Search

Electronic cigarettes (EC) are popular devices that aerosolize a nicotine and have been controversially considered tool for smoking cessation and tobacco harm reduction (THR). The purpose of this pilot study was to identify head and neck cancer (HNC) surgeons' attitudes/perspectives of EC and smoking cessation counseling.Cross-sectional survey administered to American Head and Neck Society (AHNS) members.Response rate was 136 members (15.1%) with the majority 102 (75.00%) having unfavorable attitude toward EC for smoking cessation. Fifty-eight respondents (42.7%) were familiar with THR. Those familiar with THR 37 (63.79%) routinely inquire about EC use. Compared between THR familiarity, 22 (37.93%) believed the benefits of EC for smoking cessation outweighed the potential risks.HNC specialists have an unfavorable attitude toward EC. Those familiar with THR were more likely to inquire about EC use. They were also less likely to have a definitive opinion on the benefits of quitting combustible cigarettes.

Objective: To describe the operative technique for harvesting a trapezius flap based on its pedicled arterial supply. Findings: The trapezius flap is a versatile flap allowing for reconstruction of multiple head and neck surgical defects. Results: The trapezius flap can be harvested based on the dorsal scapular artery or on the superficial cervical artery based on the orientation of the flap desired and the length of pedicle necessary. Conclusion: The trapezius flap is a useful flap for complex head and neck reconstruction with minimal donor site morbidity. It is well tolerated in a myriad of patients.

Purpose: In advanced stage head and neck squamous cell cancers (HNSCC), approximately half of the patients with lymph node metastases (LNM) are not cured. Given the heterogeneous outcomes in these patients, we profiled the expression patterns of LNMs to identify the biological factors associated with patient outcomes. Experimental Design: We performed mRNAseq and miRNAseq on 72 LNMs and 29 matched primary tumors from 34 patients with HNSCC. Clustering identified molecular subtypes in LNMs and in primary tumors. Prediction Analysis of Microarrays algorithm identified a 73-gene classifier that distinguished LNM subtypes. Gene-set enrichment analysis identified pathways upregulated in LNM subtypes. Results: Integrative clustering identified three distinct LNM subtypes: (i) an immune subtype (Group 1), (ii) an invasive subtype (Group 2), and (iii) a metabolic/proliferative subtype (Group 3). Group 2 subtype was associated with significantly worse locoregional control and survival. LNM-specific subtypes were not observed in matched primary tumor specimens. In HNSCCs, breast cancers, and melanomas, a 73-gene classifier identified similar Group 2 LNM subtypes that were associated with worse disease control and survival only when applied to lymph node sites, but not when applied to other primary tumors or metastatic sites. Similarly, previously proposed prognostic classifiers better distinguished patients with worse outcomes when applied to the transcriptional profiles of LNMs, but not the profiles of primary tumors. Conclusions: The transcriptional profiles of LNMs better predict outcomes than transcriptional profiles of primary tumors. The LNMs display site-specific subtypes associated with worse disease control and survival across multiple cancer types.

It is uncommon for a headache that is due to rhinosinusitis (aka “sinus headache”) to occur. In such a situation, an initial sinus infection by a viral or bacterial pathogen leads to formation of a viscous, discoloured discharge from the nose, hyposmia or anosmia, pain or a sense of pressure in the facial region and usually pyrexia. Pain in the face and headache normally abate within a week of the infection resolving. Ongoing pain should prompt a review of the diagnosis. The International Classification of Headache Disorders has published useful criteria which may be used to distinguish different kinds of headache. In sinus headache, pain over the face, facial pressure, blockage of the nose and sinuses are present. Additionally, the following symptoms, which are also present in migraine disorders, may occur: nausea, photosensitivity or noise intolerance, moderate to severe headache, a pulsatile or throbbing sensation and exacerbation due to activity. Despite the popularity of the term “sinus headache” among patients themselves and general practitioners, in the media and in advertising copy, its use is deprecated by ENT specialists, allergists and neurologists, who feel that the term lacks precision and may lead to inappropriate interventions. The term sinus headache is generally applied when a headache is accompanied by pain in the face or facial pressure. It is the facial pain and pressure that brings the association with sinus disease. In this chapter, nasal diseases and headache are reviewed.

Objectives/Hypothesis After concurrent chemoradiation for head and neck squamous cell cancer, patients with laryngeal incompetence may not recover function. We assessed variables predicting tracheostomy dependence as a measure of poor laryngeal function after chemoradiation. Study Design Retrospective Methods Analysis of 109 patients treated with chemoradiation for locoregionally advanced laryngohypopharyngeal squamous cell cancers between 1992 and 2013. Median follow-up was 17.0 and 17.2 months for tracheostomy and nontracheostomy dependent patients, respectively. Results For all patients, multivariate analysis demonstrated persistent tracheostomy was associated with pretreatment tracheostomy, subglottic extension, three-dimensional conformal radiotherapy (3DCRT) and postradiotherapy lymphadenectomy. When analyzed by primary site, tracheostomy dependence was associated with pretreatment tracheostomy, subglottic extension, and 3DCRT in larynx primaries, and with pretreatment tracheostomy and feeding tube dependency in hypopharynx primaries. Tracheostomy dependence did not impact local control, progression-free survival or overall survival on univariate analysis. Conclusion After curative chemoradiation, long-term tracheostomy was associated with pretreatment tracheostomy, subglottic extension, postradiotherapy lymphadenectomy, and 3DCRT but did not impact outcomes. These factors may inform treatment decision making regarding organ preservation approaches for locally advanced laryngeal and hypopharyngeal cancers. Level of Evidence 4. Laryngoscope, 2015

Importance Because locally advanced oral cavity squamous cell carcinoma (OCSCC) is often treated with surgery followed by postoperative radiotherapy (S+PORT), the effectiveness of organ preservation with concurrent chemoradiotherapy (CRT) remains unclear. Objective To compare the differences in survival between patients with locally advanced OCSCC treated with S+PORT or CRT. Design, Setting, and Participants Using the National Cancer Database, this study compared 6900 patients with stage III to IVA OCSCC treated with S+PORT and CRT from 2004 through 2012 at academic and community-based cancer clinics. Comparisons were made using Kaplan-Meier methods and Cox proportional hazards regression models using the entire cohort and a propensity score–matched cohort of 2286 patients. Main Outcomes and Measures Overall survival (OS). Results Of the 6900 study patients, 4809 received S+PORT (3080 male [64.0%] and 1792 [36.0%] female) and 2091 received CRT (1453 male [69.5%] and 638 [30.5%] female). Median follow-up for the entire group was 23.0 months overall but was shorter for patients receiving CRT (17.3-month) vs S+PORT (25.6 months). Patients receiving CRT were more likely to be older than 60 years, treated before 2007, live within 10 miles of the treating facility, treated at nonacademic centers, have more comorbidities, have T3 to T4a tumors, and have N2a to N2c nodal disease. Propensity score matching identified cohorts of patients with similar clinical variables. S+PORT was associated with improved survival among all patients (3-year OS: 53.9% for S+PORT vs 37.8% for CRT; difference = 16.1%; 95% CI, 13.6%-18.6%) and in the propensity score–matched cohort (3-year OS: 51.8% for S+PORT vs 39.3% for CRT; difference = 11.9%; 95% CI, 7.8%-16.0%). S+PORT was associated with improved survival among patients with T3 to T4a tumors (3-year OS: 49.7% for S+PORT vs 36.0% for CRT; difference = 16.1%; 95% CI, 13.6%-18.6%) but was not associated with improved survival among patients with T1 to T2 tumors (3-year OS: 59.1% for S+PORT vs 53.5% for CRT; difference = 5.6%; 95% CI, −3.1% to 14.3%). Conclusions and Relevance Compared with CRT, S+PORT was associated with improved survival for locally advanced OCSCCs, especially in T3 to T4a disease. These data support the use of surgery as the initial treatment modality for operable OCSCCs.

