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Several prospective studies report improved outcomes with pretreatment nutrition interventions prior to radiation therapy for head and neck cancer (HNC), but none have assessed similar interventions before surgery for HNC.POINT, a pilot randomized controlled trial, was conducted to evaluate a multimodal nutrition intervention. Patients undergoing primary surgery with free flap reconstruction for HNC were randomly assigned to the control arm or a preoperative multimodal nutrition intervention.POINT included 49 patients. Nutrition risk scores did not change significantly for either the intervention or control group. Control patients had a significant decrease in body weight in the preoperative period (p 0.001). Conversely, weight among intervention patients did not significantly decrease (p = 0.680). The intervention mitigated weight loss in patients with dysphagia (p = 0.001).Preoperative nutrition optimization shows potential to reduce weight loss normally experienced by patients with head and neck cancer prior to surgical extirpation, especially among those with subjective dysphagia.

ImportanceIn clinically localized (T1-2) oral cavity squamous cell carcinoma (OCSCC), regional lymph node metastasis is associated with a poor prognosis. Given the high propensity of subclinical nodal disease in these patients, upfront elective neck dissections (END) for patients with clinically node-negative disease are common and associated with better outcomes. Unfortunately, even with this risk-adverse treatment paradigm, disease recurrence still occurs, and our understanding of the factors that modulate this risk and alter survival have yet to be fully elucidated.ObjectiveTo investigate the prognostic value of lymph node yield (LNY), lymph node ratio (LNR), and weighted LNR (wLNR) in patients with clinically node-negative T1-2 OCSCC.Design, Setting, and ParticipantsIn this cohort study, data were collected retrospectively from 7 tertiary care academic medical centers. Overall, 523 patients with cT1-2N0 OCSCC who underwent elective neck dissections after primary surgical extirpation were identified.ExposuresLymph node yield was defined as the number of lymph nodes recovered from elective neck dissection. Lymph node ratio was defined as the ratio of positive nodes against total LNY. Weighted LNR incorporated information from both LNY and LNR into a single continuous metric.Main Outcomes and MeasuresLocoregional control (LRC) and disease-free survival (DFS) were both evaluated using nonparametric Kaplan-Meier estimators and semiparametric Cox regression.ResultsOn multivariable analysis, LNY less than or equal to 18 lymph nodes was found to be significantly associated with decreased LRC (aHR, 1.53; 95% CI, 1.04-2.24) and DFS (aHR, 1.46; 95% CI, 1.12-1.92) in patients with pN0 disease, but not those with pN-positive disease. Importantly, patients with pN0 disease with LNY less than or equal to 18 and those with pN1 diseasehad nearly identical 5-year LRC (69.7% vs 71.4%) and DFS (58.2% vs 55.7%). For patients with pN-positive disease, LNR greater than 0.06 was significantly associated with decreased LRC (aHR, 2.66; 95% CI, 1.28-5.55) and DFS (aHR, 1.65; 95% CI, 1.07-2.53). Overall, wLNR was a robust prognostic variable across all patients with cN0 disease, regardless of pathologic nodal status. Risk stratification via wLNR thresholds demonstrated greater optimism-corrected concordance compared with American Joint Committee on Cancer (AJCC) 8th edition nodal staging for both LRC (0.61 vs 0.57) and DFS (0.61 vs 0.58).Conclusions and RelevanceMovement toward more robust metrics that incorporate quantitative measures of neck dissection quality and regional disease burden, such as wLNR, could greatly augment prognostication in cT1-2N0 OCSCC by providing more reliable and accurate risk estimations.

ImportanceTimely initiation of postoperative radiation therapy (PORT) is associated with reduced recurrence rates and improved overall survival in patients with head and neck squamous cell carcinoma (HNSCC). Measurement of the association of social-ecological variables with PORT delays is lacking.ObjectiveTo assess individual and community-level factors associated with PORT delay among patients with HNSCC.Design, Setting, and ParticipantsThis prospective cohort study carried out between September 2018 and June 2022 included adults with untreated HNSCC who were enrolled in a prospective registry at a single academic tertiary medical center. Demographic information and validated self-reported measures of health literacy were obtained at baseline visits. Clinical data were recorded, and participant addresses were used to calculate the area deprivation index (ADI), a measure of community-level social vulnerability. Participants receiving primary surgery and PORT were analyzed. Univariable and multivariable regression analysis was performed to identify risk factors for PORT delays.ExposuresSurgical treatment and PORT.Main Outcomes and MeasuresThe primary outcome was PORT initiation delay (>42 days from surgery). Risk of PORT initiation delay was evaluated using individual-level (demographic, health literacy, and clinical data) and community-level information (ADI and rural-urban continuum codes).ResultsOf 171 patients, 104 patients (60.8%) had PORT delays. Mean (SD) age of participants was 61.0 (11.2) years, 161 were White (94.2%), and 105 were men (61.4%). Insurance was employer-based or public among 65 (38.5%) and 75 (44.4%) participants, respectively. Mean (SD) ADI (national percentile) was 60.2 (24.4), and 71 (41.8%) resided in rural communities. Tumor sites were most commonly oral cavity (123 [71.9%]), with 108 (63.5%) classified as stage 4 at presentation. On multivariable analysis, a model incorporating individual-level factors with health literacy in addition to community-level factors was most predictive of PORT delay (AOC= 0.78; R2, 0.18).Conclusions and RelevanceThis cohort study provides a more comprehensive assessment of predictors of PORT delays that include health literacy and community-level measures. Predictive models that incorporate multilevel measures outperform models with individual-level factors alone and may guide precise interventions to decrease PORT delay for at-risk patients with HNSCC.

