgical planning has contributed to technical advancements in free fibula flap mandible reconstruction. The authors present the largest comparative study on the latest modification of this technology: the use of patient-specific, preoperatively customized reconstruction plates for fixation. METHODS A retrospective chart review was performed on all patients undergoing mandibular reconstruction with virtually planned free fibula flaps at a single institution between 2008 and 2018. Patient demographics, perioperative characteristics, and postoperative outcomes were reviewed. Reconstructions using traditional fixation methods were compared to those using prefabricated, patient-specific reconstruction plates. RESULTS A total of 126 patients (mean age, 48.5 ± 20.3 years; 61.1 percent male) underwent mandibular reconstruction with a free fibula flap. Mean follow-up time was 23.5 months. A customized plate was used in 43.7 percent of cases. Reconstructions with patient-specific plates had significantly shorter total operative times compared with noncustomized fixation methods (643.0 minutes versus 741.7 minutes; p = 0.001). Hardware complications occurred in 11.1 percent of patients, with a trend toward a lower rate in the customized plate group (5.5 percent versus 15.5 percent; p = 0.091). Multivariate regression showed that the use of customized plates was a significant independent predictor of fewer overall complications (p = 0.03), shorter operative time (p = 0.014), and shorter length of stay (p = 0.001). CONCLUSIONS Compared to traditional fixation methods, patient-specific plates are associated with fewer complications, shorter operative times, and reduced length of stay. The use of customized reconstruction plates increases efficiency and represents the latest technological innovation in mandibular reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

IMPORTANCE: Genomic classifiers were developed to better guide clinicians in the treatment of indeterminate thyroid nodules (ITNs). To our knowledge, whether there is variation in the diagnostic accuracy of these tests depending on ITN size has not been previously studied. OBJECTIVE: To analyze the diagnostic performance of a genomic classifier in relation to ITN size. DESIGN, SETTING, AND PARTICIPANTS: A case series study with medical records review was conducted including all patients with a cytologic diagnosis of ITN managed with genomic classifier testing and surgery from January 2015 to December 2018 at NYU Langone Health. Demographics, ITN characteristics, genomic profiles, treatment, and final pathologic findings were recorded. Data analysis was conducted from March to April 2021. MAIN OUTCOMES AND MEASURES: The primary aim was to assess the positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of a genomic classifier test (ThyroSeq) in relation to ITN size (4 cm). The secondary aim was to investigate the risk of cancer associated with genetic signatures. RESULTS: Of the 212 patients with 218 ITNs, 158 (74.5%) were women; median (SD) age was 49 (15.6) years. Genomic classifier results were positive in 173 ITNs (79.4%) treated with surgery. In this group of 173 positive ITNs, 46 (26.6%) were malignant on final pathologic testing. Overall, the observed cancer prevalence in the population was 23.9% (52 ITNs). In 45 ITNs that underwent surgery despite a negative genomic classifier interpretation, 6 (13.3%) were malignant. The PPV of a positive test was 27% and the NPV was 87%. The PPV and NPV findings improved as the ITN size increased (4 cm [n = 33]: PPV, 50%; NPV, 89%). Test specificity was higher in larger ITNs (4 cm: 40%; P = .01). Isolated RAS sequence variations were the most common variant identified in malignant nodules (11 [21.1%] of all ITNs), followed by BRAF variants (7 [13.5%] of all ITNs). CONCLUSIONS AND RELEVANCE: In this case series, the performance of the ThyroSeq test improved for larger ITNs. The risk of cancer in large ITNs with negative test results was low. These data suggest that, in genomic classifier–negative ITNs larger than 4 cm, initial management of thyroid lobectomy may be sufficient.

Objectives/hypothesis Fibula flaps are routinely used for osseous reconstruction of head and neck defects. However, single-barrel fibula flaps may result in a height discrepancy between native mandible and grafted bone, limiting outcomes from both an aesthetic and dental standpoint. The double-barrel fibula flap aims to resolve this. We present our institution's outcomes comparing both flap designs. Study design Retrospective cohort study. Methods We conducted a retrospective review of all patients undergoing free fibula flap mandibular reconstruction at our institution between October 2008 and October 2020. Patients were grouped based on whether they underwent single-barrel or double-barrel reconstruction. Postoperative outcomes data were collected and compared between groups. Differences in categorical and continuous variables were assessed using a Chi-square test or Student's t-test, respectively. Results Out of 168 patients, 126 underwent single-barrel and 42 underwent double-barrel reconstruction. There was no significant difference in postoperative morbidity between approaches, including total complications (P = .37), flap-related complications (P = .62), takeback to the operating room (P = .75), flap salvage (P = .66), flap failure (P = .45), and mortality (P = .19). In addition, there was no significant difference in operative time (P = .86) or duration of hospital stay (P = .17). After adjusting for confounders, primary dental implantation was significantly higher in the double-barrel group (odds ratio, 3.02; 95% confidence interval, 1.2-7.6; P = .019). Conclusion Double-barrel fibula flap mandibular reconstruction can be performed safely without increased postoperative morbidity or duration of hospital stay relative to single-barrel reconstruction. Moreover, the double-barrel approach is associated with higher odds of primary dental implantation and may warrant further consideration as part of an expanded toolkit for achieving early dental rehabilitation. Level of evidence III Laryngoscope, 2021.