BACKGROUND Although black patients experience worse outcomes after treatment for squamous cell carcinoma of the head and neck (HNSCC), these conclusions were based on populations in which blacks comprised a minority of patients. The objective of the current study was to determine the impact of race on outcomes in patients with HNSCC who received radiotherapy at an institution in which blacks comprised the majority of patients. METHODS In this retrospective cohort study, the authors reviewed 366 black patients and 236 white patients who had nonmetastatic HNSCC for which they received radiotherapy between 1990 and 2012. The primary study outcome measures were locoregional control, freedom from distant metastasis, progression-free survival, and overall survival. RESULTS The median follow-up was 18.3 months for all patients. The 2-year locoregional control rate was 71.9% for black patients compared with 64.2% for white patients (hazard ratio, 0.72; P = .03). There was no difference between blacks and whites regarding 2-year freedom from distant metastasis, progression-free survival, or overall survival. Among the patients who had stage III through IVB disease, blacks and whites had similar outcomes. On multivariate analysis, race was not statistically significant for locoregional control, freedom from distant metastasis, progression-free survival, or overall survival. Despite these similar outcomes, black patients had worse socioeconomic factors and increased comorbidities but had similar treatment compliance compared with white patients. CONCLUSIONS With more adverse prognostic factors, black patients experienced oncologic outcomes similar to the outcomes of white patients after receiving radiotherapy for HNSCC. The current data suggest that centers that treat large percentages of minority patients who receive radiotherapy for HNSCCs may overcome existing health care disparities through improved treatment compliance. Cancer 2014;120:244–252. © 2013 American Cancer Society.

Background The survival outcomes for surgery + postoperative radiotherapy (S+RT) or surgery + postoperative chemoradiation (S+CRT) was compared in patients having oral tongue cancers with intermediate-risk pathological features. Methods Using the National Cancer Database (NCDB), overall survival (OS) for S+RT or S+CRT was estimated using the Kaplan-Meier methods and Cox proportional hazard models in the entire population (n = 2803) and in a propensity-matched cohort (n = 1136). Results The 3-year OS was 73.3% for S+CRT versus 66.7% for S+RT (P = .02). The S+CRT improved the 3-year OS for patients with 2 or more involved metastatic lymph nodes (≥2 MLNs; P = .01) but not for patients with

To examine the efficacy of preoperative Staphylococcus aureus screening on postoperative methicillin-resistant S aureus (MRSA) infection rates in otolaryngology.Chart review.Postoperative MRSA infection rates in unscreened patients during a 1-year period were compared with infection rates in patients after preoperative S aureus screening was initiated. Colonized patients were treated with mupirocin and chlorhexidine preoperatively.Records of 420 patients were reviewed. In the 241 patients without screening, nine patients had S aureus infections, and there were two (0.8%) postoperative MRSA surgical-site infections. Of 179 patients after screening was initiated, 24 patients (13.4%) were colonized with S aureus and underwent preoperative treatment. There were no MRSA infections in the postoperative period.Early results show the potential benefit of preoperative S aureus screening in MRSA infection rate reduction. Although larger studies are needed, screening and treatment of MRSA colonized patients preoperatively may reduce infectious complications in otolaryngology.

Thyroid reoperation is known to carry a higher risk for complications because of the increased challenge of identifying tissue planes, presence of adherent strap muscles, and generalized scarring of the thyroid bed. Consideration of postsurgical changes in the anatomy of important landmarks, such as the recurrent and superior laryngeal nerves, brachiocephalic artery, and parathyroid glands, is crucial during preoperative planning for thyroid reoperations. This article provides a review of these key changes in surgical anatomy and the implications of the anatomic changes after thyroidectomy.

Objectives/Hypothesis: To assess whether the use of continuous intraoperative f/cial nerve monitoring correlates to postoperative facial nerve injury during parotidectomy. Study Design: A retrospective analysis. Methods: Forty-five consecutive parotidectomies were performed using an electromyograph (EMG)-based intraoperative facial nerve monitor. Of those, 37 had complete data for analysis. Intraoperative findings and final interpretation of the EMGs were analyzed by a senior neurologist and neurophysiologist. All patients were analyzed, including those with preoperative weakness and facial nerve sacrifice. Results: The overall incidence of facial paralysis (House-Brackmann scale > 1) was 43% for temporary and 22% for permanent deficits. This includes an 11% incidence of preoperative weakness and 14% with intraoperative sacrifice. An abnormal EMG occurred in only 16% of cases and was not significantly associated with permanent or temporary facial nerve paralysis (χ2, P < 1.0; Fisher's exact P < .68). Of the eight patients with permanent paralysis, only two had abnormalities on the facial nerve monitor. Also, only one of five patients with intraoperative sacrifice of the facial nerve had an abnormal EMG. Factors significantly associated with the incidence of facial paralysis include malignancy, advanced age, extent of parotidectomy, and dissection beyond the parotid gland (χ2 and Fisher's, P < .05). Conclusions: The results suggest that abnormalities on the intraoperative continuous facial nerve monitor during parotidectomy do not predict facial nerve injury. The incidence of permanent and temporary facial nerve paralysis compare favorably with the literature given that this study includes patients with revision surgery, intraoperative sacrifice, and preoperative paralysis. Standard of care implications will be discussed.