To evaluate the effect of histopathologic skin invasion on 2- and 5-year disease-free survival (DFS) and overall survival (OS) in patients treated with primary surgery for locally advanced oral cavity squamous cell carcinoma (OCSCC).A retrospective case-control study was performed comparing previously untreated patients with pT4a OCSCC with and without skin invasion.Academic medical center.Propensity score-matched cohorts were derived by age, sex, surgical margins, pathologic N classification, adjuvant treatment, and primary tumor site. The Kaplan-Meier method was used to evaluate 2- and 5-year OS and DFS, which were compared between cohorts via the log rank (Mantel-Cox) test statistic.Overall 25 patients were identified to have pathologic skin invasion, and 50 were selected for the matched control group. OS was significantly lower for patients with skin invasion as compared with controls at 2 years (30.8% vs 53.3%,Histopathologic skin invasion in OCSCC is associated with dismal prognosis in patients who underwent primary surgical treatment. OS outcomes for patients with skin invasion are comparable to survival of patients with recurrent/metastatic disease and T4N2 disease.

To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries.Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids.Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054). RCT: Interim analysis for safety and futility was planned during trial's design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p 0.05). Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2.Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery.1, Randomized Clinical Trial Laryngoscope, 2022.

To assess the impact of sociodemographic factors on primary treatment choice (surgery vs radiotherapy) in patients with human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC).Retrospective analysis of the National Cancer Database.Data from1500 Commission on Cancer institutions (academic and community) via the National Cancer Database.Our sample consists of patients diagnosed with HPV+ OPSCC from 2010 to 2015. The primary outcome of interest was initial treatment modality: surgery vs radiation. We performed multivariable logistic models to assess the relationship between treatment choice and sociodemographic factors, including sex, race, treatment facility, and insurance status.Of the 16,043 patients identified, 5894 (36.7%) underwent primary surgery while 10,149 (63.3%) received primary radiotherapy. Black patients were less likely than White patients to receive primary surgery (odds ratio [OR], 0.80; 95% CI, 0.66-0.96). When compared with privately insured patients, those who were uninsured or on Medicaid or Medicare were also less likely to receive primary surgery (OR, 0.70 [95% CI, 0.56-0.86]; OR, 0.77 [95% CI, 0.65-0.91]; OR, 0.85 [95% CI, 0.75-0.96], respectively). Patients receiving treatment at an academic/research cancer program were more likely to undergo primary surgery than those treated at comprehensive community cancer programs (OR, 1.33; 95% CI, 1.14-1.56).In this large sample of patients with HPV+ OPSCC, race and insurance status affect primary treatment choice. Specifically, Black and nonprivately insured patients are less likely to receive primary surgery as compared with White or privately insured patients. Our findings illuminate potential disparities in HPV+ OPSCC treatment.

BACKGROUND Due to inherent impact on quality of life, metastatic head and neck cancer patients are well-suited to benefit from palliative care (PC). Our objective was to examine factors that shape PC utilization and implications for overall survival in stage IVc head and neck cancer patients. METHODS A retrospective study of patients with stage IVc head and neck cancer in the National Cancer Database from 2004 and 2015 was conducted. RESULTS 7794 cases met inclusion criteria, of which 19.3% received PC. PC use was associated with more recent years of diagnosis, Northeast facility geography, and non-private insurances (p

Background: Olfactory dysfunction (OD) is an early symptom of Alzheimer’s disease (AD). However, olfactory testing is not commonly performed to test OD in the setting of AD. Objective: This work investigates objective OD as a non-invasive biomarker for accurately classifying subjects as cognitively unimpaired (CU), mild cognitive impairment (MCI), and AD. Methods: Patients with MCI (n = 24) and AD (n = 24), and CU (n = 33) controls completed two objective tests of olfaction (Affordable, Rapid, Olfactory Measurement Array –AROMA; Sniffin’ Sticks Screening 12 Test –SST12). Demographic and subjective sinonasal and olfaction symptom information was also obtained. Analyses utilized traditional statistics and machine learning to determine olfactory variables, and combinations of variables, of importance for differentiating normal and disease states. Results: Inability to correctly identify a scent after detection was a hallmark of MCI/AD. AROMA was superior to SST12 for differentiating MCI from AD. Performance on the clove scent was significantly different between all three groups. AROMA regression modeling yielded six scents with AUC of the ROC of 0.890 (p

Objectives: This study seeks to (1) demonstrate how machine learning (ML) can be used for prediction modeling by predicting the treatment patients with T1–2, N0–N1 oropharyngeal squamous cell carcinoma (OPSCC) receive and (2) assess the impact patient, socioeconomic, regional, and institutional factors have in the treatment of this population. Methods: A retrospective cohort of adults diagnosed with T1–2, N0–N1 OPSCC from 2004 to 2013 was obtained using the National Cancer Database. The data was split into 80/20 distribution for training and testing, respectively. Various ML algorithms were explored for development. Area under the curve (AUC), accuracy, precision, and recall were calculated for the final model. Results: Among the 19,111 patients in the study, the mean (standard deviation) age was 61.3 (10.8) years, 14,034 (73%) were male, and 17,292 (91%) were white. Surgery was the primary treatment in 9,533 (50%) cases and radiation in 9,578 (50%) cases. The model heavily utilized T-stage, primary site, N-stage, grade, and type of treatment facility to predict the primary treatment modality. The final model yielded an AUC of 78% (95% CI, 77–79%), accuracy of 71%, precision of 72%, and recall of 71%. Conclusion: This study created a ML model utilizing clinical variables to predict primary treatment modality for T1–2, N0–N1 OPSCC. This study demonstrates how ML can be used for prediction modeling while also highlighting that tumor and facility realted variables impact the decision making process on a national level.