PURPOSE/OBJECTIVE(S) Computerized planning and 3D printing of titanium (Ti) plates attached during radical tumor resection allow for patient-specific, personalized solutions for complex osseous reconstructions in locally advanced oral cavity carcinoma. Here, we investigate dose perturbations related to such Ti plates and further interrogate whether the commonly used anisotropic analytical algorithm (AAA) dose calculation algorithm accurately predicts perturbations around Ti plates in comparison to the Boltzmann Solver Acuros XB model (AXB). MATERIALS/METHODS Twenty-three cases of radically resected oral cavity carcinoma, with or without Ti plate reconstruction, followed by VMAT were reviewed with rates of spontaneous osteoradionecrosis (ORN) documented. Clinical treatment plans using AAA (2.5mm dose grid) were retrospectively re-planned with 1mm dose grids on AAA and AXB. Seven consecutive Ti plate reconstructed cases were compared to 16 control cases (postoperative cases without Ti plate) to understand the extent of dose perturbation near reconstructed bone and surrounding tissues using previously established dose metrics, such as maximum plan dose (Dmax) and maxillary/mandibular doses (Dmax, Dmean, V35, V44). Additionally, a 3mm shell was contoured around each plate to directly assess short-range dose perturbance at tissue-to-Ti interfaces. RESULTS Of the 23 patients who underwent oral cavity resection followed by adjuvant VMAT, 4 underwent reconstruction with conventional low-profile Ti plates while 3 cases underwent reconstruction with high-profile custom plates. ORN was observed in 3 patients, all of whom had high profile custom plates. Global Dmax was significantly elevated in AXB 1mm (118.0 ± 3.3%) compared to AAA 2.5mm (109.1 ± 0.8%) and AAA 1mm (113.1 ± 2.0%), with most notable increases in the Ti plate cohort (P < 0.001; Table). Within the AXB 1mm plans, all a priori parameters were significantly higher in the Ti plate vs. no plate cohort (global Dmax: +5.7%, osseous Dmax: +4.9%, osseous Dmean: +10.9%, osseous V35: +13.4%, osseous V44: +15.9%). Furthermore, in the Ti plate population, AXB calculated significantly higher local hot spots within the 3mm shell contoured (115.6 ± 4.4% vs. 107.0 ± 1.7%; P < 0.002). CONCLUSION Using the AAA model with a clinical standard 2.5mm dose grid does not appear to adequately account for dose perturbation at the tissue-to-Ti interface in comparison to the AXB algorithm at a finer dose grid, resulting in a significant underestimation of global and osseous maximum doses. Care should be taken when delivering radiation to patients with high profile Ti plates. The impact of beam entrance restriction and alternative plate designs to minimize the profile of high-Z materials are currently being explored.

Background: Patients with head and neck cancer (HNC) experience painful, debilitating symptoms and functional limitations that can interrupt cancer treatment, and decrease their health-related quality of life (HRQoL). The Electronic Patient Visit Assessment (ePVA) for head and neck is a web-based mHealth patient-reported measure that asks questions about 21 categories of symptoms and functional limitations common to HNC. This article presents the development and usefulness of the ePVA as a clinical support tool for real-time interventions for patient-reported symptoms and functional limitations in HNC. Methods: Between January 2018 and August 2019, 75 participants were enrolled in a clinical usefulness study of the ePVA. Upon signing informed consent, participants completed the ePVA and the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ) general (C30) questionnaire v3.0 (scores range from 0 to 100 with 100 representing best HRQoL). Clinical usefulness of the ePVA was defined as demonstration of reliability, convergent validity with HRQoL, and acceptability of the ePVA (i.e., >70% of eligible participants complete the ePVA at two or more visits and >70% of ePVA reports are read by providers). Formal focus group discussions with the interdisciplinary teamthat cared for patients with HNC guided the development of the ePVA as a clinical support tool. Qualitative and quantitative methods were used throughout the study. Descriptive statistics consisting of means and frequencies, Pearson correlation coefficient, and Student���s t-tests were calculated using SAS 9.4 and STATA. Results: The participants were primarily male (71%), White (76%), diagnosed with oropharyngeal or oralcavity cancers (53%), and undergoing treatment for HNC (69%). Data analyses supported the reliability (alpha =0.85), convergent validity with HRQoL scores, and acceptability of the ePVA. Participants with the highest number of symptoms and functional limitations reported significantly worse HRQoL (sumof symptoms: r=���0.50, P

Advances in free flap reconstruction of complex head and neck defects have allowed for improved outcomes in the management of head and neck cancer. Technical refinements have decreased flap loss rate to less than 4%. However, the potential for flap failure exists at multiple levels, ranging from flap harvest and inset to pedicle lay and postoperative patient and positioning factors. While conventional methods of free flap monitoring (reliant on physical examination) remain the most frequently used, additional adjunctive methods have been developed. Herein we describe the various modalities of both invasive and noninvasive free flap monitoring available to date. Still, further prospective studies are needed to compare the various invasive and noninvasive technologies and to propel innovations to support the early recognition of vascular compromise with the goal of even greater rates of flap salvage.