Background: Telemedicine (TM) is the use of advanced information and communication technology to provide health care services. TM in general, and specifically in the field of otolaryngology, has become a reality. Because of the improvements in telecommunications and computer technology, TM applications are becoming more common in both hospitals and private practice. These applications are altering the manner in which otolaryngology is practiced both at the primary care and the specialist level. This study reviews and summarizes the use of TM specifically in otolaryngology, and discusses some of its advantages, barriers, and future. Material and Methods: A review of the current literature pertaining to the use of TM applications in otolaryngology—head and neck surgery was performed. Results: TM applications are being developed and used worldwide in the many fields of otolaryngology. As telecommunication and audio-visual technologies advance, these applications become more exacting and cost effective. Conclusion: We encourage the otolaryngologist to understand the technical, legal, ethical, and financial impact of TM on managed care in otolaryngology and to make use of the potential opportunities of TM in otolaryngology—head and neck surgery. (Am J Otolaryngol 2002;23:35-43. Copyright © 2002 by W.B. Saunders Company)

Multilevel surgery for obstructive sleep apnea syndrome (OSA) may improve success. This study's goal is to prospectively evaluate the feasibility and short-term subjective effectiveness of a new tongue-suspension technique.A multicenter nonrandomized open enrollment trial used the Repose device to treat tongue obstruction in 39 snoring and OSA patients. Outcomes include 1- and 2-month subjective reports of general health, snoring, and sleep.Twenty-three patients completed 1 month and 19 completed 2 months of follow-up. In OSA patients, activity level, energy/fatigue, and sleepiness improved. Two-month outcomes were less (activity level, energy/fatigue, and sleepiness). Fewer changes were observed in snorers than in OSA patients. There were 6 complications (18%), including sialadenitis (4), gastrointestinal bleeding (1), and dehydration (1) after the procedure.A pharyngeal suspension suture changes subjective outcomes. Improvement is incomplete. The procedure is nonexcisional, but significant complications may occur. Further evaluation is required to demonstrate effectiveness.

Background Squamous cell carcinoma (SCCA) of the oral cavity recurs with a frequency of 25%–48%, a fact that usually portends a poor prognosis. Recent studies have reported salvage cure rates as high as 67%. Investigators have also claimed that restaging recurrent tumors provides useful prognostic information, although this has not been demonstrated with tumors of the oral cavity. The purposes of this study were: (1) to report the patterns of recurrent SCCA of the oral cavity; (2) to examine the benefit of restaging oral cavity tumors, and (3) to compare different treatment modalities in the management of recurrent SCCA of the oral cavity. Materials and Methods Thirty-eight patients who developed recurrent SCCA of the oral cavity were reviewed. Salvage treatment consisted of surgery, chemotherapy, radiation therapy, or a combination of these modalities. Survival analysis was based on the stage of the primary and recurrent tumors and the type of salvage treatment received. Results The overall recurrence rate was 28%. Local recurrence was most common (58%) followed by locoregional (27%) and regional recurrence (16%). Patients who recurred more than 6 months after completion of their primary treatment had improved survival compared with those who recurred within 6 months of initial treatment. Individuals with stage I-II primary tumors had significantly improved salvage time and total survival time compared with those with stage III-IV primary tumors (p < 0.005 and p < 0.001). Conversely, the stage of the recurrent tumor was not predictive of either improved salvage time or total survival time. Patients who underwent salvage surgery had significantly improved salvage time and total survival time compared with those who received chemotherapy and/or radiation therapy (p < 0.001 and p < 0.002). The overall salvage cure rate was 21%. Neither the stage of the primary or recurrent tumors nor the type of salvage treatment received significantly correlated with an improved cure rate. However, the group of patients who underwent salvage surgery approached a statistically significant improvement in cure rate (p = 0.08). Conclusions Squamous cell carcinoma of the oral cavity is most likely to recur at the primary site. The stage of the primary tumor is significantly correlated with survival even after recurrence, but the stage of the recurrent tumor is not significantly correlated with survival. Patients most likely to benefit from retreatment are those who (1) have primary tumors stage I-II, (2) recur greater than 6 months after their initial treatment, and (3) develop recurrences that are amenable to salvage surgery. © 2000 John Wiley & Sons, Inc. Head Neck 22: 34–41, 2000.

Background Risk-stratification schemes exist for well-differentiated thyroid carcinoma and include prognostic factors such as age, sex, extent of tumor, size of tumor, and presence of metastasis. Controversy continues, however, over the aggressiveness of initial surgical intervention because of anecdotal experiences of poor clinical outcomes in low-risk patients. Our objective is to determine the prognostic significance of two biologic tumor markers, the p53 gene mutation and CD34 microvessel density (MVD) count, in well-differentiated tumors of thyroid gland. Methods We selected 38 patients with well-differentiated thyroid carcinomas from the University of Illinois Tumor Registry. Patients had an average clinical follow-up of 10 years. Paraffin-embedded tumor specimens were available for all patients. Immunohistochemistry was performed to identify mutations of the p53 gene (Ab 1801) and to determine the MVD count (CD34). Results There were significant increases in MVD counts within thyroid tumor tissue, when compared with surrounding, normal thyroid tissue. There was no significant correlation noted, however, between increased MVD and histology or recurrence rates. There was a trend toward higher MVD counts in tumor specimens of patients initially seen with metastatic lymphadenopathy. The incidence of p53 mutation expression was 28%, and there was no correlation between p53 status and histology, sex, recurrence rate, or survival. Conclusions This study supports the concept of tumor neovascularization but fails to correlate MVD with clinical behavior or pathologic features in well-differentiated thyroid carcinoma. Furthermore, we found that the p53 mutation status was not an independent prognosticator of tumor behavior in these lesions. © 1998 John Wiley & Sons, Inc. Head Neck20: 152–158, 1998.

It is estimated that 11% of all patients requiring active intervention for acute upper airway obstruction develop negative-pressure pulmonary edema. This pathologic process typically has a benign and rapidly resolving clinical course with the prompt use of mechanical ventilation and positive end expiratory pressure. A review of the literature, however, has revealed a morbidity and mortality rate of 11% to 40% in reported series. During the years 1991 through 1993, six patients were identified in whom negative-pressure pulmonary edema developed after various otolaryngologic procedures. Five (84%) of the six patients had complete resolution of the pulmonary edema within 24 hours, and the sixth patient progressed to prolonged mechanical ventilation and eventual death. In an effort to further understand the pathophysiology of this disease, a cardiac evaluation was performed by use of echocardiography on all six patients. In three of the six patients, studies revealed an underlying cardiac anomaly not previously identified by history or physical examination. Findings included one case of hypertrophic cardiomyopathy and two cases of pulmonary and tricuspid valvular insufficiency. This 50% incidence of cardiac anomalies is striking, in contrast to the less than 1% incidence of these anomalies in the general adult population. To our knowledge, this is the first study to implicate an underlying cardiac cause for the generation of negative-pressure pulmonary edema. On the basis of this study, we recommend that echocardiography be a part of the routine evaluation of all patients who manifest negative-pressure pulmonary edema.