Background The coronavirus disease 2019 pandemic has led to increased telemedicine visits. This study examines current preferences and barriers for telemedicine among patients with head and neck cancer. Methods Single institution retrospective analysis of 64 patients scheduling visits with the head and neck surgical oncology clinic at a tertiary academic medical center. Data were collected detailing patient preferences and barriers regarding telemedicine appointments. Patients electing to participate in telemedicine were compared to those preferring in‐person appointments. Results Most patients (68%) were not interested in telemedicine. Preference for in‐person examination was the most common reason for rejecting telemedicine, followed by discomfort with or limited access to technology. Patients elected telemedicine visits to avoid infection and for convenience. Conclusions When given a choice, patients with head and neck cancer preferred in‐person visits over telemedicine. Although telemedicine may improve health care access, patient preferences, technology‐related barriers, and limitations regarding cancer surveillance must be addressed moving forward.

Use of artificial intelligence (AI) is a burgeoning field in otolaryngology and the communication sciences. A virtual symposium on the topic was convened from Duke University on October 26, 2020, and was attended by more than 170 participants worldwide. This review presents summaries of all but one of the talks presented during the symposium; recordings of all the talks, along with the discussions for the talks, are available at https://www.youtube.com/watch?v=ktfewrXvEFg and https://www.youtube.com/watch?v=-gQ5qX2v3rg . Each of the summaries is about 2500 words in length and each summary includes two figures. This level of detail far exceeds the brief summaries presented in traditional reviews and thus provides a more-informed glimpse into the power and diversity of current AI applications in otolaryngology and the communication sciences and how to harness that power for future applications.

Diagnosis and treatment of Ménière's disease remains a significant challenge because of our inability to understand what is occurring on a molecular level. MicroRNA (miRNA) perilymph profiling is a safe methodology and may serve as a "liquid biopsy" equivalent. We used machine learning (ML) to evaluate miRNA expression profiles of various inner ear pathologies to predict diagnosis of Ménière's disease.Prospective cohort study.Tertiary academic hospital.Perilymph was collected during labyrinthectomy (Ménière's disease, n = 5), stapedotomy (otosclerosis, n = 5), and cochlear implantation (sensorineural hearing loss [SNHL], n = 9). miRNA was isolated and analyzed with the Affymetrix miRNA 4.0 array. Various ML classification models were evaluated with an 80/20 train/test split and cross-validation. Permutation feature importance was performed to understand miRNAs that were critical to the classification models.In terms of miRNA profiles for conductive hearing loss versus Ménière's, 4 models were able to differentiate and identify the 2 disease classes with 100% accuracy. The top-performing models used the same miRNAs in their decision classification model but with different weighted values. All candidate models for SNHL versus Ménière's performed significantly worse, with the best models achieving 66% accuracy. Ménière's models showed unique features distinct from SNHL.We can use ML to build Ménière's-specific prediction models using miRNA profile alone. However, ML models were less accurate in predicting SNHL from Ménière's, likely from overlap of miRNA biomarkers. The power of this technique is that it identifies biomarkers without knowledge of the pathophysiology, potentially leading to identification of novel biomarkers and diagnostic tests.

BACKGROUND Lymph node yield (LNY) is a proposed quality indicator in neck dissection for oral cavity squamous cell carcinoma (OCSCC). METHODS Retrospective series including 190 patients with OCSCC undergoing neck dissection between 2016 and 2018. A change in pathologic grossing protocol was initiated during the study period to assess residual adipose tissue. A generalized linear model was used to assess the impact of multiple variables on LNY. RESULTS Mean LNY was 28.59 (SD = 17.65). The protocol identified a mean of 10.32 lymph nodes per case. Multivariable analysis identified associations between LNY and use of the pathology protocol (P = .02), number of dissected lymph node levels (P

Introduction The COVID‐19 pandemic has raised controversies regarding safe and effective care of head and neck cancer patients. It is unknown how much the pandemic has changed surgeon practice. Methods A questionnaire was distributed to head and neck surgeons assessing opinions related to treatment and concerns for the safety of patients, self, family, and staff. Results A total of 67 head and neck surgeons responded during the study period. Surgeons continued to recommend primary surgical treatment for oral cavity cancers. Respondents were more likely to consider non‐surgical therapy for patients with early glottic cancers and HPV‐mediated oropharynx cancer. Surgeons were least likely to be concerned for their own health and safety and had the greatest concern for their resident trainees. Conclusions This study highlights differences in the willingness of head and neck surgeons to delay surgery or alter plans during times when hospital resources are scarce and risk is high. This article is protected by copyright. All rights reserved.