Background Collaboration has been shown to be beneficial when we have complex problems and highly specialized groups, such as in head and neck reconstruction. Otolaryngology, plastic surgery, and oral maxillofacial surgeons perform head and neck reconstruction research. While the specialties represent unique backgrounds, the degree of interdisciplinary collaboration and subtopic focus is unknown. We sought to describe the frequency of interinstitutional interdisciplinary collaboration and examine the association of specialty with research subtopics. Methods Oral presentations from 2014 to 2018 focused on head and neck reconstruction or associated principles at the main reconstructive academic meetings in otolaryngology (American Head and Neck Society), plastic surgery (American Society for Reconstructive Microsurgery), and oral maxillofacial surgery (American Association of Oral and Maxillofacial Surgeons) were reviewed. Author specialty and institution data were recorded. All abstracts were assigned a research subtopic, chosen based on identified themes. Subtopic frequencies among the specialties were compared. Results Thirteen of 88 (15%) US institutions participate in interdisciplinary collaboration in head and neck reconstruction research. Of the remaining institutions, 23 (31%) have researchers performing parallel work and not collaborating. Certain research subtopics were more often presented by each specialty, representing differing interests. Conclusion Collaboration among head and neck reconstruction research at the US institutions is low compared with the potential. Specialties focus on different research subtopics, and therefore can benefit from working together.

We describe the use of the medial sural artery musculocutaneous perforator (MSAP) flap at our institution. It is a relatively new flap, originally described in 2001 for lower extremity defects, that has become increasingly popular for head and neck reconstruction due to its versatility, thinness, pliability, long pedicle, and particularly favorable donor site. It has been described for reconstruction of oral defects, but there is little published on its use in pharyngeal reconstruction. We suggest that the MSAP is an ideal flap for addressing defects caused by pharyngoesophageal stenosis, pharyngeal fistulas, or laryngopharyngectomies. We review 5 cases at our institution from June 2016 to November 2017.

Objectives/hypothesis To determine if a long segment of trachea can be transplanted as a vascularized organ and to determine if a tracheal transplant is a potential surgical option for a long-segment circumferential tracheal defect. Study design Animal model. Methods Four (two donors and two recipients) adult domestic Yorkshire swine were used. Two sets of transplants were performed from a donor to recipient pig. The transplant was placed heterotopically (not in continuity with the airway), and the recipient animals were monitored for 14 days to ensure the transplants were well vascularized. Immunosuppressive therapies included methylprednisolone, cyclosporine, and azathioprine. Gross as well as histological examination of multiple tissues types including mucosa, cartilage, muscle, and blood vessels were performed postsacrifice on day 14. Results Recipient animal weights ranged from 40 to 42 kilograms. Both recipient pigs survived the full 14 days of study and exhibited normal activity and appetite. Ischemia time of transplanted grafts ranged from 63 to 72 minutes. Transplanted tracheas included a minimum of 15 cartilaginous rings and measured greater than 10 cm in length. Both grafts maintained a robust blood supply throughout the duration of study. Conclusions The entire visceral compartment can be reliably transplanted, either as a single component (trachea) or as a chimeric flap with multiple components (trachea, esophagus, larynx, and pharynx). Further studies in the swine model should be considered to study the effects of transplanting the trachea orthotopically into the native airway. Further studies are needed into the reliability of this technique of transplantation in humans. Level of evidence NA Laryngoscope, 128:S1-S9, 2018.

Purpose/Objective(s) Lacrimal gland cancer is a rare tumor with little data regarding outcomes and optimal management. We performed a large database analysis using the National Cancer Database (NCDB) to elucidate patterns of care and outcomes for this rare malignancy. Materials/Methods Patients with lacrimal gland cancer diagnosed between 2004 and 2016 were included in analysis. All histologies were included with the exception of malignant melanoma and lymphoma; squamous cell carcinoma was also excluded as it is rarely found in the lacrimal gland, and likely reflects lacrimal duct or sac cancer. Patients without recorded follow up or with less than 6 months of follow up were excluded. Patients were stratified by sex, age, race, Charlson-Deyo comorbidity score, facility type, and pathologic T stage. Patterns of care including treatment with surgery, chemotherapy and/or radiation therapy were noted. Outcomes were analyzed using Kaplan-Meier analysis, and Cox proportional hazards regression was used to study the effect of surgery and radiation therapy on overall survival. Results 460 patients with lacrimal gland cancer were included in the database. Median follow up for all patients was 42.7 months. The most common histology was adenoid cystic carcinoma (185 patients, 40.2%), followed by adenocarcinoma (85, 18.5%). Most patients were of unknown T stage (63.9%). 362 patients (78.7%) underwent surgical resection, 104 (22.6%) received chemotherapy, and 292 (63.5%) underwent radiotherapy. Median overall survival for all patients was 106.8 months (95% CI: 85.3 months - not reached). Variables associated with worse overall survival on univariate analysis included age over 60 (P Conclusion The ideal management for lacrimal gland cancer is still unknown due to the rarity of this tumor. Retrospective study of a large national database suggests that patients who undergo surgical resection may have better outcomes than those who do not, although a benefit for radiotherapy is not apparent. Further data collection is required for this unusual tumor.