The purpose of this study was to determine whether neutral endopeptidase (NEP; EC 3.4.24.11) is decreased in the uvula epithelium of patients with obstructive sleep apnea (OSA). Tissues were obtained by uvulopharyngopalatoplasty in seven patients with moderate OSA and by autopsy in five individuals not known to have OSA. Using antisera to human NEP and immunoperoxidase staining, we found that NEP was localized in uvula epithelial cells of both patients with OSA and controls. However, there was a significant decrease in the number of epithelial cells staining for NEP in patients with OSA relative to controls (67 ± 10 cells versus 261 ± 33 cells, in 5 randomly selected high-power microscopic fields, respectively; mean ± SEM; p

Although carcinoma of the breast has a propensity toward distant metastasis, metastasis to the head and neck is uncommon. Most patients with metastasis to the head and neck region present with cervical lymphadenopathy; however, spread to the upper aerodigestive tract has been described previously. We present a case of a patient found to have a pedunculated mass in her right piriform sinus. When she swallowed, the mass would completely prolapse into the esophagus and cause symptoms. Subsequent workup revealed widespread metastatic disease, for which the patient was treated with chemoradiotherapy. Microlaryngoscopy with excision of the mass was performed for palliation of her dysphagia, and a diagnosis of metastatic breast carcinoma was obtained. The patient healed well from the excision and went on to be treated for the metastatic breast cancer. To our knowledge, our report represents the first case of metastatic breast carcinoma presenting as severe dysphagia.

Despite recent diagnostic advances, the laryngopharynx remains an area where accurate assessment of tumor size and extent is difficult. Computed tomography has proven helpful in delineating lesions in these areas, yet significant limitations exist. In an attempt to more accurately evaluate laryngopharyngeal neoplasms, MR imaging was performed in 25 consecutive patients with squamous cell carcinoma of the larynx and hypopharynx. Mr imaging was analyzed for its utility in clinical staging, assistance in selection of candidates for conservation, Laryngeal surgery, and ability to reliably predict cartilage invasion. MR imaging improved the accuracy of tumor staging by 40% and was valuable in the selection of candidates for conservation surgery. In addition, MR imaging was able to predict cartilage invasion in 6 of 6 patients with pathologic confirmation with a single false-positive case. MR imaging appears to be a reliable indicator of tumor size and location and should be judiciously incorporated into the staging and pretreatment planning of patients presenting with laryngopharyngeal malignancies.

PURPOSE To determine survival rates and the pattern of failure in head and neck cancer patients treated with induction chemotherapy, limited surgery and concomitant chemoradiotherapy. PATIENTS AND METHODS Three cycles of induction chemotherapy with cisplatin, fluorouracil (5-FU), leucovorin, and interferon alfa-2b (PFL-IFN) were followed by optional surgery, and seven or eight cycles of 5-FU, hydroxyurea, and concurrent radiation for 5 days (FHX) for a total radiation dose of 65 to 75 Gy. Surgical resection was performed with the intent to spare organ function. RESULTS Seventy-one patients were treated at three institutions. Sixty-five patients (91%) had stage IV disease with N2/3 in 46. Thirty-three patients (51%; 95% confidence interval, 39% to 63%) achieved a clinical complete response (CR) to PFL-IFN. Local therapy consisted of surgery in 37 and/or FHX in 55 patients. With a median follow-up duration of 37 months, there have been 20 recurrences (15 local, four distant, and one both local and distant), and 29 deaths, 15 in patients with disease progression and 14 not directly related to the primary tumor. Four patients have developed second malignancies. At 3 years, 69% (+/- 6%) are progression-free and the overall survival rate is 60% (+/- 6%). Toxicity of PFL-IFN included severe or life-threatening mucositis (54%) and myelosuppression (60%). Five patients died of toxicity. During FHX, 70% of patients had grade 3 or 4 mucositis. CONCLUSION PFL-IFN is highly active, producing clinical CRs in 51% of patients, and, when followed by FHX, resulting in high local and distant control and overall survival rates. Second malignancies and intercurrent medical disease emerge as major risks to long-term survival. In view of the high toxicity and long treatment duration, further modifications of this approach are required.

Background. Injury to the recurrent laryngeal nerve is a well-recognized complication of thyroid surgery. Injury to the superior laryngeal nerve is less documented, perhaps due to the difficulty in recognizing its manifestations. This study was designed to document the incidence of injury to the superior laryngeal nerve in a series of patients who underwent thyroidectomy. Methods. Twenty consecutive patients with thyroidectomy during a 9-month period underwent evaluation for superior laryngeal nerve injury 3 months postoperatively. Methods for evaluation included laryngeal videostroboscopy, laryngeal electromyography, and a subjective interview. Results. One patient (5%) was diagnosed with unilateral superior laryngeal nerve injury. Conclusions. The risk of injury to the superior laryngeal nerve during thyroidectomy is significant, and the result may be devastating to those patients who rely on their voices professionally. Laryngeal videostroboscopy and electromyography may be necessary to diagnose superior laryngeal nerve injury. © 1995 Jons Wiley & Sons, Inc.

Advanced lesions of the oropharynx are known to have increased survival with surgical excision combined with radiation therapy. Traditional surgery involves either a mandibular resection or, more recently, a mandibular sparing approach primarily through a lip-splitting incision. At our institution posterior oropharyngeal lesions are approached via a combined intraoral and transhyoid technique. Nineteen sequential procedures using this approach were compared with a similar number of previous, stage-matched controls in an attempt to obtain valid comparable information. No significant difference between the groups was noted with respect to surgical margins. A significant difference was, however, seen with respect to the need for flap closure with none required in the transhyoid group and five in the mandibulotomy group. Furthermore, a statistical difference was observed with respect to the presence of significant complications in favor of the transhyoid group. These results indicate that similar cure rates can be achieved with lower morbidity by use of a transhyoid pharyngotomy approach to tumors of the oropharynx.

The lateral arm free flap has proved to be both a versatile and successful method of reconstruction. Since its introduction a decade ago, however, its application in head and neck reconstruction has been fairly limited. Dissection of the flap, based on the posterior radial collateral branch of the profunda brachii artery, is relatively simple and provides a thin, dependable flap that has the potential to be used as a osteocutaneous flap or as a fasciocutaneous flap alone. The flap contains a sensory nerve that is readily anastomosed and donor site morbidity is limited. Although the pedicle is short, several modifications exist that allow its extension. This flap has been used successfully to reconstruct various defects in the head and neck. Pertinent anatomy, indications, and guidelines for clinical application will be discussed.