The specificity of sentinel lymph node biopsy (SLNB) for detecting lymph node metastasis in head and neck melanoma (HNM) is low under current National Comprehensive Cancer Network (NCCN) treatment guidelines.Multiple machine learning (ML) algorithms were developed to identify HNM patients at very low risk of occult nodal metastasis using National Cancer Database (NCDB) data from 8466 clinically node negative HNM patients who underwent SLNB. SLNB performance under NCCN guidelines and ML algorithm recommendations was compared on independent test data from the NCDB (n = 2117) and an academic medical center (n = 96).The top-performing ML algorithm (AUC = 0.734) recommendations obtained significantly higher specificity compared to the NCCN guidelines in both internal (25.8% vs. 11.3%, p 0.001) and external test populations (30.1% vs. 7.1%, p 0.001), while achieving sensitivity97%.Machine learning can identify clinically node negative HNM patients at very low risk of nodal metastasis, who may not benefit from SLNB.

Background Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion. Methods A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time. Results One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union. Conclusion This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

BACKGROUND While quality of life (QOL), psychosocial health, and adverse treatment outcomes have been studied in head and neck cancer (HNC) patients, decision regret is an important and understudied complication that can negatively impact future health care decision making. METHODS Data collected using a HNC patient registry with questionnaires administered at initial consultation visits plus 3 and 6 months after treatment completion was retrospectively analyzed. A visual analog anxiety scale and the University of Washington Quality of Life were given at clinic visits. Decision regret was determined using a validated scale. Demographic and clinical variables were collected retrospectively and at baseline. RESULTS Patients with higher anxiety and lower self-reported QOL had higher concurrent regret at 3-month (n = 140) and at 6-month (n = 82) post-treatment. Later disease stage at presentation, nonprimary surgical treatment, and lower health literacy were associated with greater regret. CONCLUSIONS Decision regret was highest in HNC patients with high anxiety, low QOL, and more advanced disease.

OBJECTIVES/HYPOTHESIS Human papillomavirus (HPV) is a DNA virus that causes cancer in multiple sites. Although sexual activity is the primary means of oropharyngeal HPV acquisition, studies suggest HPV transmission through occupational exposure from medical instruments and surgical fumes. We assess if aerosolization of HPV16 DNA via electrocautery places otolaryngologists at risk for exposure. STUDY DESIGN Animal and human laboratory model. METHODS Plasmid (pLXSN16E6E7) expressing HPV p16 E6/E7 genes was transformed into DH5α Escherichia coli cells using the heat shock method. Miniprep and maxiprep purification of transformed DNA with subsequent restriction enzyme double digestion confirmed presence of E6E7 fragment. We injected 2 μg plasmid DNA in 20 μL TE (Tris and ethylenediaminetetraacetic acid) buffer intradermally into freshly severed mouse tail then cauterized for 5 to 10 seconds. Generated fumes were collected through a suction tube fitted with Whatman filter paper. Filter paper was placed in 100 μL TE buffer. Additionally, six patients undergoing transoral robotic surgery for resection of oropharyngeal cancer were identified, three with p16-negative tumors and three with p16-positive tumors. Intraoperatively, Whatman filter paper was exposed to electrocautery fumes, then placed in 100 uL TE buffer. Additional samples were collected from the suction tubing and filter, the surgical mask of the surgeon at head of the bed, and the robot arm. RESULTS Samples were analyzed via polymerase chain reaction with an assay sensitivity of 1.5 ng E6E7 DNA. None of the patient or mouse tail samples yielded detectable HPV16 DNA in the electrocautery fumes. We did not detect HPV16 DNA on the surgical masks, suction apparatus, or robot arm intraoperatively. CONCLUSIONS There is likely minimal risk of occupational exposure to HPV16 via electrocautery fumes. LEVEL OF EVIDENCE NA Laryngoscope, 130:2366-2371, 2020.

To provide a state of the art review of artificial intelligence (AI), including its subfields of machine learning and natural language processing, as it applies to otolaryngology and to discuss current applications, future impact, and limitations of these technologies.PubMed and Medline search engines.A structured search of the current literature was performed (up to and including September 2018). Search terms related to topics of AI in otolaryngology were identified and queried to identify relevant articles.AI is at the forefront of conversation in academic research and popular culture. In recent years, it has been touted for its potential to revolutionize health care delivery. Yet, to date, it has made few contributions to actual medical practice or patient care. Future adoption of AI technologies in otolaryngology practice may be hindered by misconceptions of what AI is and a fear that machine errors may compromise patient care. However, with potential clinical and economic benefits, it is vital for otolaryngologists to understand the principles and scope of AI.In the coming years, AI is likely to have a major impact on biomedical research and the practice of medicine. Otolaryngologists are key stakeholders in the development and clinical integration of meaningful AI technologies that will improve patient care. High-quality data collection is essential for the development of AI technologies, and otolaryngologists should seek opportunities to collaborate with data scientists to guide them toward the most impactful clinical questions.

Vessel depleted necks present a challenge to identifying suitable recipient vessels for microvascular head and neck reconstruction. Many alternative recipient vessels have been described. The purpose of this report is to describe the feasibility of using the lateral thoracic artery as a recipient vessel for head and neck free flap reconstruction in vessel depleted necks. In this report we describe surgery for a 62 year old male with osteoradionecrosis of the right mandibular body in which we performed right segmental mandibulectomy with free fibular flap reconstruction in a vessel depleted neck. We used the lateral thoracic artery which was ~10 cm in length. It provided good reach to the neck, proper blood flow, and acceptable vessel diameter of ~1.5 mm at 6 cm above the clavicle. The patient had an uncomplicated postoperative course and the flap was viable and well healed at 2 months follow-up. The lateral thoracic artery could be considered as one of the options for recipient vessels for microvascular reconstruction in patients with vessel depleted necks.