Background Unilateral radiotherapy (RT) of oropharyngeal carcinomas is accepted for patients with lateralized primary and low-volume nodal disease. Utilizing prospectively defined criteria of laterality and staging positron emission tomography (PET)/CT, we studied outcomes in patients with advanced-stage oropharyngeal cancer undergoing unilateral RT. Methods Thirty-seven patients with oropharyngeal tumors >1 cm from midline regardless of node status underwent unilateral RT and were followed prospectively. Patient characteristics: T1 = 11; T2 = 22; T3 = 4; N0 = 3; N1 = 9; N2a = 3; N2b = 21; and Nx = 1. Dosimetry were determined and weekly National Comprehensive Cancer Network (NCCN) distress thermometer data were collected. Results At median follow-up of 32 months, 3-year locoregional control, contralateral regional failure, distant metastasis-free survival, and disease-free survival were 96%, 0%, 7%, and 93%, respectively. Conclusion Low rates of contralateral neck failure are demonstrated utilizing prospectively defined criteria for unilateral RT. The tolerances of contralateral organs are respected and patients report low to moderate levels of distress throughout treatment.

Background: The Alexis retractor is a device that provides simultaneous radial retraction and wound protection during surgical procedures. Although typically used in abdominal and pelvic surgeries, there has been increased development of novel operative techniques utilizing the Alexis retractors in head and neck surgeries. Methods: We describe 2 cases of utilizing the Alexis retractor to attain transoral exposure in the setting of free flap reconstruction of intraoral defects. Results: In both cases, the Alexis retractor provided improved retraction, decreasing the number of instruments required for adequate exposure. Additionally, the polyurethane sheath component acted as a protective membrane over the lips and mucosa. Conclusions: The Alexis retractor can be a powerful retraction tool for certain surgical procedures involving the head and neck regions.

Supplemental Digital Content is available in the text., Summary: Trismus is a known complication following treatment of oral and oropharyngeal cancers, with radiation therapy reported as a known risk factor for its development. The prevention of trismus after radiation therapy is hard to achieve, with no clear benefit of early prophylactic rehabilitation. Pterygomasseteric myotomy and coronoidectomy are well described procedures in the management of extra-articular trismus. Herein, we present 2 cases of temporomandibular joint dislocation as a cautionary tale of the potential risk for temporomandibular joint dislocation and need for closed reduction and maxillomandibular fixation.

Background: Annually, over 65,000 persons are diagnosed with head and neck cancer in the United States. During treatment, up to 50% of patients become severely symptomatic with pain, fatigue, mouth sores, and inability to eat. Long term complications are lymphedema, fibrosis, dysphagia, and musculoskeletal impairment. Patients��� ability to perform daily activities and to interact socially may be impaired, resulting in poor quality of life. A pragmatic, clinically useful assessment is needed to ensure early detection and intervention for patients to report symptoms and functional limitations over time. We developed the Electronic Patient Visit Assessment (ePVA) that enables patients to report 42 symptoms related to head and neck cancer and 17 limitations of functional status. This manuscript reports (I) the development of the ePVA, (II) the content validity of the ePVA, and (III) the usability and reliability of the ePVA. Methods: Usability was evaluated using the ���Think Aloud��� technique to guide the iterative process to refine the ePVA based on participants��� evaluations. After signing the informed consent, 30 participants with head and neck cancer completed the ePVA using digital tablet devices while thinking aloud about ease of use. All patient conversations were recorded and professionally transcribed. Reliability of the ePVA symptom and functional limitation measures was estimated using the Kuder-Richardson test. Convergent validity of the ePVA was evaluated using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 global QoL/health scale. Transcribed qualitative data were analyzed using directed content analysis approach. Quantitative analyses consisted of descriptive statistics and correlation analyses. Results: Among participants, 90% strongly agreed or agreed that the ePVA system was easy to use and 80% were very satisfied. Only minor usability problems were reported due to formatting and software ���bugs���. Reporting of usability problems decreased in frequency over the study period and no usability problems were reported by the last 3 participants who completed the ePVA. Based on participants��� suggestions during the iterative process, refinement of the ePVA included increased touch sensitivity of the touch screen technology and customized error messages to improve ease of use. The ePVA also recorded patient reported symptoms (mouth symptoms: 93%, fibrosis: 60%, fatigue: 60%). The ePVA demonstrated acceptable reliability (alpha =0.82���0.85) and convergent validity (ePVA total number of reported symptoms and function limitations was negatively correlated with EORTC QLQ-C30 global QOL/health scale: r=���0.55038, P