PURPOSE To increase the activity of cisplatin, fluorouracil (5-FU), and leucovorin (PFL) through further biochemical modulation and study the pharmacologic interaction of 5-FU and interferon alfa-2b (IFN). PATIENTS AND METHODS Escalating doses of IFN (0.5 to 4.0 x 10(6) U/m2/d x 6) were added to cisplatin 100 mg/m2, continuous infusion 5-FU 800 or 640 mg/m2/d x 5, and leucovorin 100 mg orally every 4 hours. Forty-eight previously untreated patients with locoregionally advanced head and neck cancer received up to three cycles of PFL-IFN. RESULTS Twenty-one patients were treated during a phase I cohort study. Dose-limiting mucositis was seen with 800 mg/m2/d of 5-FU and 0.5 x 10(6) U/m2/d of IFN. After decreasing the 5-FU dose to 640 mg/m2/d, the maximally tolerated dose (MTD) of IFN was 2.0 x 10(6) U/m2/d. Mucositis and myelosuppression were dose-limiting. Of 34 patients treated at this MTD, 56% (95% confidence interval, 39% to 73%) had a complete remission. There was no correlation between 5-FU clearance and IFN dose. Pharmacodynamic analyses at the MTD showed that older age, female sex, and higher 5-FU area under the time versus concentration curve (AUC) were associated with lower nadir counts and/or increased mucositis. Seven patients with diabetes mellitus had significantly increased myelosuppression, serum creatinine, hypocalcemia, higher 5-FU concentrations, and lower 5-FU clearance compared with nondiabetics. CONCLUSION The recommended doses for PFL-IFN are 640 mg/m2/d for 5-FU and 2.0 x 10(6) U/m2/d for IFN. Sex, age, 5-FU AUC, and diabetes mellitus may have an impact on the pharmacodynamics of this regimen.

ANESTHESIOLOGISTS are faced with myriad surgical procedures designed to alleviate sleep-disordered breathing in patients with obstructive sleep apnea (OSA). The main concern in caring for these patients is the potential difficult airway in many of these patients and also the comorbidities caused by OSA. We report a case of immediate postoperative airway obstruction that necessitated emergency cricothyrotomy after performance of a relatively new procedure called tongue suspension or tongue base surgery.

Although the operation has been practiced for centuries, the modern technique of tracheotomy was introduced and popularized in the beginning of the 20th century. The initial indication for tracheotomy was limited to impending airway obstruction resulting from trauma, but current indications are broader. Tracheotomy is one of four methods available to intubate the trachea and is associated with physiologic changes that are dependent on the duration of tracheotomy. Although surgical in nature, it is employed to relieve or prevent airway obstruction and to offer ventilatory support. Tracheotomy may be performed as an elective or an emergency procedure. Ideally, it is done in a controlled situation. However, when performed in an emergency setting, variations of the procedure, such as minitracheotomy or cricothyroidotomy, may be temporarily substituted. Preferably, tracheotomy is performed in an operating room; however, it may be carried out successfully in an intensive care unit as well.

Panfacial injuries are those that involve trauma to the lower, middle, and upper facial bones. They often are accompanied by multisystem- or polytrauma and require a team approach for management. Although stabilization of the overall status of the patient takes precedence, early and total restoration of facial form and function should be the goal of the maxillofacial surgeon.

ObjectiveTo examine the efficacy of pre-operative Staphylococcus aureus screening by nasal swab on post-operative Methicillin-resistant Staphylococcus aureus (MRSA) infection rates in surgical patients undergoing varied otolaryngological procedures.MethodsRetrospective review of MRSA colonization and infection rates in surgical otolaryngology patients at a single institution. MRSA infection rates in unscreened patients undergoing procedures during a one-year period were compared to infection rates in patients undergoing pre-operative Staphylococcus aureus screening in an 11-month time frame. Patients colonized with Staphylococcus aureus were treated with Mupirocin and Chlorhexidine prior to the procedure.ResultsRecords of 420 patients undergoing varied otolaryngological procedures were evaluated. In the 241 patients without pre-operative screening, 9 patients had Staphylococcus aureus-infected wounds. There were two (0.83%) post-operative MRSA surgical site infections. Out of 179 patients followed after s...

Mandibular continuity defects arising from trauma, infection, or tumor resection can often lead to serious and crippling disabilities. Loss of hard tissue (i.e., bone) will result in the inability to support the soft tissues of the oral cavity and oropharynx. This, in turn, will translate into significant deficiencies in the functions of swallowing, chewing, and talking as well as creating a disfiguring facial appearance.

Despite advances in treatment of primary tumors of the head and neck region, recurrent disease signals an ominous outcome for the patient. Recurrent and/or metastatic head and neck squamous cell carcinoma continues to be a significant cause of cancer-related morbidity and mortality. Improved surveillance and surgical reconstruction methods should help to enhance the capability of surgery to salvage tumors resistant to prior chemotherapy and radiation therapy. Several recently introduced chemotherapeutic agents either alone or in combination with other agents or re-irradiation appears to be extremely active and effective in this patient population. The upcoming decade is likely to see many trials of novel agents either alone or in combination with currently available treatment options. The availability of these new therapeutic regimens may expand the options of patients with recurrent disease and hopefully will help improve the outcome in a group of patients who otherwise have little prospect of attaining cure.

Background: Locoregionally advanced, stage IV head and neck cancer has traditionally carried a poor prognosis. We sought to assess changes in patterns of failure, prognostic factors for recurrence, and overall outcome, using two different strategies of chemoradiotherapy conducted in prospective, multi-institutional phase II trials. Patients and methods: Three hundred and thirty-seven stage IV patients were treated from 1989 to 1998. We compared locoregional and distant recurrence rates, overall survival and progression-free survival from two different treatment strategies: intensive induction chemotherapy followed by split-course chemoradiotherapy (type 1, n=127), or intensified, split-course, hyperfractionated multiagent chemoradiotherapy alone (type 2, n=210). Univariate and multivariate analyses of 12 chosen covariates were assessed separately for the two study types. Results: The pattern of failure varied greatly between study types 1 and 2 (5-year locoregional failure of 31% and 17% for study types 1 and 2, respectively, P=0.01; 5-year distant failure rate of 13% and 22% for study types 1 and 2, P=0.03). Combined 5-year overall survival was 47% [95% confidence interval (CI) 41% to 53%) and progression-free survival was 60% (95% CI 55% to 66%). Both treatment strategies yielded similar survival rates. Poor overall survival and distant recurrence were best predicted by advanced nodal stage. Locoregional recurrence was extremely rare for patients with T0–T3 tumor stage, regardless of lymph-node stage. Conclusions: This analysis suggests that pattern of failure in primary head and neck cancer may be dependent upon treatment strategy. Randomized clinical trials of induction chemotherapy are warranted as a means to determine if a decrease in distant metastases can lead to an increase in survival rates in the setting of effective chemoradiotherapy for locoregional control. Additionally, this analysis provides impetus for randomized clinical trials of organ preservation chemoradiotherapy in sites outside the larynx and hypopharynx.