IMPORTANCE: Facial reanimation procedures share the same surgical field as a parotidectomy and are most easily accomplished at the time of facial nerve sacrifice. Early reanimation would also reduce the duration of paralysis and may lead to better functional outcomes. OBJECTIVE: To assess the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study identified 285 patients who underwent total parotidectomy with facial nerve sacrifice (Current Procedural Terminology code 42425) and evaluated the various types of facial reanimation procedures performed concurrently. Patients were identified from the ACS-NSQIP database encompassing 603 community and academic hospitals and underwent treatment from January 1, 2010, through December 31, 2015. Data were analyzed from September 20, 2017, through February 21, 2018. MAIN OUTCOMES AND MEASURES: Comparison of demographics in nonreanimation and reanimation groups and subgroups of nerve- and sling-type reanimation procedures. RESULTS: Of 285 patients who underwent total parotidectomy with facial nerve sacrifice (61.8% men; mean [SD] age, 64 [15] years), 89 (31.2%; 95% CI, 26.0%-37.0%) underwent at least 1 concurrent facial reanimation procedure. Of the facial nerve procedures performed, 41 (46.1%; 95% CI, 36.0%-56.0%) were nerve-type repairs, 31 (34.8%; 95% CI, 26.0%-45.0%) were sling-type repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) included both types. Patients treated with nerve-type repairs only were significantly younger than those treated with sling-type repairs only (mean [SD] age, 57.6 [16.0] vs 72.1 [13.8] years; P

Given that early-stage oral cavity squamous cell carcinoma (OCSCC) has a high propensity for subclinical nodal metastasis, elective neck dissection has become standard practice for many patients with clinically negative nodes. Unfortunately, for most patients without regional metastasis, this risk-averse treatment paradigm results in unnecessary morbidity.To develop and validate predictive models of occult nodal metastasis from clinicopathological variables that were available after surgical extirpation of the primary tumor and to compare predictive performance against depth of invasion (DOI), the currently accepted standard.This diagnostic modeling study collected clinicopathological variables retrospectively from 7 tertiary care academic medical centers across the US. Participants included adult patients with early-stage OCSCC without nodal involvement who underwent primary surgical extirpation with or without upfront elective neck dissection. These patients were initially evaluated between January 1, 2000, and December 31, 2019.Largest tumor dimension, tumor thickness, DOI, margin status, lymphovascular invasion, perineural invasion, muscle invasion, submucosal invasion, dysplasia, histological grade, anatomical subsite, age, sex, smoking history, race and ethnicity, and body mass index (calculated as weight in kilograms divided by height in meters squared).Occult nodal metastasis identified either at the time of elective neck dissection or regional recurrence within 2 years of initial surgery.Of the 634 included patients (mean [SD] age, 61.2 [13.6] years; 344 men [54.3%]), 114 (18.0%) had occult nodal metastasis. Patients with occult nodal metastasis had a higher frequency of lymphovascular invasion (26.3% vs 8.1%; P .001), perineural invasion (40.4% vs 18.5%; P .001), and margin involvement by invasive tumor (12.3% vs 6.3%; P = .046) compared with those without pathological lymph node metastasis. In addition, patients with vs those without occult nodal metastasis had a higher frequency of poorly differentiated primary tumor (20.2% vs 6.2%; P .001) and greater DOI (7.0 vs 5.4 mm; P .001). A predictive model that was built with XGBoost architecture outperformed the commonly used DOI threshold of 4 mm, achieving an area under the curve of 0.84 (95% CI, 0.80-0.88) vs 0.62 (95% CI, 0.57-0.67) with DOI. This model had a sensitivity of 91.7%, specificity of 72.6%, positive predictive value of 39.3%, and negative predictive value of 97.8%.Results of this study showed that machine learning models that were developed from multi-institutional clinicopathological data have the potential to not only reduce the number of pathologically node-negative neck dissections but also accurately identify patients with early OCSCC who are at highest risk for nodal metastases.

To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions.Cross-sectional analysis of US national database.American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017.A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared.When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis.We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors.

Objective Nonphysician health care workers are involved in high-risk patient care during the COVID-19 pandemic, placing them at high risk of mental health burden. The mental health impact of COVID-19 in this crucial population has not been studied thus far. Thus, the objective of this study is to assess the psychosocial well-being of these providers. Study Design National cross-sectional online survey (no control group). Setting Academic otolaryngology programs in the United States. Subjects and Methods We distributed a survey to nonphysician health care workers in otolaryngology departments across the United States. The survey incorporated a variety of validated mental health assessment tools to measure participant burnout (Mini-Z assessment), anxiety (Generalized Anxiety Disorder–7), distress (Impact of Event Scale), and depression (Patient Health Questionnaire–2). Multivariable logistic regression analysis was performed to determine predictive factors associated with these mental health outcomes. Results We received 347 survey responses: 248 (71.5%) nurses, 63 (18.2%) administrative staff, and 36 (10.4%) advanced practice providers. A total of 104 (30.0%) respondents reported symptoms of burnout; 241 (69.5%), symptoms of anxiety; 292 (84.1%), symptoms of at least mild distress; and 79 (22.8%), symptoms of depression. Upon further analysis, development of these symptoms was associated with factors such as occupation, practice setting, and case load. Conclusion Frontline otolaryngology health care providers exhibit high rates of mental health complications, particularly anxiety and distress, in the wake of COVID-19. Adequate support systems must be put into place to address these issues.