Keywords: Mandibular reconstruction; oral cavity; double barrel fibular flap; transoral; quality of life

Background Review patient and defect factors in which this donor site is an optimal choice for reconstruction and to discuss strategies to overcome the perceived drawbacks of this system of flaps. Methods A retrospective medical chart review was conducted on all patients who underwent the subscapular system of free flaps for head and neck reconstruction. Results Ninety-eight reconstructions were performed for mandibular defects, 4 for maxillary defects alone and 3 for combined mandible-maxilla defects. The overall success rate was 98%. Conclusion The subscapular system of free flaps is an excellent option in patients for whom the alternative donor sites are either not usable or lack the associated soft tissue elements required for a successful reconstruction. This flap should also be considered as a first choice for patients with complex/extensive surgical defects requiring multiple, independently mobile, soft tissue components; in patients who will benefit from a large muscle flap placed over the vital structures in the neck; patients of advanced age; and patients in whom early mobilization is critical. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1200–1206, 2015

Oromotor and clinical swallow assessments are routinely performed by speech-language pathologists (SLPs) who see head and neck cancer (HNC) patients. However, the tools used to assess some of these variables vary. SLPs routinely identify and quantify abnormal functioning in order to rehabilitate the patient. However, function in terms of tongue range of motion (ROM) is typically described using a subjective severity rating scale. The primary objective of this study was to gain insight via survey into what variables SLPs consider important in assessing and documenting function after HNC treatment. A second objective was to seek feedback regarding a scale designed by the authors for assessing tongue ROM for this cohort of patients. This survey also was developed to elucidate salient factors that might have an impact on the prognosis for speech and swallow outcomes. Of the 1,816 SLPs who were sent the survey, 292 responded who work with HNC patients. Results revealed that although 95 % of SLPs assess tongue strength, only 13 % use instrumental methods. Although 98 % assess tongue ROM, 88 % estimate ROM based on clinical assessment. The majority of respondents agreed with the utility of the proposed tongue ROM rating scale. Several variables were identified by respondents as having an impact on overall prognosis for speech and swallow functioning. Tracking progress and change in function with treatment can be accomplished only with measurable assessment techniques. Furthermore, a consistent measuring system can benefit patients with other diagnoses that affect lingual mobility and strength.

PURPOSE: To retrospectively review our single institution experience of patients with tonsillar squamous cell carcinoma. MATERIAL AND METHODS: Between 1999 and 2005, a total of 79 patients were identified. Stage distribution was as follows: stages I-II, III, IVA, and IVB were in 6, 14, 43, and 16 patients, respectively. Sixty-three patients (80%) were male. Median age was 55.5 years. Treatment generally consisted of external beam radiation therapy (RT) (median dose, 70 Gy), concomitant chemotherapy (CCRT) (cisplatin 100 mg/m on days 1, 22, and 43), and neck dissection (ND), and was administered as follows: stages I/II, 6 patients received RT alone; stages III/IVA, 20, 5, and 32 patients received RT alone, CCRT, and CCRT followed by ND, respectively; stage IVB, 9 and 7 patients received CCRT and CCRT plus ND, respectively. RESULTS: After a median follow-up of 56 months (range, 12 to 122 mo), the 5-year local control (LC), regional control (RC), distant control (DC), and overall survival (OS) by stage were as follows: stage I-II 100%, 100%, 100%, 100%; stage III-IVA 98%, 96%, 95%, and 88%; stage IVB 100%, 100%, 69%, and 66%, respectively. Among stage IVB patients, DC was significantly lower (P=0.01) and a trend toward lower OS was noted (P=0.08). Long-term percutaneous endoscopic gastrostomy dependence was noted in 3% of them who had received CCRT. The effect of both chemotherapy and ND on treatment outcomes was analyzed; in stage III/IVA patients treated with or without chemotherapy, LC was 97% and 100% (P=0.43); RC was 92% and 100%(P=0.27); and DC was 91% and 94% (P=0.92), respectively. In stage III/IVA, patients treated with CCRT with or without ND, RC was 100% and 88%, respectively (P=0.087). CONCLUSIONS: Primary radiotherapy with or without CCRT followed by ND provides excellent tumor control with acceptable toxicity in treating squamous cell carcinoma of the tonsil.