The purpose of this study was to evaluate the role of neck lymph node (ND) in the combined dissection modality therapy for locoregionally advanced head and neck.We identified patients with N2-N3 head and neck cancers who were enrolled in three consecutive multicenter phase II studies of concurrent chemoradiotherapy utilizing 5-fluorouracil and hydroxyurea on an alternate-week schedule with radiotherapy twice daily plus either cisplatin (C-FHX) or paclitaxel (T-FHX). Patients with unknown primary tumors, nasopharyngeal or paranasal sinus primaries, nonsquamous histology, progression or death during therapy, or incomplete therapy were excluded.A total of 131 patients were analyzed. Seventy-nine percent had N2 stage. ND was performed in 92 patients (70%), either prior to enrollment (n = 31) or after chemoradiotherapy (n = 61). With a median follow-up of 4.6 years, the 5-year locoregional and neck progression-free survival (PFS) rates were higher in patients with ND versus patients without ND: 88% versus 74% (p =.02) and 99% versus 82% (p =.0007). respectively; there was also a trend toward improved overall survival (OS) with ND, but PFS and distant PFS were comparable. In the subset of patients with N3 disease, ND was associated not only with better locoregional control but also with improved distant PFS. However, in patients with clinical complete response (n = 92), no significant differences in PFS (68% vs 75% at 5 years, p =.53) or any other survival parameters with or without ND were observed.ND improves neck control and is required for patients with clinically residual disease or N3 neck cancer but has no significant impact on the outcome of patients with N2 stage disease who are rendered clinically disease-free with intensive concurrent chemoradiotherapy.

Importance After chemoradiation for head and neck cancer, more than 90% of patients who achieve a complete clinical response on imaging have their disease regionally controlled without postradiotherapy neck dissections (PRNDs). Because several groups have reported that lymph node involvement also predicts failure at both the primary and distant sites, the extent to which PRND affects nonregional sites of disease remains unclear. Objective To evaluate how PRND affects local control (LC) and distant control in patients who achieve a complete clinical response. Design, Setting, and Participants We retrospectively reviewed 287 patients (74 of whom underwent PRND) from the University of Illinois at Chicago Medical Center who were treated for stage III/IV disease with definitive chemoradiation from January 1, 1990, through December 31, 2012. Interventions Chemoradiation followed by lymph node dissection or observation. Main Outcomes and Measures End points evaluated included LC, regional control, freedom from distant metastasis, progression-free survival (PFS), and overall survival using first-failure analysis. Results Patients with advanced nodal disease (stage N2b or greater; n = 176) had improved PFS (74.6% vs 39.1%; P P P P = .03), and overall survival (84.5% vs 61.7%; P = .004) but not regional control (96.9% vs 90.1%; P = .21). The benefit in LC (87.4% vs 66.2%; P = .02) and PFS (80.7% vs 53.4%; P = .01) persisted for those with negative posttreatment imaging results who underwent PRND. On univariate analysis, PRND, alcohol use, nodal stage, and chemoradiation significantly affected 2-year LC and/or PFS. On multivariate analysis, PRND remained strongly prognostic for 2-year LC (hazard ratio, 0.22; 95% CI, 0.07-0.54; P P = .002). Conclusions and Relevance Postradiotherapy neck dissection improved control of nonregional sites of disease in patients with advanced nodal disease who achieved a complete response after chemoradiation. Thus, PRND may affect the control of nonnodal sites through possible mechanisms, such as clearance of incompetent lymphatics and prevention of reseeding of the primary and distant sites.

Objective To assess whether transhyoid resection of the tongue base and tonsil lesions is an effective approach to tumors involving this region compared with more traditional anterior surgical approaches that arbitrarily involve either segmental resection or division of the mandible. Study Design Retrospective review. Methods Since 1988, we have used a combined transhyoid and transoral approach to resect lesions involving the tongue base, tonsil, or both. Forty-one patients were identified who underwent surgical resection of lesions involving this region via this combined approach during this period. A stage-matched group of 41 patients was also identified in which patients underwent resection via traditional composite or mandibulotomy approaches and was used as a basis for comparison. Factors assessed included status of surgical margins, postoperative complications, degree of postoperative dysphagia, and long-term outcome. Results Comparison between the two groups revealed similar rates of negative surgical margins. Levels of postoperative dysphagia, notably severe primarily in patients with either T4 or recurrent disease, were also similar between groups. Complication rates, especially with regard to fistula occurrence and mandible-healing problems, were significantly lower in the transhyoid group. Analysis of long-term outcome revealed similar patterns with regard to disease status in both groups. Conclusions The combined transhyoid and transoral approach is an effective surgical option for a number of lesions affecting the tongue base, tonsil, or both. Although similar to other approaches with regard to postoperative function and disease outcome, the transhyoid approach is associated with decreased postoperative morbidity. However, tumors that e-tend to involve the mandible or pterygoid musculature or skull base are probably best suited for traditional approaches that involve division of the mandible.

Objective This study sought to examine the influence of cigarette smoking and alcohol consumption on the stage of laryngeal cancer at diagnosis. Study Design A retrospective review of 499 laryngeal cancer patients diagnosed between 1978 and 1997 was conducted. Methods Parameters that included smoking history, history of alcohol consumption, and the tumor stage and location at diagnosis were analyzed using the proportional odds model, correlation coefficient, and Student t test. Results Three hundred sixteen patients met the inclusion criteria, and 180 (56%) had advanced-stage disease at the time of presentation. The statistical model demonstrated a small but significant relationship between tobacco and alcohol on the stage of laryngeal cancer at diagnosis. Patients diagnosed with an advanced-stage tumor (stage III or IV) smoked a significantly greater amount and were more likely to be heavy drinkers than those diagnosed with a localized laryngeal cancer. Conclusions Our results demonstrate that for every incremental increase in pack years of smoking, there is a small but measurable increase in the odds that a patient's laryngeal cancer will be stage III or IV at diagnosis. Likewise, being a “heavy” drinker as opposed to a “social” drinker raises the likelihood of an advanced tumor. Given the preventable nature of these risk factors, the moderation of alcohol consumption and cessation of smoking is prudent advice that should be conveyed to all patients.