OBJECTIVES/HYPOTHESIS To investigate national trends in admission status after thyroidectomy in the United States and to evaluate the factors associated with 30-day unplanned readmission and reoperation. STUDY DESIGN Retrospective review of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) METHODS: The ACS-NSQIP database was queried for patients who underwent a partial or total thyroidectomy between 2005 and 2014. Outpatient surgery was defined as discharge on the day of surgery. Patient demographic information, unplanned hospital readmission, and reoperation were reviewed. Risk factors were identified using logistic regression modeling. RESULTS A total of 76,604 cases met inclusion criteria as described above. There were 1,473 (1.9%) patients who underwent reoperation and 477 unplanned 30-day readmissions (1.4%) for procedures performed since 2012. There was a significant positive trend in the percentage of thyroidectomy (partial and total) patients who underwent outpatient procedures by year of operation (P < .001). Outpatient procedures were not more likely to have unplanned readmissions or reoperations. Independent patient risk factors for unplanned readmission and reoperation included current dialysis, chronic steroid use, unintentional weight loss, American Society of Anesthesiologists class 3 to 4, and active bleeding disorders. CONCLUSIONS Over the past decade there has been a clear trend toward increasing outpatient thyroid surgery. Thyroidectomy performed as an outpatient was not found to be an independent risk factor for readmission or reoperation. Patients with serious medical comorbidities and active bleeding disorders are at increased risk of unplanned readmission or reoperation and should have their surgery performed on an inpatient basis. LEVEL OF EVIDENCE 2c. Laryngoscope, 128:1249-1254, 2018.

Objectives/Hypothesis To develop and evaluate a high-fidelity training simulator for transoral robotic posterior hemiglossectomy. Study Design Prospective observational study. Methods We constructed a transoral robotic surgery (TORS) simulator using porcine tongue in a modified airway mannequin. Twenty-nine surgeons performed transoral robotic posterior hemiglossectomy on the simulator. The 20 resident subjects completed six trials each, and the five fellows and four attending surgeons completed two trials each. In addition to instrument vibrations, surgical video was recorded for each trial and was blindly rated using the Global Evaluative Assessment of Robotic Skill (GEARS), a validated instrument for assessing robotic surgical skill. Results Attending surgeons were faster (P = .004) and demonstrated greater technical skill than fellows or residents (P < .001). Resident completion time generally decreased over the study, becoming significantly faster by the fifth trial (P = .02). A similar trend was seen in resident GEARS scores, which generally increased and were significantly improved by the fourth trial (P = .008). Instrument vibrations were not significantly different between subject groups. Finally, subjects highly rated the realism and training value of the TORS simulator (mean 4.4 and 4.7 out of 5, respectively). Conclusions The reported findings support using the described simulator as a training tool for TORS. Residents significantly improved in speed and technical skill over the course of six trials but did not achieve the performance levels of attending surgeons. These results demonstrate that high-fidelity simulation is a valuable tool for training novice surgeons in transoral robotic surgery. Level of Evidence NA Laryngoscope, 2017

Objective To determine which complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, correlate with 30-day mortality in surgery for malignancies of the head and neck. Study Design Retrospective review of prospectively collected national database. Setting NSQIP. Subjects and Methods NSQIP data from 2005 to 2014 were queried for ICD-9 codes head and neck malignancies. Multivariate logistic regression was used to examine the correlation of individual complications with 30-day mortality. Results In total, 15,410 cases met criteria with 3499 complications in 2235 cases. After controlling for patient and surgical variables, postoperative pneumonia ( P = .02; odds ratio [OR], 2.39; 95% confidence interval [CI], 1.15-4.72), progressive renal insufficiency ( P < .001; OR, 21.28; 95% CI, 4.22-87.94), bleeding requiring transfusion ( P = .02; OR, 2.10; 95% CI, 1.12-3.84), sepsis ( P = .02; OR, 2.86; 95% CI, 1.15-6.46), septic shock ( P = .045; OR, 2.87; 95% CI, 0.98-7.81), stroke ( P < .001; OR, 19.81; 95% CI, 6.23-56.03), and cardiac arrest ( P < .001; OR, 135.59; 95% CI, 65.00-286.48) were independently associated with increased odds of 30-day mortality. Conclusion The NSQIP database has been extensively validated and used to examine surgical complications, yet there is little analysis on which complications are associated with death. This study identified complications associated with increased risk of 30-day mortality following head and neck cancer surgery. These associations may be used as a measure of complication severity and should be considered when using the NSQIP database to evaluate outcomes in head and neck surgery.

Artificial intelligence (AI) is quickly expanding within the sphere of health care, offering the potential to enhance the efficiency of care delivery, diminish costs, and reduce diagnostic and therapeutic errors. As the field of otolaryngology also explores use of AI technology in patient care, a number of ethical questions warrant attention prior to widespread implementation of AI. This commentary poses many of these ethical questions for consideration by the otolaryngologist specifically, using the 4 pillars of medical ethics-autonomy, beneficence, nonmaleficence, and justice-as a framework and advocating both for the assistive role of AI in health care and for the shared decision-making, empathic approach to patient care.