Sinonasal undifferentiated carcinoma (SNUC) is a rare and aggressive malignancy with optimal management remains unclear. We performed a review of the impact of trimodality approach on SNUC outcome.This is a single-institution retrospective study of 18 patients, who were managed between 1997 and 2009. The median age at presentation was 52 years (28 to 82). Nine patients (50%) were female. Three patients had stage II disease and underwent surgery alone, 12 had stages III and IVa and underwent surgery combined with chemoradiation, and 3 had stage IVb and underwent definitive chemoradiation. Patients who underwent preoperative, postoperative, and definitive chemoradiation received 60, 66, and 70 Gy of radiation, respectively. In all patients receiving concurrent chemoradiation, cisplatin was used, at a dose of 100 mg/m every 3 weeks for 3 cycles. Neoadjuvant chemotherapy included docetaxel, cisplatin, and 5-fluorouracil (TPF) every 3 weeks for 2 to 3 cycles.After a median follow-up of 26 months (16 to 120), a total of 8 patients (44%) have experienced the following: 1 persistent disease (5.5%), 4 local failure (22%), and 3 distant metastases (DM, 16.5%). Five of the 8 patients had preexisting cranial nerve deficits or gross cranial invasion. The 2-, 3-, and 4-year local control (LC), disease-free survival (DFS), and overall survival (OS) were 78%, 72%, and 56%; 75%, 65%, and 52%; and 75%, 50%, and 48%, respectively. Trimodality approach provided 83% LC and 92% DM-free survival, whereas other modalities provided 50% LC and 33% DM-free survival. The causes of death for the entire cohort were DM and local invasion. Acute chemoradiotherapy toxicity was 100% grades 1 and 2 dermatitis, mucositis, and fatigue, 55% developed grades 1 and 2 dysphagia, and 6% had grade 3 mucositis. Long-term toxicity was 28% grade 1 xerostomia, 11% retinopathy and optic neuropathy, and 6% orbital exenteration and grade 3 peripheral neuropathy.SNUC is an aggressive neoplasm that frequently presents at an advanced stage. Our data show that trimodality approach in the form of surgery combined with chemoradiation seems to offer better LC and lower DM compared with other modalities.

Objectives: Surgical resection of oral cancer can result in altered speech, swallowing, and quality of life (QOL). To date, the oral outcome variables of tongue strength, tongue and jaw range of motion, and saliva production have not been extensively assessed. This pilot study was done to assess tongue strength along with other oral outcomes and their relationship to performance status for speech, swallowing, and QOL after partial glossectomy. Our aim was to create a norm for what should be considered a normal tongue strength value in this population. We hypothesized that patients with tongue strength of 30 kPa or greater would perform better on the performance status scale and various QOL measures than do patients with tongue strength of less than 30 kPa. Methods: We used a cross-sectional design in this study. The postoperative assessment included 1) Performance Status Scale and Karnofsky Performance Status Scale; 2) oral outcome variables of tongue strength, jaw range of motion, and saliva production; and 3) patient-rated QOL ratings via Eating Assessment Tool, M. D. Anderson Dysphagia Inventory, EORTC-H&N35, and Speech Handicap Index. Results: Patients with tongue strength of at least 30 kPa performed better on the performance status scales and various QOL measures. The cutoff score of 30 kPa for tongue strength measures revealed a trend in predicting performance on the scales and QOL measures. Conclusions: The oral outcome variables correlated with performance status for speech, swallowing, and QOL. We propose a norm for tongue strength in this population, based on the trend seen in this group of patients, as none previously existed. Future studies are under way that incorporate a larger sample size to further validate this norm. Future studies will also examine oral functional outcome measures in a larger population by including other oral and oropharyngeal sites to help predict speech and swallow performance status and QOL.

Objectives/Hypothesis To report tolerance and toxicity of radiotherapy (RT) with or without chemotherapy in HIV seropositive patients with squamous cell carcinoma of the head and neck (SCCHN). Methods This is a single institution retrospective study of 73 HIV seropositive patients with SCCHN treated from January 1997 through 2010. Stages I, II, III, and IV were 8%, 10%, 24%, and 58%, respectively. The median age at RT, HIV diagnosis. and the duration of HIV seropositive were 51 (32–72), 34 (25–50), and 11 (6–20) years, respectively. Patients were treated definitively with RT alone (35%) or concurrent chemo-RT (65%). Median dose of 70 Gy (66–70) was delivered to the gross disease. Median duration of treatment was 52 (49–64) days. Fifty patients (70%) were on HAART. Results RT± chemotherapy induced acute toxicity was: median weight loss 20 pounds (6–40), 100% developed dysgeusia and xerostomia (grades 1–3). Acute mucositis and dysphagia/odynophagia grades ≤2 and 3 were 83% and 17%, respectively. Treatment breaks in excess of 10, 7, and 3 days were found in 5%, 13%, and 15% of patients, respectively. With a median follow-up of 4 years (2–12) the RT ±chemotherapy induced late dysphagia and xerostomia grades >2 were 26% and 23% of patients, respectively. Conclusion Our data show that primary RT ±chemotherapy for HIV seropositive SCCHN is less tolerated compared to the historical data for SCCHN without HIV. Level of Evidence 2b.