PURPOSE: In 1986, a multi-institutional phase II trial was begun to study the use of chemotherapy with concomitant radiation in patients with stage II and III head and neck cancer. End points were overall survival, progression-free survival, local/regional control, and toxicity in the setting of organ preservation with concomitant treatment. METHODS: Eligible patients with stage II or III disease received chemotherapy and radiation on a 2-week cycle. Chemotherapy consisted of continuous infusion fluorouracil (5-FU) at 800 mg/m2/d for 5 consecutive days (days 1 to 5) and hydroxyurea (HU) at 1 g orally every 12 hours for 13 doses starting the evening before the start of irradiation. Radiation therapy was given as single 1.8- to 2.0-Gy fractions for 5 consecutive days (days 1 to 5) with chemotherapy. Each 5 days of treatment was followed by a 9-day break (days 6 to 14), during which no additional treatment was given. Treatment cycles were repeated until the completion of the planned radiation dose (six to eight cycles). RESULTS: Between 1989 and 1996, 60 patients were enrolled. All patients were eligible for analysis, with a median follow-up of 52 months for surviving patients and 42 months for all patients. Grade 3 to 4 mucositis occurred in 57% of patients. The 5 year-actuarial overall survival, progression-free survival, and local/regional control were 65%, 82%, and 86%, respectively. Eight patients developed local and/or regional recurrence after treatment. Surgical salvage was possible in three of these patients. Thus, the ultimate 5-year local/regional control was 91%. CONCLUSION: Concomitant radiation and chemotherapy with 5-FU and HU is an effective regimen in patients with stage II and III head and neck cancer. Progression-free survival and local/regional control appear to be superior to expected rates in patients treated with surgery and radiation. Further testing of this regimen in a phase III setting is indicated.

The incidence of second esophageal primary tumors in patients diagnosed as having squamous cell carcinoma of the head and neck varies in the literature. However, in large series, an incidence of about 1% to 2% is commonly reported. This relatively low overall incidence has led some authors to question the traditional use of panendoscopy, including the use of either rigid or flexible esophagoscopy to screen for simultaneous second primary tumors of the esophagus in patients with head and neck cancer. Arguments in this regard cite the exposure of most patients to unnecessary additional risk from potential complications and prolonged operating time associated with endoscopy, as well as reduced cost-effectiveness from the routine use of such procedures in which the overall positive yield is low. In addition, an increased survival advantage in the small percentage of patients with head and neck cancer diagnosed as having a simultaneous esophageal malignancy vs those patients who are subsequently diagnosed at a later date as having an esophageal primary lesion has not been demonstrated in retrospective studies, and prospective studies specifically addressing this issue are currently lacking. Barium swallow has been demonstratedtobearelativelysafeandinexpensiveprocedurethat iseasilyperformedandhasbeendescribed in the radiological and thoracic surgery literature as having a diagnostic accuracy of greater than 90% in identifying thepresenceofesophagealpathological features. Levine et al found a sensitivity rate of esophagography of 96%inaseriesof50patientswithcarcinomaof theesophagusandesophagogastric junction. In addition, this studyreviewedanadditional2484patientswhounderwentbariumesophagographyovera1-yearperiod.Endoscopywasrecommendedin26patients (1%) to rule out malignant tumor, 11 (42%)ofwhomwereeventuallyfound to have cancer. Those authors subsequently concluded that barium studies, particularly those using doublecontrast techniques, achieved good sensitivityaswell as satisfactorypositive predictive yield in those cases in whichendoscopywasrecommended. Although it might be expected that the sensitivity of esophagography decreases in cases of early esophageal malignancies, the use of esophagography to detect even relatively small esophageal lesions also finds some support within the literature. Moss et al assessed the accuracy of esophagrams in the detection of small esophageal carcinoma (,3.5 cm). In this article, the radiographic studies of 35 patients, 11 of whom showed evidence of small esophageal carcinomas with the remainder having either benign lesions or normal findings, were presented without accompanying history to 4 clinical radiologists. Although the exact diagnosis was made in only 8 (73%) of 11 patients with carcinoma, abnormal results indicating the need for further endoscopy were detected in 10 (94%) of 11 patients with small esophageal carcinoma, supporting esophagography’s role in the detection of smaller and presumably earlierstage esophageal malignancies. Nino-Murcia et al carried out a double-blind prospective study of 182 patients diagnosed as having head and neck carcinoma, 148 of whom underwent both esophagography and esophagoscopy in an effort to compare the 2 procedures in the detection of simultaneous esophageal carcinoma. Concordance of findings between the 2 procedures was found in 86% of patients. One case of simultaneous esophageal cancer was found in this series and was detected by both methods. FurtherAmit Agrawal, MD Barry L. Wenig, MD, MPH

PURPOSE To determine tumor response rate, patterns of failure, toxicity, and survival in advanced squamous head and neck cancer after a combined treatment program that consists of induction chemotherapy, organ-sparing surgery, and concurrent chemoradiation. Long-term outcome data are presented. PATIENTS AND METHODS Between July 1991 and March 1993, 93 patients received three cycles of induction chemotherapy that consisted of cisplatin, fluorouracil (5-FU), l-leucovorin, and alpha-interferon2b (PFLl-alpha) followed by optional limited surgery and six to eight cycles of 5-FU, hydroxyurea, and concurrent radiation (FHX) to a total radiation dose of 65 to 75 Gy. RESULTS Ninety-three patients were entered onto this study and 97% had stage IV disease, with 66 patients who were N2 or N3. Sixty-one patients (66%) achieved a clinical complete remission (CR) after induction therapy. Thirty-four patients underwent surgery. Seventy-nine patients proceeded to FHX. With a median follow-up time of 43 months for surviving patients, 20 patients have had disease progression (13 local, two distant, five both), and there have been 35 deaths (18 from disease, six treatment-related, two from a second primary, and nine for other medical reasons). At 5 years, progression-free survival is 68%, and overall survival is 62%. Surgery was organ-preserving, as only a single laryngectomy and no glossectomies were performed in primary management. Acute toxicity related to PFLl-alpha consisted of severe or life-threatening mucositis in 57% and leucopenia in 65% of patients. During FHX, 81% of patients had grade 3 or 4 mucositis. CONCLUSION PFLl-alpha is a highly active regimen that induced clinical CR in two thirds of patients. When followed by limited surgery and FHX, resultant local and distant disease control, organ preservation, and overall 5-year survival are very promising in high-risk stage IV patients. Based on these local control and survival data, further evaluation of this treatment sequence, induction chemotherapy followed by concurrent chemoradiation, is warranted. Identification of similarly active but less toxic regimens is a high priority.