Importance Data regarding outcomes after major head and neck ablation and reconstruction in the growing geriatric population (specifically ≥80 years of age) are limited. Such information would be extremely valuable in preoperative discussions with elderly patients about their surgical risks and expected functional outcomes. Objectives To identify patient and surgical factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline; to explore whether an association exists between the type of reconstructive procedure and outcome; and to create a preoperative risk stratification system for these outcomes. Design, Setting, and Participants This retrospective, multi-institutional cohort study included patients 80 years or older undergoing pedicle or free-flap reconstruction after an ablative head and neck surgery from January 1, 2015, to December 31, 2017, at 17 academic centers. Data were analyzed from February 1 through April 20, 2019. Main Outcomes and Measures Thirty-day serious complication rate, 90-day mortality, and 90-day decline in functional status. Preoperative comorbidity and frailty were assessed using the American Society of Anesthesiologists classification, Adult Comorbidity Evaluation–27 score, and Modified Frailty Index. Multivariable clustered logistic regressions were performed. Conjunctive consolidation was used to create a risk stratification system. Results Among 376 patients included in the analysis (253 [67.3%] men), 281 (74.7%) underwent free-flap reconstruction. The median age was 83 years (range, 80-98 years). A total of 193 patients (51.3%) had 30-day serious complications, 30 (8.0%) died within 90 days, and 36 of those not dependent at baseline declined to dependent status (11.0%). Type of flap (free vs pedicle, bone vs no bone) was not associated with these outcomes. Variables associated with worse outcomes were age of at least 85 years (odds ratio [OR] for 90-day mortality, 1.19 [95% CI 1.14-1.26]), moderate or severe comorbidities (OR for 30-day complications, 1.80 [95% CI, 1.34-2.41]; OR for 90-day mortality, 3.33 [95% CI, 1.29-8.60]), body mass index (BMI) of less than 25 (OR for 30-day complications, 0.95 [95% CI, 0.91-0.99]), high frailty (OR for 30-day complications, 1.72 [95% CI, 1.10-2.67]), duration of surgery (OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), flap failure (OR for 90-day mortality, 3.56 [95% CI, 1.47-8.62]), additional operations (OR for 30-day complications, 5.40 [95% CI, 3.09-9.43]; OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), and surgery of the maxilla, oral cavity, or oropharynx (OR for 90-day functional decline, 2.51 [95% CI, 1.30-4.85]). Age, BMI, comorbidity, and frailty were consolidated into a novel 3-tier risk classification system. Conclusions and Relevance Important demographic, clinical, and surgical characteristics were found to be associated with postoperative complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck surgery. Free flap and bony reconstruction were not independently associated with worse outcomes. A novel risk stratification system is presented.

Background Delays in postoperative radiotherapy (PORT) for head and neck cancer (HNC) increase the risk for recurrence and mortality. The multifactorial nature of delays calls for an in-depth understanding of potential contributors from the patient's and provider's perspectives. We sought to identify causes of delays in adjuvant radiotherapy initiation for HNC. Methods We performed a mixed-methods study including patients with HNC care team members. Forty in-depth interviews were performed (26 patients; 14 care team members). Timing and demographic data were collected from medical records. Results Median time from surgery to radiotherapy initiation was 45 days; 15 participants began after 42 days. Process delays and failure to communicate the urgency and significance of PORT initiation contributes to delays. Patients with a strong social support system experience less delays. Conclusions Achieving reductions in PORT initiation requires efficient care coordination, improved communication between interdisciplinary teams, and strengthening social support systems for patients with HNC.

Importance Predicting survival of oral squamous cell carcinoma through the use of prediction modeling has been underused, and the development of prediction models would augment clinicians’ ability to provide absolute risk estimates for individual patients. Objectives To develop a prediction model using machine learning for 5-year overall survival among patients with oral squamous cell carcinoma and compare this model with a prediction model created from the TNM (Tumor, Node, Metastasis) clinical and pathologic stage. Design, Setting, and Participants A retrospective cohort study was conducted of 33 065 patients with oral squamous cell carcinoma from the National Cancer Data Base between January 1, 2004, and December 31, 2011. Patients were excluded if the treatment was considered palliative, staging demonstrated T0 or Tis, or survival or staging data were missing. Patient, tumor, treatment, and outcome information were obtained from the National Cancer Data Base. The data were split into a distribution of 80% for training and 20% for testing. The model was created using 2-class decision forest architecture. Permutation feature importance scores were used to determine the variables that were used in the model’s prediction and their order of significance. Statistical analysis was conducted from August 1, 2018, to January 10, 2019. Main Outcomes and Measures Ability to predict 5-year overall survival assessed through area under the curve, accuracy, precision, and recall. Results Among the 33 065 patients in the study, the mean (SD) age was 64.6 (14.0) years, 19 791 were men (59.9%), 13 274 were women (40.1%), and 29 783 (90.1%) were white. At 60 months, there were 16 745 deaths (50.6%). The median time of follow-up was 56.8 months (range, 0-155.6 months). Age, pathologic T stage, positive margins at the time of surgery, lymph node size, and institutional identification were identified among the most significant variables. The calculated area under the curve for this machine learning model was 0.80 (95% CI, 0.79-0.81), accuracy was 71%, precision was 71%, and recall was 68%. In comparison, the calculated area under the curve of the TNM staging system was 0.68 (95% CI, 0.67-0.70), accuracy was 65%, precision was 69%, and recall was 52%. Conclusions and Relevance Using machine learning algorithms, a prediction model was created based on patient social, demographic, clinical, and pathologic features. The developed prediction model proved to be better than a prediction model that exclusively used TNM pathologic and clinical stage according to all performance metrics. This study highlights the role that machine learning may play in individual patient risk estimation in the era of big data.