Purpose Squamous cell carcinoma of unknown primary (SCCHNUP) is commonly treated with comprehensive radiation to the laryngopharynx and bilateral necks. In 1998, we established a departmental policy to treat SCCHNUP with radiation directed to the oropharynx and bilateral neck. Methods From 1998–2011, 60 patients were treated – N1: 18%, N2: 75% and N3: 7%. 82% underwent neck dissection. 55% received IMRT and 62% underwent concurrent chemoradiotherapy. Results At median follow-up of 54 months, 5 patients failed regionally and 4 emerged with a primary (tongue base, hypopharynx and thoracic esophagus). Five-year rates of regional control, primary emergence, distant metastasis, disease-free survival and overall survival were 90%, 10%, 20%, 72% and 79%, respectively. The 5 year rate of primary emergence in a non-oropharynx site was 3%. Conclusion This is the first demonstration that an oropharynx-directed approach yields low rates of primary emergence in SCCHNUP with excellent oncologic outcomes.

Osteoradionecrosis (ORN) of the mandible is a significant complication of radiation therapy for head and neck cancer. In this condition, bone within the radiation field becomes devitalized and exposed through the overlying skin or mucosa, persisting as a non-healing wound for three months or more. In 1926, Ewing first recognized the bone changes associated with radiation therapy and described them as "radiation osteitis". In 1983, Marx proposed the first staging system for ORN that also served as a treatment protocol. This protocol advocated that patients whose disease progressed following conservative therapy (hyperbaric oxygen (HBO), local wound care, debridement) were advanced to a radical resection with a staged reconstruction utilizing a non-vascularized bone graft. Since the introduction of Marx's protocol, there have been advances in surgical techniques (i.e. microvascular surgery), as well as in imaging techniques, which have significantly impacted on the diagnosis and management of ORN. High resolution CT scans and orthopantamograms have become a key component in evaluating and staging ORN, prior to formulating a treatment plan. Patients can now be stratified based on imaging and clinical findings, and treatment can be determined based on the stage of disease, rather than determining the stage of disease based on a patient's response to a standardized treatment protocol. Reconstructions are now routinely performed immediately after resection of the diseased tissue rather than in a staged fashion. Furthermore, the transfer of well-vascularized hard and soft tissue using microvascular surgery have brought the utility of HBO treatment in advanced ORN into question.

The term "collision tumor" refers to the coexistence of two histologically distinct malignant tumors within the same mass. Collision tumors involving the thyroid gland and/or neck region are especially uncommon, with most reported cases involving papillary thyroid carcinoma in coexistence with medullary thyroid carcinoma, follicular carcinoma, and metastatic disease, the latter including a rare occurrence of metastatic liposarcoma and thyroid papillary carcinoma. A collision tumor of papillary thyroid carcinoma and squamous cell carcinoma primary to the thyroid has also been reported.We now report a collision tumor comprised of well-differentiated papillary thyroid carcinoma and squamous cell carcinoma that originated as a laryngeal primary tumor. Histologically, the thyroid mass is consisted of well-differentiated papillary thyroid carcinoma. The laryngeal mass consisted of in situ and invasive squamous cell carcinoma. Both cancers were extensively infiltrative into the soft tissues of the neck and paraglottic space where the histologically distinct tumor types approximated one another but were not admixed with each other. Additionally, cervical lymph nodes showed metastatic carcinoma, including independent cervical lymph nodes with metastatic squamous cell carcinoma only, cervical lymph nodes with metastatic papillary thyroid carcinoma only, and cervical lymph nodes with foci of both papillary thyroid carcinoma and squamous cell carcinoma.As best we can determine this is the first publication of a collision tumor comprised of a well-differentiated papillary thyroid carcinoma and squamous cell carcinoma that originated as a laryngeal primary tumor. For any patient with a thyroid mass that appears to be in continuity with a laryngeal mass, more commonly one would find invasive thyroid cancer, but one must consider a collision tumor in the differential diagnosis.

Background. In the neck, the recipient vessels most frequently used for microsurgical reconstruction are compromised by prior surgery and radiation. Methods. We conducted a retrospective chart review of all patients who underwent microvascular reconstruction between July 2001 and June 2005. Donor vessels, vein grafts, and flap survival were examined. Results. Fourteen of 197 patients (7%) were identified with a vessel-depleted neck. All patients had undergone a prior neck dissection and radiation (100%) or chemoradiation (42%). Free flap revascularization was achieved using the transverse cervical artery with a vein graft and a cephalic vein (4 patients), thoracoacromial artery and cephalic vein (3 patients), internal mammary artery and vein (3 patients), and inferior thyroid artery and cephalic vein (1 case). In 3 patients, the reverse flow thoracodorsal artery and cephalic vein were used to vascularize the scapular flap. Conclusion. The cephalic vein, transverse cervical, internal mammary, and thoracoacromial vessels represent reliable alternatives in the vessel-depleted neck. © 2007 Wiley Periodicals, Inc. Head Neck, 2008

We report a very rare case of a chondromyxoid fibroma of the mastoid portion of the temporal bone in a 38-year-old woman who presented with left-sided hearing loss. Magnetic resonance imaging identified an expansile mass in the left mastoid bone with a heterogeneous hyperintense signal on T2-weighted imaging and peripheral enhancement. Subsequent positron emission tomography/computed tomography identified erosive bony changes associated with hypermetabolism. The patient underwent an infra-temporal fossa resection with a suboccipital craniectomy/cranioplasty. We briefly review the aspects of this case, including a discussion of the differential diagnosis and the correlation between histologic and imaging findings.