To determine the incidence of human papillomavirus (HPV) infection and p53 gene mutation expression in squamous cell carcinomas (SCCs) of the oral cavity and tonsils, to correlate the presence of HPV and p53 gene mutation with known clinical and pathological features of SCC, and to determine whether infection with HPV or the presence of p53 gene mutations are independent prognosticators of patient survival.To accomplish this goal, 58 patients with SCCs of the oral cavity and 42 patients with SCCs of the tonsils were randomly examined. The cases examined met the criteria of 5-year clinical follow-up, availability of complete staging information and treatment history, and the presence of paraffin-embedded tumor specimens. Immunohistochemical tests were performed to identify the mutant p53 protein. Human papillomavirus identification was accomplished with polymerase chain reaction, with confirmation via restriction fragment length polymorphisms.The incidence of p53 gene mutation expression for this series was 66%. Human papillomavirus infection was found in 11 patients (11%). There was a trend toward increased p53 gene mutation expression with advancing stage of tumor in the oral cavity cancer group, although this was less evident in the tonsil cancer population. The p53 gene mutation status was found not to correlate with the histological grade of the tumor, patient age or sex, recurrence rates, or survival status. Like p53 expression, there were no correlations found between the presence of HPV and age, sex, histological grade, or recurrence rates. However, a correlation did exist between HPV and survival status in the tonsil cancer group, with improved survival noted among patients with tonsil cancers infected with HPV compared with those not infected with HPV. A significant correlation existed with both p53 gene mutation status and HPV status with respect to alcohol and tobacco use. The presence of the p53 gene mutation positively correlated with increased tobacco and alcohol use, whereas infection with HPV predicted a significantly lower rate of alcohol and tobacco consumption.Human papillomavirus infection is an independent risk factor for the development of oral cavity and tonsil SCCs in those patients with a relatively low alcohol and tobacco use history. Conversely, there is a strong association between heavy alcohol and tobacco use and mutation of the p53 gene. Neither p53 gene mutation nor HPV infection serve as prognosticators of tumor behavior in SCCs of the oral cavity or tonsils, with the exception of improved survival noted among patients with tonsil cancers infected with HPV.

Purpose/Objective(s): Patients with head and neck cancer (HNSCC) avoid post-radiation therapy neck dissection (PRND) when post-treatment imaging (PTI) is negative as the risk of regional failure is felt to be low. However, some suggest that negative PTI may not sufficiently predict relapse. We evaluated the therapeutic impact of PRND in those having a complete response by PTI. Materials/Methods: We reviewed patients treated for stage III/IV HNSCC with definitive RT at the University of Illinois from 1990-2012 (n Z 356), of whom 87 received PRND. We evaluated local (LC), regional (RC), locoregional (LRC), and distant control (DC) using first-failure analysis. The Kaplan-Meier method was used to estimate progression-free (PFS) and overall survival (OS). Chi-squared analyses were performed to examine differences between groups. Results: Median follow-up was 17.5 months. Groups were balanced in terms of gender, Karnofsky performance status (KPS), marital status, and alcohol/tobacco use. Patients who underwent PRND were younger (54.6 vs 58.5 years, p < .01), less often had high or very high levels of comorbidities (24.1 vs 31.7%; p Z .03), had more advanced disease (stage IVA/ B: 90.8 vs 56.2%; p < .01), more oropharyngeal (48.3 vs 27.3%; p < .01) and less laryngeal primaries (14.9 vs 31.9%; p < .01). For those with involved lymph nodes, the positive predictive value (PPV) and negative predictive value (NPV) for CT prior to PRND was 74.1% and 91.1%, respectively. The median time to PTI was 7.5 weeks. For all patients at 2 years, LC (84.6 vs 66.8%; p < .01), RC (92.0 vs 83.4%; p Z 0.02), and LRC (78.9 vs 61.4%; p < .01) were superior for PRND. This translated into improved 2 year PFS (62.6 vs 50.5%; p Z .01) but similar DC (78.4 vs 82.3%; p Z .40) and OS (80.0 vs 73.2%; p Z .31). The benefit in LC (85.7 vs 64.7%; p < .01) and RC (94.9 vs 79.9%, p < .01) persisted for those with negative PTI who underwent PRND. A planned subset analyses demonstrated that patients with advanced nodal disease ( N2b; n Z 204) had improved LRC with PRND (81.7 vs 42.1%; p < .01), whereas those with less nodal disease did not (61.0 vs 67.8%; p Z .62). Additionally, PFS (66.0 vs 30.3%; p < .01) was superior in those with advanced nodal disease who underwent PRND. On UVA, PRND, stage, primary site, alcohol use, and RT delay significantly impacted 2 year LC and/or PFS. These factors, as well as known prognostic factors of KPS and low neck disease, were included on MVA. Importantly, PRND remained strongly prognostic for 2 year PFS (HR 0.52; p < .01). Additionally, low neck disease (HR 1.67; p Z .01) impacted PFS adversely. Conclusions: In HNSCC with advanced nodal disease, PRND improved LC and RC despite negative post-radiation therapy imaging. Despite a complete clinical response, PRND may impact the control of non-nodal sites through possible mechanisms such as clearing incompetent lymphatics and preventing re-seeding of the primary site. Author Disclosure: M.C. Ranck: None. G.F. Liu: None. A.A. Solanki: None. B. Wenig: None. A. Kolokythas: None. M.T. Spiotto: None.

This study was conducted to determine whether inflammation is present in the uvula mucosa of patients with obstructive sleep apnea (OSA). Uvulas were obtained by uvulopalatopharyngoplasty in 21 patients with moderate OSA (mean apnea/hypopnea index and standard error of the mean: 32 +/- 4) and by autopsy in 5 individuals not known to have OSA. Using point counting in five randomly selected high-power microscopic fields (X100), the authors found that the number of leukocytes in the lamina propria of the uvula mucosa was significantly higher in patients with OSA than in the controls (179 +/- 12 cells vs. 71 +/- 4 cells, respectively; P < .05). This was due to a significant increase in the number of plasma cells in patients with OSA as compared with controls (89 +/- 15 cells vs. 21 +/- 5 cells, respectively; P < .05). The thickness of the lamina propria (an index of interstitial edema) was also significantly increased in patients with OSA compared with controls (0.99 +/- 0.12 mm vs. 0.27 +/- 0.02 mm, respectively; P < 0.05). The authors conclude that inflammation, characterized by plasma cell infiltration and interstitial edema, is present in the uvula mucosa of patients with moderate OSA. They also suggest that soft palate inflammation contributes to upper airway occlusion observed during sleep in these patients.

Since its introduction by Blom and Singer in 1980, tracheoesophageal puncture with a voice prosthesis has become the most frequently recommended choice for speech rehabilitation of total laryngectomees. Many studies have reviewed the initial speech acquisition success rates following tracheoesophageal puncture; however, long-term follow-up in these initial successes has been lacking. In addition, factors predictive of long-term success with tracheoesophageal speech have not been defined. Over a 10-yearperiod, we retrospectively reviewed all total laryngectomy patients, including those who have undergone primary or secondary tracheoesophageal puncture, at the University of Illinois Hospital and Clinics and the Westside Veterans Administration Hospitals. Survival in the total laryngectomy cohort of 202 patients ranged from 35% to 50%. Forty of these patients underwent tracheoesophageal puncture, in whom survival was 75%. Short-term success with tracheoesophageal speech was approximately 70% for our patients, while long-term success was achieved in 66%. Despite low socioeconomic status and relatively high alcoholism rates, successful maintenance of tracheoesophageal speech was achieved in the majority of cases. Tracheoesophageal speech should therefore be considered as a primary method of vocal rehabilitation in all patients undergoing total laryngectomy.