Clinical practice guidelines (CPGs), developed to inform clinicians, patients, and policy makers about what constitutes optimal clinical care, are one way of increasing implementation of evidence into clinical practice. Many factors must be considered by multidisciplinary guideline panels, including strength of available evidence, limitations of current knowledge, risks/benefits of interventions, patient values, and limited resources. Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a framework for summarizing evidence that has been endorsed by many national and international organizations for developing CPGs. But is GRADE the right choice for CPGs developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF)? In this commentary, we will introduce GRADE, discuss its strengths and limitations, and address the question of what potential benefits GRADE might offer beyond existing methodology used by the AAO-HNSF in developing CPGs.

To apply a novel methodology with machine learning (ML) to a large national cancer registry to help identify patients who are high risk for delayed adjuvant radiation.Observational cohort study.National Cancer Database (NCDB).A total of 76,573 patients were identified from the NCDB who had invasive head and neck cancer and underwent surgery, followed by radiation. The model was constructed from 80% of the patient data and subsequently evaluated and scored with the remaining 20%. Permutation feature importance analysis was used to understand the weighted model construction.A total of 76,573 patients met inclusion and exclusion criteria. Our ML model was able to predict whether patients would start adjuvant therapy beyond 50 days after surgery with an overall accuracy of 64.41% and a precision of 58.5%. The 2 most important variables used to build the model were treating facility and urban versus rural demographics.Statistics can provide inferences within an overall system, while ML is a novel methodology that can make predictions. We can identify patients who are "high risk" for delayed radiation using information from75,000 patient experiences, which has the potential for a direct impact on clinical care. Our inability to achieve greater accuracy is due to limitations of the data captured by the NCDB, and we need to continue to identify new variables that are correlated with delayed radiation therapy. ML will prove to be a valuable clinical tool in years to come, but its utility is limited by available data.

Objectives To develop and validate an algorithm to predict occult nodal metastasis in clinically node negative oral cavity squamous cell carcinoma (OCSCC) using machine learning. To compare algorithm performance to a model based on tumor depth of invasion (DOI). Materials and methods Patients who underwent primary tumor extirpation and elective neck dissection from 2007 to 2013 for clinical T1-2N0 OCSCC were identified from the National Cancer Database (NCDB). Multiple machine learning algorithms were developed to predict pathologic nodal metastasis using clinicopathologic data from 782 patients. The algorithm was internally validated using test data from 654 patients in NCDB and was then externally validated using data from 71 patients treated at a single academic institution. Performance was measured using area under the receiver operating characteristic (ROC) curve (AUC). Machine learning and DOI model performance were compared using Delong’s test for two correlated ROC curves. Results The best classification performance was achieved with a decision forest algorithm (AUC = 0.840). When applied to the single-institution data, the predictive performance of machine learning exceeded that of the DOI model (AUC = 0.657, p = 0.007). Compared to the DOI model, machine learning reduced the number of neck dissections recommended while simultaneously improving sensitivity and specificity. Conclusion Machine learning improves prediction of pathologic nodal metastasis in patients with clinical T1-2N0 OCSCC compared to methods based on DOI. Improved predictive algorithms are needed to ensure that patients with occult nodal disease are adequately treated while avoiding the cost and morbidity of neck dissection in patients without pathologic nodal disease.

Background The anterolateral thigh (ALT) free flap is one of the most commonly used donor sites in head and neck reconstruction, however, it is not typically considered when an osseous component is needed. Methods Soft tissue harvests, cadaveric study, and retrospective analysis of a series of 10 patients undergoing angiography were performed to assess vascular supply to the femoral cortex. In 6 patients, corticocancellous split-femur was incorporated into the ALT to reconstruct bony defects of the head and neck. Results There is a consistent blood supply to the femur from the lateral femoral circumflex artery both intraoperatively and on angiography. No fractures or orthopedic injuries have been seen to date. None of the patients had complications of bone harvest, such as deep vein thrombosis or pulmonary embolism. Conclusion The ALT osteomyocutaneous (ALTO) flap has consistent vascular anatomy to the femoral cortex. This flap provides additional corticocancellous bone and overlying vastus intermedius muscle for the reconstruction of complex craniofacial defects. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

As Otolaryngologists we have witnessed a rise in a new disease with human papilloma virus (HPV) associated oropharyngeal squamous cell carcinoma (OPSCC). As of 2018, HPV associated OPSCC has surpassed the incidence of HPV associated cervical cancer within the United States. Non-HPV related head and neck cancer is largely a preventable disease through avoidance of various environmental factors, and we have seen a significant decline in cancer rates through anti-tobacco campaigns and other public health efforts. Given the success of HPV vaccination campaigns and reduction in HPV associated cervical and other anogenital cancers, some would argue HPV OPSCC is largely a preventable disease through vaccination as well. The question remains is how do we as otolaryngologist, non-primary care providers yet surgeons for this disease, help to promote public health efforts to reduce HPV related OPSCC. Within this article, we discuss preliminary data that supports HPV vaccination with HPV related OPSCC and the ongoing needs by our profession to help support public efforts in reducing the burden of this HPV related cancer.