INTRODUCTION Osteoradionecrosis (ORN) of the mandible is reported to occur in approximately 5% of the patients who undergo external beam radiation therapy for a head and neck malignancy. The management of ORN is based on the clinical stage at presentation and response to initial management. We utilized the Marx staging system and treatment algorithm to guide our decision making. In recent years, it has been our philosophy and that of others to perform a segmental mandibulectomy with an immediate reconstruction utilizing the transfer of vascularized bone for patients with Marx stage III disease. We feel that the placement of vascularized tissue into this unfavorable environment has greatly improved our outcomes in patients with advanced ORN.

Objectives/Hypothesis: The successful harvest and transplant of a fibular flap depends on many factors, including healthy inflow and outflow systems. A contraindication to harvesting a fibular flap is disease of the lower extremity arterial system; therefore, preoperative evaluation of the arterial system is routine. Preoperative evaluation of the venous system is not routine, unless there is clinical suspicion of venous disease. Methods: Retrospective chart review. Results: Two cases of occult deep venous thrombosis (DVT) were encountered intraoperatively resulting in nontransplantable flaps. Conclusions: This finding represents a serious concern, and we believe that venous imaging should be considered in patients with significant risk factors for harboring an occult DVT.

Concomitant chemoradiotherapy provides organ preservation for those patients with head and neck cancer. We report the results of a prospective study that examined functional outcomes and quality of life (QOL) after chemoradiotherapy over the first 6 months post-treatment (tx). Twenty-nine patients with head and neck cancer were treated with chemoradiotherapy. All were seen baseline and 3 and 6 months post-tx. Assessments included the performance status scale (PSS), Karnofsky performance status scale, tongue strength, jaw opening, and saliva weight. QOL was patient-rated using the eating assessment tool (EAT-10), MD Anderson dysphagia inventory, speech handicap index (SHI), and the EORTC H&N35 scale. Repeated-measures ANOVAs were used, with significance at p < 0.05. PSS scores were significantly different across time points. Tongue strength, jaw range of motion (ROM), and saliva weight were significantly lower at 3 and 6 months than at baseline. QOL was significantly worse after tx, although it improved by 6 months as rated with the EAT-10 and the SHI scores were significantly worse at 3 and 6 months. EORTC domains of swallowing, senses, speech, dry mouth, and sticky saliva were significantly worse at 3 and 6 months. Concomitant chemoradiotherapy for treatment of head and neck tumors can result in impaired performance outcomes and QOL over the first 6 months post-tx. However, performance status, tongue strength, jaw ROM, and eating QOL were only mildly impaired by 6 months post-tx. Saliva production and speech QOL remained significantly impaired at 6 months post-treatment. Current studies are examining outcomes at 12 and 24 months post-treatment to better predict outcomes over time in this population.

Importance Functional recovery for patients who undergo maxillomandibular reconstruction with vascularized bone free flaps (VBFFs) is potentially more attainable with computer-assisted implant rehabilitation. This prosthodontic-driven approach uses software planning and surgical templates for implant placement supporting fixed dental prostheses (FDP). Implant success with immediate load (IL) provisional and definitive FDP restorations in VBFFs is reported for the first time in a patient cohort. Objectives To determine implant success for FDP restorations and IL restorations. To determine factors that may influence success and predictability to provide FDP restorations in VBFFs. Design A retrospective medical chart review was conducted of patients who underwent VBFF reconstruction and computer-assisted planning (CP) for FDP implant rehabilitation. This study was conducted with approval from the institutional review board at Beth Israel Medical Center, New York, New York. Setting Clinical procedures were conducted in operating room and outpatient facilities in a tertiary referral medical center. Participants Twenty-eight consecutive patient treatments were reviewed. Inclusion criteria for all patients were VBFF reconstruction and CP for FDP restoration prior to stage 1 implant surgery. Patients were evaluated for implant success, surgical templates, IL provisional restorations, and prosthodontic framework design. A comparison is made between patients with IL provisional restorations and those patients who did not receive an immediate restoration. Main Outcomes and Measures Implants that achieved osseointegration and used for prosthetic reconstruction determined success. Prosthodontic design considerations included whether the patient received an IL provisional restoration and 3 categories of FDP metal framework design. Results Ninety-nine implants of 116 implants placed were used for prosthetic restorations, achieving an 85.4% success rate. Twenty-five of 28 patients received FDP restorations. Thirteen of 28 patients received IL provisional restorations at stage 1 implant surgery. Fifty of 56 implants were successful (89.3%) in the IL group. Conclusions Computer-assisted implant rehabilitation of reconstructed defects can achieve superior results to provide FDP and IL provisional restorations. This prosthodontic-driven approach also uses unique framework design to account for mandible height discrepancy after fibula free flap reconstruction. Patient management for FDP rehabilitation is also dependent on radiation status, soft-tissue modification, and patient selection.